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ATI Module
Fluid, Electrolyte, and Acid-Base Regulation (Exam 3)
| Question | Answer |
|---|---|
| acid-base balance | The homeostasis of acidic and basic (alkaline) compounds in the blood to maintain a blood pH of between 7.35 and 7.45. |
| acidosis | Levels of acid in the blood are too high, a pH of less than 7.35. |
| active transport | The movement of electrolytes or molecules across a cell membrane with the use of energy in the form of enzymes. |
| air embolism | Obstruction of a vessel by air. |
| alkalosis | The blood is too alkaline, a pH of greater than 7.45. |
| antidiuretic hormone (ADH) | A hormone excreted by the hypothalamus in the brain that maintains blood pressure and fluid volume. Also known as vasopressin. |
| antigens | Substance that can trigger an immune response if foreign in the body. |
| apoptosis | Destruction of a cell. |
| arrhythmias | Abnormal heart rhythm. |
| basic metabolic panel (BMP) | A blood test that provides information regarding electrolyte and fluid balance and includes information regarding renal function and glucose levels. |
| blood type | A classification of the blood that includes 4 main groups: A, B, AB and O. |
| bradycardia | A heart rate that is less than the expected reference range. |
| central venous access devices (CVADs) | Device inserted in the body through a central vein such as the subclavian or jugular and allows administration of fluids, blood, medications, and other therapies. |
| Chvostek sign | Test which may indicate low calcium or magnesium levels. A positive result results in a twitching response of the side of the face when facial nerves are tapped. |
| circulatory overload | A complication of IV therapy in which too much fluid is administered too quickly. |
| colloidal solutions | Intravenous solutions that contain large molecules unable to pass through capillary membranes. |
| complete metabolic panel (CMP) | A blood test that provides information regarding electrolyte and fluid balance. In addition to those findings included in the BMP, the CMP also includes information regarding the body's metabolism, including protein and liver function. |
| creatinine (CR) | Reflection of renal function; a byproduct of skeletal muscle contractions (creatine), which is then excreted through the urine |
| dehydration | Excess water loss without a loss of sodium. |
| diffusion | Movement of solutes from an area of higher concentration to one of lower concentration. |
| diuretics | A category of medications that cause increased urination. |
| edema | Swelling due to excess fluid. |
| electrocardiogram (ECG) | A test to check heart activity including heart rate and rhythm |
| electrolytes | Minerals in the body that conduct electricity. |
| extracellular space | The space outside the cell that includes the interstitial and intravascular areas. |
| extravasation | Inadvertent administration of a vesicant fluid into tissues surrounding an intravenous cannula. |
| flow rate | Rate at which fluids are being infused intravenously. |
| fluid volume deficit | A condition caused by the loss of water; also referred to as hypovolemia. |
| fractionation | Removing components of plasma for use. |
| granulocytes | A type of white blood cell responsible for immune responses during infections and allergic reactions that is comprised of neutrophils, eosinophils, and basophils. |
| half-life | The amount of time required for 50% of a drug to be excreted from the body. |
| hematocrit | A measure of RBCs in total blood volume. |
| hemodialysis | Process of filtering waste from the blood using a machine. |
| hemoglobin | A component of the red blood cell that carries oxygen and carbon dioxide to and from the cells. |
| heparin | Anticoagulant agent. |
| homeostasis | A state of equilibrium. |
| Hypercalcemia | Calcium level above expected reference range of 9 to 10.5 mg/dL (total calcium). |
| hyperkalemia | Potassium level above expected reference range of 3.5 to 5 mEq/L. |
| hypermagnesemia | Magnesium level above expected reference range of 1.3 to 2.1 mEq/L. |
| hypernatremia | Sodium level above expected reference range of 136 to 145 mEq/L. |
| hyperparathyroidism | Overactive parathyroid gland. |
| hypertonic | A solution that has more solutes than are present within the cell and results in fluid movement out of the cell. |
| hyperventilation | An increase in the rate and depth of breathing that leads to excessive loss of carbon dioxide from the blood. |
| hypervolemia | Fluid overload, the body has too much water. |
| hypocalcemia | Calcium level below expected reference range of 9 to 10.5 mg/dL (total calcium). |
| hypoglycemia | A blood glucose level below the expected reference range. |
| hypokalemia | Potassium level below expected reference range of 3.5 to 5 mEq/L. |
| hypomagnesemia | Magnesium level below expected reference range of 1.3 to 2.1 mEq/L. |
| hyponatremia | Sodium level below expected reference range of 136 to 145 mEq/L. |
| hypoparathyroidism | Body produces low levels of parathyroid hormone (PTH). |
| hypotension | A blood pressure that is below the expected reference range. |
| hypotonic | A solution that has fewer solutes than cell components and results in fluid moving into the cell. |
| hypovolemia | Decrease in blood volume due to body fluid or blood loss. |
| hypovolemic shock | When the body loses 20% or one-fifth of its blood or fluid supply |
| infiltration | The inadvertent administration of fluid into the tissue surrounding an IV site due to displacement of the intravenous catheter tip. |
| infusate | The solution being infused through an intravenous access device. |
| intake | Amount taken in by the client, including oral, intravenous, and enteral routes, in addition to irrigation. |
| interstitial space | The space outside the cells; a component of the extracellular space. |
| intracellular space | The space within a cell. |
| intravascular | The space within the vascular system including within the chambers of the heart, the arteries, and veins. |
| intravenous (IV) | Within the vein. |
| ionized calcium level | Circulating calcium within the blood that is not attached to proteins. |
| isotonic | A solution that has the same number of solutes than cell components and results in no fluid movement into or out of the cell |
| kidney failure | The inability of the kidneys to function properly and remove waste from the body. |
| kidneys | Organs that filter the blood and excrete waste as urine |
| leukocytes | Also known as white blood cells; a component of the blood that make up the immune system. |
| magnesium | Electrolyte that helps with regulation of nerve and muscle function, blood pressure, and blood glucose levels, and making DNA, protein, and bone. |
| metabolic acidosis | When the blood in the body is too acidic, with an HCO3- less than 22 and a pH less than 7.35. |
| metabolic alkalosi | Blood in the body is too alkaline, with an HCO3- greater than 26 and a pH greater than 7.45. |
| osmolality | A measurement of the solutes within a solution. |
| osmosis | The movement of water across a semipermeable membrane from an area of higher concentration to one of lower concentration, such as fluid moving into or out of a cell, in an effort to maintain homeostasis. |
| osteopenia | Low bone mass. |
| output | The amount produced and eliminated by the client's body, including urine, vomitus, drainage, and liquid stools. |
| paralysis | Loss of muscle function. |
| paralytic ileus | A cessation of intestinal motility. |
| parathyroid hormone (PTH) | Hormone secreted by the parathyroid gland that regulates serum calcium concentration. |
| peripheral intravenous catheters | Single-lumen plastic cannulas inserted into a peripheral vein, also known as peripheral venous access device or peripheral IV. |
| peripherally inserted central catheters (PICCs) | Device inserted peripherally through a vein in the arm with the tip centrally located to administer fluids, blood, medications, and other therapies. |
| phlebitis | Inflammation of the inner lining of the vein, the tunica intima, caused by mechanical, chemical, or bacterial factors. |
| plasma | Straw-colored liquid portion of blood containing water, proteins, salts, and antibodies. |
| potassium | Electrolyte for nerve and muscle function, especially for the heart. |
| potassium-sparing diuretic | A medication that promotes the excretion of urine while retaining potassium. |
| red blood cells (RBCs) | Also known as erythrocyte; a component of the blood that contains hemoglobin that is responsible for oxygen and carbon dioxide transport throughout the body. |
| rehydration | Process of restoring lost water back into the body tissues and fluids either orally or through the administration of intravenous fluids. |
| resin | Medication taken to decrease potassium levels via bowel movements. |
| respiratory acidosis | A buildup of carbon dioxide in the lungs and the body fluids, which results in a PaCO2 greater than 45 and a pH less than 7.35. |
| respiratory alkalosis | Low carbon dioxide levels in the body, with a PaCO2 less than 35 and a pH greater than 7.45. |
| Rh factor | Protein of the blood type represented as (+) if present and (-) if absent. |
| rhabdomyolysis | Muscle breakdown resulting in the release of the protein myoglobin into the bloodstream, which can cause damage to the kidneys. Characterized by red-colored urine, low urine output, weakness, and muscle pain. |
| scope of practice | Sets forth the services or activities that licensed professionals are deemed competent and permitted to perform. |
| sodium | Electrolyte that supports the function of nerves and muscles, maintains normal blood pressure, and regulates fluid balance in the body. |
| tachycardia | Heart rate above the expected reference range. |
| tachypnea | Respiratory rate greater than expected range. |
| third spacing | Movement of fluid from the intravascular space (within the veins) to the interstitial space. |
| thirst response | Mechanism used to promote water consumption. |
| thrombocytes | Also known as platelets; responsible for blood clotting. |
| tonicity | A solution's ability to make water move in our out of cells; includes isotonic, hypotonic, and hypertonic solutions. |
| Trousseau sign | Test that can indicate low calcium or magnesium levels and spasms in the wrist and hand (carpopedal spasms) when a blood pressure cuff is inflated above the systolic blood pressure. |
| urine specific gravity | A test that measures the solutes in a sample of urine and provides information regarding the body's fluid balance. The expected reference range of urine specific gravity is 1.005 to 1.030. |
| vasopressin | A hormone excreted by the hypothalamus in the brain that maintains blood pressure and fluid volume. Also knows as antidiuretic hormone (ADH). |
| vesicants | An intravenous fluid that is damaging to the surrounding tissue outside the vein. |
| white blood cells (WBCs) | Also known as leukocytes; a component of the blood that makes up the immune system. |
| whole blood | Combination of red cells, white cells, and platelets in blood plasma. |
| Common electrolytes include | potassium, sodium, calcium, and magnesium |
| the basic metabolic panel (BMP) or the complete metabolic panel (CMP)—laboratory blood tests that determine whether | electrolyte levels are outside the expected reference range |
| basic metabolic panel (BMP) | Blood Urea Nitrogen (BUN) Carbon Dioxide (CO2) Creatinine (CR) Glucose Chloride Potassium Sodium Calcium |
| complete metabolic panel (CMP) | BUN (Blood Urea Nitrogen) CO2 CR Glucose CI K Na Ca Liver Enzymes - Alkaline Phosphate (ALP) - Alanine transaminase (ALT) - Aspartate aminotransferase (AST) Bilirubin Protein Albumin |
| BMP and CMP lab has BUN and Indication | Kidney Function |
| BMP and CMP lab has Carbon Dioxide (CO2) and Indication | Blood Bicarbonate level |
| BMP and CMP lab has Creatinine (CR) and Indication | Kidney Function |
| BMP and CMP lab has Glucose and Indication | Blood Glucose level |
| BMP and CMP lab has Chloride and Indication | Blood chloride level |
| BMP and CMP lab has Potassium and Indication | Blood potassium level |
| BMP and CMP lab has Sodium and Indication | Blood sodium level |
| BMP and CMP lab has calcium and Indication | Liver function |
| CMP Lab Liver enzymes | Alkaline phosphate (ALP) Alanine transaminase (ALT) Aspartate aminotransferase (AST) |
| CMP Lab liver enzymes indication | Liver function |
| CMP lab Bilirubin (total) indication | Liver function |
| CMP lab Protein (total) Indication | Total Blood protein |
| CMP lab Albumin indication | liver function |
| Electrolytes are responsible for the following functions within the body | Maintaining the balance of water in the body Balancing the blood pH (acid–base) level Moving nutrients into the cells Moving wastes out of the cells Maintaining proper function of the body’s muscles, heart, nerves, and brain) |
| It is critical to maintain the balance of water in the body to prevent | hypovolemia, dehydration, tachycardia, tachypnea, confusion, headache, kidney stones, and numerous other medical complications. |
| Water loss from the body primarily occurs through the | excretion of urine by the kidneys. Situations such as prolonged vomiting, severe diarrhea, and profuse sweating can greatly increase water loss as well. |
| serum osmolality of the blood | keeping water and electrolytes at a constant level in the blood. This level can be monitored by determining the |
| serum osmolality of the blood—that is, by performing a laboratory test that measures | the concentration of solutes to water. |
| the most frequently used laboratory indicator of the body’s fluid status | Serum osmolality |
| The expected reference range of serum osmolality is | 285 to 295 mOsm/kg. |
| Osmolality can also be measured using | urine and is used to assess renal function as well as hydration status |
| expected reference range for urine osmolality is | 50 to 1,200 mOsm/kg for a random specimen. |
| The body has three main fluid compartments, | largest the intracellular space, which holds 67% of water. The other two, collectively referred to extracellular space, comprise the interstitial space, contains 25% of the body’s water, and the intravascular space, holds remaining 8% of body water. |
| Water passes easily among the various compartments by the process of | Osmosis |
| homeostatic mechanisms to increase or conserve water. The most obvious mechanism is the | Thirst response |
| When the neurons of the lamina terminalis sense a need to increase the body’s water supply, they send signals that stimulate | thirst |
| As serum osmolality rises, the hypothalamus stimulates the | posterior pituitary |
| As serum osmolality rises, the hypothalamus stimulates the posterior pituitary to release | antidiuretic hormone (ADH), also known as vasopressin |
| As serum osmolality rises, the hypothalamus stimulates the posterior pituitary to release antidiuretic hormone (ADH), also known as vasopressin, which acts on the | nephrons of the kidneys |
| The collecting ducts of the nephrons respond to | ADH by increasing the reabsorption of water, decreasing the excretion of urine, and increasing the fluid volume of the body. |
| The final mechanism used to maintain water balance is | osmosis, which allows the passive flow of water between body compartments to maintain equilibrium |
| the kidneys also help maintain fluid and electrolyte balance by | removing cellular waste and excess fluid through urination |
| kidneys maintain homeostasis by | filtering the blood and eliminating waste products, but also by returning needed water and electrolytes to the circulation. |
| Potassium (K+): | 3.5–5 mEq/L |
| Sodium (Na+): | 136–145 mEq/L |
| Calcium (Ca2+): | 9–10.5 mg/dL |
| Magnesium (Mg2+) | 1.3–2.1 mEq/L |
| Serum osmolality: | 285–295 mOsm/kg |
| Urine specific gravity: | 1.005–1.030 |
| Most of the daily fluid loss from the water occurs from | sweat and from the urinary and gastrointestinal systems, such as urine and liquid stool |
| sensible fluid loss | sweat and from the urinary and gastrointestinal systems, such as urine and liquid stool |
| Insensible fluid loss is | hard to measure because it occurs from the respiratory system, skin, and water in formed stool. |
| Several factors can contribute to fluid and electrolyte imbalances, including | dehydration; hypovolemia; overhydration; certain medications; heart, kidney, or liver disorders; and incorrect intravenous fluids or feedings. |
| electrolytes and other solutes in a solution, such as blood, move across those membranes via | diffusion and active transport |
| Diffusion is a | passive process, meaning it does not require the use of energy. |
| An example of electrolyte movement via active transport is | the movement of sodium and potassium into and out of the cells through the sodium–potassium pump. |
| Potassium is the body’s largest intracellular electrolyte. Its function is to | support the transmission of electrical impulses of the body’s nerves and muscles. Potassium also plays a major role in the conduction of nerve cells within the heart |
| the primary excretion of potassium | The kidneys are responsible for the primary excretion of potassium, while a small amount is lost through sweat and the digestive tract. |
| The most common cause of hypokalemia is | loss of potassium from the kidneys or gastrointestinal tract. |
| Potassium-wasting diuretics | (loop, thiazide, and osmotic) |
| (loop, thiazide, and osmotic) | medications that most commonly result in hypokalemia through urinary loss |
| Other medications that can lead to decreased potassium levels include | amphotericin B, high doses of penicillin, and theophylline |
| Decreased potassium from gastrointestinal losses may result from | prolonged diarrhea and vomiting, as well as from chronic laxative use, bowel diversion, or gastric suctioning. |
| Common manifestations that can be seen with hypokalemia of less than 3 mEq/L include | muscle weakness, cardiac arrhythmias, constipation, and fatigue |
| severe life-threatening hypokalemia, defined as a potassium level less than 2.5 mEq/L | respiratory paralysis and failure can occur. Other manifestations of severe hypokalemia may include paralytic ileus (obstruction in the intestine), hypotension, tetany, rhabdomyolysis (muscle tissue breakdown), and life-threatening cardiac arrhythmias. |
| Repeated episodes of hypokalemia can affect | renal function |
| Treatment of hypokalemia starts with identifying | the underlying cause |
| mild hypokalemia (3 to 3.5 mEq/L) may or may not exhibit any signs of the condition. Manifestations can include | muscle weakness, constipation, cardiac arrhythmias, and fatigue |
| Manifestations of severe hypokalemia (less than 2.5 mEq/L) can include | respiratory paralysis or failure, paralytic ileus, hypotension, rhabdomyolysis, tetany, and life-threatening cardia arrhythmias. |
| A nurse is caring for a client who is admitted to the medical unit for hypokalemia. Which of the following conditions can cause hypokalemia? | - Medications - Diabetes Ketoacidosis - Chronic Kidney Disease - Folic Acid deficiency |
| Potassium is considered a high-alert medication when given | intravenously |
| Foods High in Potassium | Backed potato- Highest Veg (900mg) Prune Juice - Highest juice (689mg) - Plain, Nonfat yogurt- highest dairy product (625mg) - Salmon- highest fish (400mg) - Banana - Highest fruit (451mg) |
| The most common cause of hyperkalemia is | renal failure |
| the medications most commonly associated with hyperkalemia | Potassium-sparing diuretics, nonsteroidal anti-inflammatory drugs (NSAIDs), and angiotensin-converting enzyme (ACE) inhibitors |
| Mild hyperkalemia is usually asymptomatic. However, high potassium levels may cause | life-threatening cardiac dysrhythmias, muscle weakness, or paralysis |
| With severe life-threatening hyperkalemia, defined as a potassium level greater than 7 mEq/L | paralysis and heart failure are possible; if severe hyperkalemia is untreated, death can occur. |
| Treatment for Hyperkalemia | identifying and treating the cause, with the goal of removing excess potassium and stabilizing the heart |
| treatment options for hyperkalemia include | hemodialysis, medications such as calcium gluconate and diuretics. |
| Calcium gluconate or calcium chloride can be used to | reduce the effects of elevated potassium levels on the heart |
| Loop and thiazide diuretics cause the body to | excrete excess potassium through urination |
| resin medication | sodium polystyrene sulfonate, to help decrease potassium levels. |
| Resins bind to | potassium in the body and are then excreted through the stool |
| Other treatments of hyperkalemia include the administration of | insulin, which causes potassium to enter cells, lowering the serum potassium level |
| Salt substitutes are commonly used by clients who have to limit their sodium intake. However, these substitutes can contain | potassium chloride, which increases a client’s potassium level. Clients should monitor their use of salt substitutes, as many contain potassium. |
| the body’s most common extracellular electrolyte | sodium |
| Sodium supports proper | neurological and neuromuscular function, regulates the body’s fluid balance, and helps maintain blood pressure |
| Hyponatremia occurs when sodium levels fall below | 136 mEq/L. Critical values occur at less than 120 mEq/L |
| the most common cause of hyponatremia | Excess water in the body, rather than a lack of sodium, is the most common cause of hyponatremia because too much water dilutes sodium levels |
| the medications that most commonly result in hyponatremia | thiazide diuretics as they cause loss of sodium through urinary loss. Gastrointestinal losses can occur with prolonged diarrhea or vomiting |
| Diseases that lead to increased fluid retention in the body, which dilutes sodium | heart failure and cirrhosis |
| mild hyponatremia | Manifestations such as nausea and a feeling of general unwellness |
| hyponatremia The neurological manifestations are related to | fluid shifts in the brain, which lead to cerebral edema |
| Moderate hyponatremia often manifests first with | lethargy and confusion. Other neurological changes may include headache, restlessness, and irritability |
| hyponatremia becomes more severe | muscle twitching, further decreases in level of consciousness, seizures, and coma can occur. If hyponatremia is not reversed, a client can become unrousable, and death can occur |
| Treatment of hyponatremia begins with | identifying the underlying cause and determining the level of sodium deficiency |
| It is important to raise sodium levels slowly to prevent further | neurological complications |
| If the cause of the low sodium level is related to excessive water intake or an alteration in fluid balance, treatment may include | fluid restriction to correct the dilutional effect of too much body water |
| Along with the manifestations of hyponatremia, the nurse should educate the client on the following measures | Drink water in moderation. Check urine for a pale, yellow color to indicate adequate hydration. sports drinks with electrolytes when participating in demanding physical activities. Use thirst as an indicator of whether or not drinking water is necessary |
| Hypernatremia occurs when the sodium level exceeds | 145 mEq/L. Critical values occur at levels greater than 160 mEq/L |
| Hypernatremia is most commonly seen when | the body water loss is greater than the solute loss |
| most common cause of hypernatremia | Loss of body water |
| Dehydration occurs most often in infants and older adults due to | their inability to communicate the thirst response or diminished thirst response (in older adults). |
| High sodium levels result in manifestations like those seen in hyponatremia: | confusion, lethargy, and irritability |
| hypernatremia becomes more severe, | muscle twitching and further changes in level of consciousness with seizures and coma can occur. If not corrected, hypernatremia will eventually lead to death. |
| Hypernatremia is diagnosed by | evaluation of a BMP or CMP. A plasma osmolality test can also be performed, which will indicate elevated blood viscosity above the expected reference level of 295 mOsm/kg. |
| Treatment for hypernatremia includes | identifying the cause and initiating intravenous fluid replacement containing water and a small amount of sodium. When treating hypernatremia, it is important to reduce sodium levels slowly to prevent cerebral edema. |
| Foods High in sodium | Highest- Roasted ham (1117mg) Veg juice- low sodium (140mg) |
| the most abundant mineral in the body | Calcium |
| Calcium plays a role in the following activities: | bone mineralization, muscle contraction, nerve transmission, blood clotting, hormone secretion, and normal functioning of the heart |
| Absorption of calcium by the intestines depends on | an adequate supply of vitamin D |
| Excretion of calcium occurs through | the kidneys and is controlled by the action of parathyroid hormone. |
| The expected reference range for serum calcium for adults is | 9 to 10.5 mg/dL |
| calcium in the body is bound to protein, so a more accurate analysis is obtained by assessing | ionized calcium levels |
| The expected reference range for ionized calcium for an adult is | 4.5 to 5.6 mg/dL |
| Hypocalcemia occurs when serum calcium levels are below | 9 mg/dL and ionized levels are less than 4.5 mg/dL |
| Hypocalcemia Critical values occur at less than | 6 mg/dL and less than 2.2 mg/dL, respectively. |
| A client’s ionized calcium level is generally estimated to be | about 50% of their total calcium. |
| Medications that can lead to hypocalcemia include | stimulant laxatives- decrease the absorption of calcium -long-term use of glucocorticoids- deplete calcium stores by increasing a client’s risk of developing osteoporosis -loop diuretics, which can lead to excess calcium excretion by the kidneys. |
| Medications used to decrease the body’s gastric acid—for example, proton-pump inhibitors and histamine-2 blockers—can also lead to hypocalcemia by | decreasing the breakdown of fat, a factor that is important for calcium absorption. |
| Another potential cause of hypocalcemia is a lack of circulating | parathyroid hormone (PTH). |
| Hypocalcemia can lead to | osteopenia, also known as low bone mass, and increase the risk of bone fractures and osteoporosis |
| The function of PTH is to | maintain the proper amount of calcium in the body. |
| Hypocalcemia affects multiple body systems, including the | respiratory, cardiac, neurological, sensory, neuromuscular, and integumentary systems. |
| Hypocalcemia affects multiple body systems. Acute cases can be associated with | cardiovascular manifestations such as chest pain, dysrhythmias, heart failure, and syncope |
| Hypocalcemia Neuromuscular manifestations may be more noticeable to the client and include | noticeable to the client and include numbness and tingling of the fingers and toes, and around the mouth; muscle cramping; and spasms, particularly in the back and lower extremities. |
| Hypocalcemia Neurological manifestations may include | confusion, depression, psychosis, dementia, lethargy, seizures, and personality changes. |
| Hypocalcemia Respiratory changes may include | wheezing, laryngeal and airway spasms, dysphagia, and voice changes |
| Hypocalcemia Integumentary changes include | coarseness of the hair, hair loss (alopecia), brittle nails, dry skin, and itching. Other manifestations can include development of vision difficulties and dental problems. |
| Two distinct findings can be elicited if hypocalcemia is suspected: | the Chvostek sign and the Trousseau sign |
| Chvostek sign | use the fingertips to tap the facial nerve, which is located 2 cm in front of the tragus of the ear. A twitching of the facial muscles on the same side being tapped is a positive Chvostek sign |
| Trousseau sign | BP cuff on arm and inflate it 20 mm Hg above systolic BP for 3 to 5 min, cause irritability of the nerves in the arm. A positive result occurs with flexion of the wrist, thumb, and first joints of the fingers, combined with hyperextension of the fingers. |
| Two distinct findings can be elicited if hypocalcemia is suspected what is considered a more specific indicator of hypocalcemia | The Trousseau sign |
| Hypocalcemia may resolve on its own, or treatment may be required. Treatment options, depending on the severity of the hypocalcemia, may include | e calcium and vitamin D supplements, dietary changes, or calcium injections. |
| Foods high in calcium | almond milk (highest milk)- 349mg |
| Hypercalcemia occurs at a serum calcium level greater than | 10.5 mg/dL and an ionized calcium level greater than 5.6 mg/dL. |
| Hypercalcemia Critical values are greater than | 13 mg/dL and 7 mg/dL, respectively |
| Elevated serum calcium levels can lead to development of | kidney stones, weaken bones, and affect the function of the heart and brain. |
| Hypercalcemia is most commonly caused by | hyperparathyroidism and cancer |
| hyperparathyroidism and cancer Both of these conditions result in excessive | excessive calcium being drawn from the bones and into the bloodstream |
| In hyperparathyroidism, the parathyroid glands secrete | excessive amounts of the PTH. Elevated PTH levels in the body then lead to increased calcium absorption in the intestines, increased renal reabsorption, and increased bone resorption—a process that ultimately results in excessive blood calcium levels. |
| As cancer progresses and invades the bones, bone | resorption occurs As a result of this process, cancer tumors release a hormone similar to PTH, leading to increased blood calcium levels |
| Hypercalcemia can be caused by medications, such as | thiazide diuretics and lithium carbonate, and supplements, such as calcium and vitamins D and A. |
| prolonged bed rest can result in | serum calcium levels. This condition occurs over a period of days or weeks but is quickly reversed when the client resumes weight-bearing activities and becomes more active overall. |
| Mild hypercalcemia rarely produces symptoms. Gastrointestinal manifestations such as | constipation and abdominal pain, nausea and vomiting, and anorexia are usually the first indications that a client will notice |
| As calcium levels increase | confusion and behavioral changes can occur, along with thirst, polyuria, bone pain, and muscle weakness |
| If hypercalcemia reaches critical levels, | arrhythmias, delirium, coma, and renal failure can occur. If left untreated, hypercalcemia is potentially life-threatening |
| Abdominal Groans, painful Bones, kidney Stones, psychiatric Moans, and fatigue Overtones Abdominal groans refer to | gastrointestinal manifestations such as constipation, nausea, and vomiting. |
| Abdominal Groans, painful Bones, kidney Stones, psychiatric Moans, and fatigue Overtones Painful bones refer to | the aching pain that occurs in cases of hypercalcemia caused by hyperparathyroidism. |
| Abdominal Groans, painful Bones, kidney Stones, psychiatric Moans, and fatigue Overtones Kidney stones refer to | the development of calcium renal stones that can cause intense flank pain. |
| Abdominal Groans, painful Bones, kidney Stones, psychiatric Moans, and fatigue Overtones Psychiatric moans refer to | confusion and behavioral changes such as delirium and psychosis that can occur. |
| Abdominal Groans, painful Bones, kidney Stones, psychiatric Moans, and fatigue Overtones Fatigue overtones refer to | the lethargy and general feelings of malaise that occur with hypercalcemia. |
| mild hypercalcemia who has manifestations | phosphate by mouth is prescribed to decrease calcium levels by blocking absorption. To promote excretion of calcium, an intravenous saline bolus, followed by a loop diuretic, may be prescribed |
| moderate hypercalcemia includes | administering medications to prevent calcium from leaving the bones or to decrease calcium absorption in the intestine |
| severe hypercalcemia and severe symptoms | hemodialysis to remove excess calcium from the blood is the treatment of choice. |
| body’s second most common intracellular electrolyte | magnesium |
| Magnesium’s role in the body is to | assist in regulating nerve and muscle function, maintain blood pressure and serum glucose levels, support bone and tooth health, and synthesize proteins, DNA, and RNA |
| Magnesium is excreted through the | urine and feces. |
| Magnesium has an expected reference range of | 1.3 to 2.1 mEq/L. |
| Hypomagnesemia occurs when magnesium levels fall below | 1.3 mEq/L |
| Hypomagnesemia Critical values occur at less than | 0.5 mEq/L or greater than 3 mEq/L. |
| Medications that can lead to magnesium loss include | loop or thiazide diuretics, certain antibiotics, and proton-pump inhibitors. |
| Clinical signs of hypomagnesemia usually do not occur until levels drop below | 1.2 mg/dL |
| Symptoms of moderate hypomagnesemia can include | nausea, vomiting, decreased appetite, fatigue, and weakness. |
| When magnesium levels drop further, manifestations become | neuromuscular change: muscle cramps and spasticity, numbness and tingling, seizures, tetany (Chvostek and Trousseau signs), and personality changes. Cardiac dysrhythmias and spasms |
| what may also be present if magnesium levels are severely low | Hypokalemia and hypocalcemia |
| Foods high in magnesium | Cooked spinage (156mg) Dark Chocolate (192-253 mg) Pumpkin seeds (156mg) |
| Intravenous magnesium is a | high-alert medication |
| IV administration of magnesium can cause | flushing, sweating, and potentially respiratory depression if the medication is administered too quickly |
| Hypermagnesemia is a magnesium level above the expected reference range of | 1.3 to 2.1 mEq/L |
| Although hypomagnesemia is relatively common, excess | magnesium in the blood is rare |
| The most common cause of hypermagnesemia is | acute or chronic kidney disease, as the impaired kidneys fail to excrete enough magnesium through the urine |
| Although hypermagnesemia is unlikely to result from dietary intake, underlying | bowel conditions can reduce gastrointestinal motility, leading to increased magnesium absorption. |
| may also cause hypermagnesemia | Laxatives and antacids containing magnesium may also cause hypermagnesemia if intake is excessive, as can use of psychotropic medications containing lithium. |
| When magnesium levels exceed 7 mg/dL, moderate neurological manifestations may occur, such as | increasing confusion, sleepiness, blurred vision, and headache. Decreasing reflexes, bladder paralysis, flushing, and constipation may also be present. |
| Hypermagnesemia levels greater than 12 mg/dL cause severe reactions such as | muscle flaccid paralysis, decreased respiratory rate, hypotension, bradycardia, and dysrhythmias. If the imbalance is not corrected, seizures, coma, cardiac arrest, and death can occur. |
| High magnesium levels (10 mEq/L or greater) cause muscle weakness and the loss of deep tendon reflexes, which together result in an absent | patellar reflex. |
| mild hypermagnesemia, treatment may focus on | eliminating intake of magnesium through sources such as magnesium supplements, laxatives, or antacids. |
| Magnesium has a long | half- life |
| Magnesium has a long half-life, so decreasing serum levels will take more than | 24 hr |
| severe case of hypermagnesemia, the provider may prescribe | intravenous calcium gluconate or calcium chloride to suppress manifestations. The provider may also prescribe intravenous diuretics to promote urination to rid the body of the extra magnesium. |
| kidney function is impaired or hypermagnesemia is severe | hemodialysis may be required to remove excess magnesium from the body). |
| Three distinct imbalances can threaten homeostasis: | dehydration, hypovolemia, and hypervolemia |
| Dehydration occurs when there is a | loss of water or lack of water intake without a concomitant loss of sodium. |
| water is depleted, the electrolyte–water balance is altered, and | hypernatremia and increased osmolality occur. Body water then shifts from inside the cell to the extracellular space, which can result in cellular shrinkage |
| Dehydration can occur from the following causes. | Diarrhea Vomiting Excessive perspiration Excessive urination, due to medications Illnesses, such as diabetic ketoacidosis Fever Insufficient intake of water or other fluids |
| Manifestations of moderate dehydration include | altered cognitive and neuromuscular function related to hypernatremia. Thirst, lethargy, dry mucosa, and oliguria can occur. |
| if water is not replaced, dehydration can become severe, with | tachycardia, hypotension, and lactic acidosis increasing the risk of shock. Coma and death due to organ hypoperfusion can occur if the dehydration is not reversed. |
| Laboratory tests to identify dehydration include a | BMP or CMP, which will confirm the presence of hypernatremia. Serum osmolality will also be elevated. Urine will be concentrated with an increased urine specific gravity level. |
| The treatment of dehydration focuses on | restoring the body's water balance while also addressing the cause of water loss |
| hypovolemia involves a | loss of both fluid and electrolytes. It can lead to decreased circulating blood volume and perfusion to tissues |
| Hypovolemia is also identified as a | fluid volume deficit. |
| Hypovolemia can occur from the following causes. | Blood loss Gastrointestinal losses Severe burns Third spacing Excessive sweating Fever Medications Trauma |
| Third spacing, in which fluids become sequestered in other body cavities, is an outcome of disorders such as | cirrhosis and pancreatitis. |
| Early manifestations of hypovolemia include | thirst, dryness of mucous membranes, decreased skin turgor, and decreased urine output |
| If hypovolemia fluid loss is not corrected | lethargy, muscle weakness, and orthostatic hypotension will occur |
| hypovolemia becomes more severe | tachycardia occurs as the body attempts to maintain the circulating blood volume and perfuse vital organs |
| If hypovolemia goes untreated | confusion, tachypnea, chest pain with palpitations, oliguria, and increasing hypotension. |
| hypovolemic shock | If the volume lost from circulation exceeds 20% of the total volume |
| hypovolemic shock not reversed | lack of perfusion to the vital organs can lead to multiple organ failure, in which the lungs, kidneys, brain, and heart experience tissue death. |
| Diagnostic tests for hypovolemia include | BMP or CMP, which can be used to identify electrolyte imbalances and increased BUN and CR levels. A BUN/CR ratio of greater than 20:1 indicates a lack of blood flow to kidneys. |
| the hypovolemia is due to bleeding, the | hematocrit and hemoglobin levels will be decreased. The urine will be highly concentrated with little sodium present, as the kidneys attempt to reabsorb sodium and water. The urine specific gravity will be elevated |
| Treatment for hypovolemia depends on the cause and aims to | control fluid or blood loss, replace lost components, and restore circulation |
| Hypervolemia is a fluid condition in which | the body has too much water and sodium in the extracellular space, particularly the interstitial compartment. |
| Hypervolemia can result from the following factors | Heart failure Kidney failure Nephrotic syndrome Cirrhosis or end-stage liver disease |
| Although no specific tests are used to diagnose hypervolemia, the provider will perform a | physical exam, weight and checking for edema. A BMP or CMP may be collected to evaluate sodium levels. A urine sodium test may be completed to determine if the kidneys are responsible for the fluid and sodium buildup |
| The goal of treatment for clients with hypervolemia is to | manage the underlying cause while removing excess fluid from the body. |
| commonly used to increase urine output and reduce the body’s fluid volume | Diuretics |
| Actual fluid removal may be required through dialysis for clients with | kidney failure or paracentesis for clients with cirrhosis |
| Older adult clients are at higher risk for dehydration for several reasons | Diminished thirst response Decline in total body fluid Decreased kidney function Underlying health conditions Medications |
| the nurse should avoid the use of tourniquets in clients with the following conditions | High risk for bleeding Compromised circulation Fragile skin |
| The tourniquet should be applied | 5 to 10 cm above the selected site |
| confirm that the tourniquet is not applied too tightly | assess the client’s pulse distal to the tourniquet |
| What are the three types of crystalloid solutions? | Hpotonic (fluid moves into cells), Isotonic (no movement of fluid), and Hypertonic (fluid leaves cells); each is used for different clinical needs. |
| What are potential complications of IV therapy? | Possible complications include infection, fluid overload, allergic reactions, and blood clotting disorders. |
| How can nurses reduce infection risk with IV therapy? | Nurses should use aseptic technique, keep IV sites clean, and change tubing and dressings according to facility policy and standards. |
| What technique should nurse use when handling IV solution containers and tubing? | Aseptic technique keeps IV sites clean and helps prevent infection when manipulating IV supplies. |
| How often should IV tubing and dressings be changed? | Facility policies and standards help ensure safe timing and methods for changing tubing and dressings. |
| Which actions help prevent infection at IV sites? | Using aseptic technique, keeping IV sites clean, and changing tubing and dressings per facility policy are all important infection prevention steps. |
| What is one consequence of neglecting IV site cleaning and maintenance? | Keeping IV sites clean and maintained helps prevent infections and complications. |
| Solutions used to treat fluid imbalances include | crystalloid solutions and colloidal solutions |
| Crystalloids are | fluids that contain solutes such as electrolytes or dextrose |
| crystalloid solutions are classified according to their osmolality | hypotonic, isotonic, or hypertonic |
| Crystalloid solutions are further categorized by their | tonicity, or the ability to make water move in or out of cells via osmosis. |
| Three types of crystalloid solutions for fluid replacement are commonly used: | hypotonic, hypertonic, and isotonic. |
| Crystalloid Intravenous Solutions: Hypotonic (less than 250 mOsm/L) Movement: | Extracellular fluid has fewer solutes than fluid in cells. Water moves from extracellular space into cells. |
| Crystalloid Intravenous Solutions: Hypotonic (less than 250 mOsm/L) Solution facts: | Treats hypernatremia and diabetic ketoacidosis. Monitor for hypotension. Contraindicated in clients with burns, liver disease, increased intracranial pressure, and trauma. |
| Crystalloid Intravenous Solutions: Hypertonic (greater than 375 mOsm/L) Movement: | Extracellular fluid has more solutes than within the cells. Water leaves the cells and interstitial fluid moves into the plasma. |
| Crystalloid Intravenous Solutions: Hypertonic (greater than 375 mOsm/L) Solution facts: | - volume expander in emergent-solutes, cerebral edema, & symptomatic hyponatremia. -Maintenance IV fluid & to treat hypovolemia. -electrolytes (sodium, chloride), water, & calories. - calories, electrolytes, & water(metabolic acidosis) -hypoglycemia. |
| Hypertonic solutions may be contraindicated in cases of | cardiac or renal disease. |
| Crystalloid Intravenous Solutions: Isotonic (250 to 375 mOsm/L) : Movment: | No movement of water between extracellular and intracellular fluids, as osmolarity is the same. Causes expansion of the extracellular fluid |
| Crystalloid Intravenous Solutions: Isotonic (250 to 375 mOsm/L): Solution facts: | One of the most commonly used IV fluids. Commonly used for burn and trauma clients. Used for hypovolemia, acute blood loss, electrolyte imbalances, and metabolic acidosis Administered for hypernatremia |
| Colloidal solutions, often referred to as | plasma or volume expanders, contain large molecules that are too large to pass through the semipermeable membrane that forms the capillary walls. As a result, they remain within the circulating volume. |
| Colloidal solutions, | increase osmotic pressure with the plasma. This increase in osmotic pressure draws fluid into the intravascular space (recall that fluid moves from an area of lower concentration to one of greater concentration), thereby increasing blood volume |
| Colloidal solutions can be | synthetic (human-made) or natural. |
| Albumin is a naturally occurring | colloid that is considered a blood product |
| Adverse effects associated with the administration of colloidal solutions include | allergic reactions, renal failure, and blood-clotting disorders |
| During transfusion of colloids, the nurse should carefully monitor for manifestations of | hypervolemia, such as hypertension, jugular venous distention, edema, dyspnea, and adventitious breath sounds. |
| The flow rate—that is, the rate at which IV fluids are infused—is based on the | clinical presentation and need for replacement fluids |
| To administer IV fluids, nurses need to calculate the | flow rate, infusion time, and total volume based on the provider’s prescription |
| IV fluids can be administered using a | volume-control pump, which regulates the rate of administration of the IV solution. IV fluids can also be administered by gravity, which requires the nurse to regulate the flow rate manually. |
| Other responsibilities of the nurse when caring for a client receiving IV therapy relate to the | exchange of bags of solutions and the tubing that connects the bag of IV fluid to the client |
| primary tubing | main tubing set that delivers IV solutions to the client |
| secondary tubing | which is used to administer medications and attaches to the primary set using a needleless adapter. |
| Specialized tubing is also available for administering | specific fluids such as blood, lipids, nitroglycerin, and total parenteral nutrition |
| Tubing that is designed for gravity flow requires | the nurse to be knowledgeable about calculating a dose and setting the flow rate |
| Central venous access devices (CVADs) are | intravenous lines that are inserted into large veins (internal jugular, subclavian, femoral, brachiocephalic). |
| What risk increases the longer a CVAD is in place? | The risk of central line-associated bloodstream infections (CLABSI) increases. |
| How often should CVAD dressings with chlorhexidine gluconate be changed? | They should be changed at least every 7 days, depending on facility policy, and whenever the dressing becomes soiled or is not intact. |
| What should be used to cleanse the injection port each time a CVAD is accessed? | An alcohol-based chlorhexidine gluconate (CHG) solution should be used every time the port is accessed. |
| What is an alternative to scrubbing the hub for CVAD infection prevention? | Passive disinfection devices, like sterile caps with 70% isopropyl alcohol or CHG, can be placed on the CVAD hub and replaced when accessed. |
| Why is it important to change the dressing and hub cap regularly on a CVAD? | Changing them reduces the risk of infection, especially CLABSI. |
| When should a dressing NOT be changed with chlorhexidine gluconate? | If chlorhexidine gluconate is contraindicated for the client. |
| Nurses should follow facility policy regarding how often tubing should be changed. Standards established by the Infusion Nurses Society (INS) state that tubing sets should be changed every | 96 hr for continuous infusions, or according to facility policy, and every 24 hr for intermittent infusions. However, the IV tubing set should be changed immediately if contamination is suspected or the integrity of the closed system has been disrupted |
| INS standards indicate that the tubing for lipids should be changed every | every 12 hr and with each new container |
| Blood administration sets should be changed | after every unit or every 4 hr according to INS standards |
| Complications of improperly stabilized sites can include | movement of the cannula inside the vein, phlebitis, loss of access, or infection due to micro-organisms entering the vessel. |
| The components of blood include | red blood cells, white blood cells, plasma, and platelets |
| Whole blood has a shelf life of | 21 to 35 days and is rarely used outside of severe traumatic injury |
| Through centrifugation, the volume of whole blood is divided into | two components: cells and a liquid called plasma. |
| The cellular portion of blood contains | red cells, white cells, and platelets and accounts for approximately 45% of the blood volume |
| Red blood cells (RBCs), or erythrocytes, account for | 41% of the cellular portion of whole blood. |
| RBCs are made in the | red bone marrow, in a process stimulated by the hormone erythropoietin, which is produced in the kidneys. |
| RBCs have a lifespan of approximately | 120 days. |
| Complete Blood Count Components and Expected Values: Red blood cell count | Male: 4.7 to 6.1 RBC × 1012/L Female: 4.2 to 5.4 RBC × 1012/L |
| Complete Blood Count Components and Expected Values: Hemoglobin | Male:14 to 18 g/dL Female: 12 to 16 g/dL |
| Complete Blood Count Components and Expected Values: Hematocrit | Male:42% to 52% Female: 37% to 47% |
| Complete Blood Count Components and Expected Values: White blood cells count | Male: 5,000 to 10,000/mm3 Female: 5,000 to 10,000/mm3 |
| Complete Blood Count Components and Expected Values: Platelet Count | Male: 150,000 to 400,000/mm3 Female: 150,000 to 400,000/mm3 |
| Indications for the transfusion of RBCs include | surgery, anemia, trauma, blood loss, cancer, and blood disorders such as sickle cell disease |
| Plasma contains several types of proteins, with albumin being the | largest molecule |
| Plasma transfusions are most often given to clients who have | experienced trauma, who have a major burn, or who are in shock. |
| he derivatives of plasma, which are obtained through a process known as fractionation, include | lbumin, factor VIII concentrate, factor IX concentrate, and immune globulins. Cryoprecipitate (Cryo) is also derived from plasma. |
| autologous donation include a | scheduled, elective surgery that has an increased risk for a large blood loss, such as a total hip arthroplasty, and anticipation of a high likelihood for blood transfusion. |
| The four basic blood types are | A, B, AB, and O |
| The Rh factor is a | protein represented by (+) if it is present in the blood, and (–) if it is absent. |
| Adding the Rh factor to the blood type produces eight distinct blood types: | A+, A–, B+, B–, AB+, AB–, O+, O–. |
| Universal donor blood type: | O– |
| Universal recipient blood type: | AB+ |
| Prior to receiving a blood transfusion, a client must be | typed and crossmatched to ensure that the donated blood is compatible. |
| Transfusion reactions can be acute, occurring within 24 hr of the transfusion, often while the blood is being transfused. Manifestations may vary depending on the cause, but include the following. | Fever Chills BP (elevated or decreased) Resp difficulty (wheezing, coughing, dyspnea) Pain (chest, abdomen, low back, or flank) Nausea and/or vomiting Skin manifestations including pruritus, urticaria, flushing, edema (localized), and rash Jaundice |
| The most common acute transfusion reactions include | acute hemolytic reactions, |
| acute hemolytic reactions | when the blood transfused is not compatible with the blood of the client |
| febrile nonhemolytic transfusion reactions; allergic reactions, | which can range from mild to anaphylactic |
| transfusion-related acute lung injury (TRALI) | which results in edema of the lung tissues and airways |
| transfusion-associated circulatory overload (TACO) | which is often the result of too-rapid administration of blood products . |
| Delayed reactions can occur | early as 2 days to as long as several weeks after a transfusion and are the result of an incompatibility between the donor’s and the client’s RBC or T-lymphocyte antigens. |
| two examples of delayed transfusion reactions | Delayed hemolytic transfusion reaction (delayed HTR) and transfusion-associated graft-versus-host disease (TA-GVHD) |
| Acute hemolytic transfusion reactions commonly present with | ever and chills due to an immune-mediated response when incompatible blood is transfused. Pain in the chest, abdomen, low back, or flank is a classic manifestation of acute hemolytic reactions and is related to RBC destruction |
| Hemoglobin released from destroyed RBCs can cause | hematuria, resulting in red or dark-colored urine |
| Acute hemolytic reactions are more often associated with | hypotension, not hypertension, due to systemic inflammatory and circulatory responses. |
| Localized edema is more consistent with | infiltration or mild allergic reactions, not an acute hemolytic transfusion reaction. |
| t bronchospasms, hypotension, tachycardia, urticaria, nausea, vomiting, anxiety, and shock are manifestations that occur during an | anaphylactic reaction while the client is receiving blood |
| Fever is a manifestation that occurs with an | acute hemolytic reaction during a blood transfusion. |
| TACO occurs when a | large volume of blood is transfused too rapidly, leading to fluid overload and respiratory difficulty such as dyspnea |
| Increased intravascular volume causes elevated | venous pressure, which is a hallmark finding of circulatory overload |
| TACO is associated with | increased blood pressure, not hypotension |
| Hypotension is more consistent with acute hemolytic or | anaphylactic reactions |
| Fever and chills are common in febrile nonhemolytic or | acute hemolytic transfusion reactions |
| Red-colored urine indicates | hemolysis and is a manifestation of an acute hemolytic transfusion reaction. |
| Nontunneled CVADs can be inserted | jugular, subclavian, or femoral veins |
| Subcutaneously tunneled cuffed catheters are utilized for | prolonged therapy and can remain in place for several years. They are referred to as “tunneled” because they are placed through the subcutaneous tissue into a tunnel created during the insertion |
| Phlebitis is inflammation of the inner lining of the vein (the tunica intima). It can be caused by | cannula movement, inadequate dressing, speed of fluid infusion, type of medication infused, length of therapy, failure to follow aseptic technique when initiating or managing an intravenous site, or administration of a contaminated solution. |
| Manifestations of phlebitis include | pain at, surrounding, or proximal to the insertion site; swelling; erythema; fever; and the presence of a palpable cord along the vein. |
| Circulatory overload This complication can occur as a result of | failure to monitor the infusion or an inability of the client’s cardiopulmonary or renal systems to manage the fluid bolus. |
| . If not addressed, circulatory overload can result in | pulmonary edema, heart failure, shock, or cardiac arrest |
| Manifestations of circulatory overload include | tachycardia; increases in blood pressure, client weight, and/or central venous pressure; jugular venous distention; edema; cough; tachypnea; crackles in the lungs; decreased oxygen saturation; pallor, or cyanosis. |
| The risk of circulatory overload can be minimized through the following interventions. | in/out & daily weight manifestations of circulatory overload Maintain the IV at the prescribed rate; do not try to “catch up” if IV fluids are delayed. Report any changes in client weight or condition, and if intake is greater than output. |
| If circulatory overload appears to have occurred | notify the client’s provider immediately. Improve respiratory function by positioning the client in semi-Fowler’s or high-Fowler’s position, if possible. Monitor vital signs, daily weight, and intake and output. Administer oxygen therapy |
| client who is experiencing circulatory overload can exhibit the following manifestations: | tachycardia, hypertension, increase weight, cough, jugular vein distention, edema, tachypnea, crackles in the lung, decreased oxygen saturation, pallor, or cyanosis. |
| Infiltration involves a | nonvesicant fluid |
| extravasation occurs with | inadvertent administration of a vesicant fluid into the tissues surrounding the vein |
| A vesicant is a | fluid or medication that is harmful to surrounding tissues and capable of causing tissue damage or necrosis |
| Manifestations of infiltration or extravasation include | coolness of the skin surrounding the IV site; leakage of fluid from the cannulation site; localized edema; pallor and delayed capillary refill; client-reported pain, burning, or discomfort at the site; and changes in the infusion rate. |
| causes of respiratory acidosis including | trauma, spinal cord injury, anesthesia, impaired respiratory function, atelectasis, pneumonia, obstructive pulmonary disorders, and pulmonary embolism |
| Respiratory alkalosis is caused by conditions that result in hyperventilation such as | anxiety, severe stress, pain, pregnancy, infection, sepsis, trauma, or fever. |
| Metabolic acidosis → | The kidneys are not able to rid the body of excess acid → The lungs try to exhale the acid (carbon dioxide) by increasing the respiratory rate and depth |
| Metabolic alkalosis → | The body is holding on to too much bicarbonate → The lungs try to retain acid by slowing the respiratory rate while the kidneys decrease bicarbonate through excretion into the urine. |
| Respiratory acidosis → | The body is retaining too much carbon dioxide, often due to respiratory depression → The kidneys increase the amount of bicarbonate in the body while excreting hydrogen through the urine. |
| Respiratory alkalosis → | Carbon dioxide levels drop due to too much being exhaled, usually due to hyperventilation → The kidneys excrete bicarbonate through the urine while decreasing the amount of new bicarbonate being produced. |
| Metabolic acidosis can be the result of | losses of bicarbonate (a base) caused by diarrhea. body tries to eliminate acids. One way increasing the amount of CO2 expelled through long and deep respirations. |
| instructing the client to breathe into a partial rebreather mask | intervention can help increase the client's carbon dioxide levels by allowing the client to rebreathe some exhaled CO₂, addressing the underlying cause of the respiratory alkalosis due to hyperventilation |
| A 3% sodium chloride solution is hypertonic and is used for | emergent replacement of solutes, such as in clients experiencing manifestations of hyponatremia. This solution can cause fluid shifts and is not the best option for a client experiencing vomiting and diarrhea. |
| A 0.9% sodium chloride solution is isotonic and is used for | hydration needs such as from vomiting, diarrhea, hemorrhage, and shock. This is the most appropriate solution for the provider to prescribe for this client. |
| A 0.45% sodium chloride solution is hypotonic and is used to | treat hypernatremia and diabetic ketoacidosis. This solution is not the best option for a client experiencing vomiting and diarrhea. |
| Dextrose 10% in water is hypertonic and is used to treat | hypoglycemia. This solution is not the best option for a client experiencing vomiting and diarrhea. |
| Instead of using a tourniquet, the nurse should apply a blood pressure cuff set to 30 mm Hg prior to starting an IV for this client who is a high risk for bleeding | This will help protect the client's extremity from bruising and bleeding. |
| Acid- base balance The expected reference ranges are: | pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, and HCO3- 21 to 28 mEq/L. |
| Respiratory alkalosis is indicated by a pH value greater than | 7.45 and PaCO2 value less than 35 mm Hg. |
| Respiratory acidosis is indicated by a pH value less tha | 7.35 and a PaCO2 value greater than 45 mm Hg |
| Metabolic acidosis is indicated by a pH value less than | 7.35 and an HCO3- value less than 21 mEq/L. |
| When a diuretic dose is decreased, the client will experience a | decrease in urination. This should not cause a fluid and electrolyte imbalance. |
| Metabolic alkalosis is indicated by a pH value above the expected reference range of | 7.35 to 7.45, an HCO3- value above the expected reference range of 21 to 28 mEq/L, and a PaCO2 level within the expected reference range of 35 to 45 mm Hg |
| experiencing metabolic acidosis to have a PaCO2 level above the expected reference range of | 35 to 45 mm Hg, such as PaCO2 49 mm Hg. |
| A state of respiratory alkalosis indicates that the client's carbon dioxide level is | currently below the expected reference range. The goal of treatment should be to raise the level of carbon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm Hg. |
| Blood can be administered over a period of | 1 to 4 hr |
| risk for circulatory overload, such as a client who has heart failure, a disorder in which compromised cardiac output results in poor tissue perfusion and fluid overload, the transfusion should be administered slowly | (maximum time of 4 hr) to avoid increasing the workload of the heart. After 4 hr blood becomes unsafe as it is susceptible to bacterial invasion |
| what kind of tubing for blood administration to remove any clots and platelet clumps that might be present in the unit of blood. | tubing with a filter |
| the only IV solution that should be used to prime the tubing for blood administration. | 0.9% sodium chloride |
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