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Adult Health Test 1
Fluid and electrolytes
| Question | Answer |
|---|---|
| Normal sodium range | 135-145 mEq/L |
| Normal potassium range | 3.5-5 mEq/L |
| Calcium Normal range | 9-10.5 mg/dL |
| dehydration | fluid intake that is less than what is needed to meet the body's needs |
| Hypertonic | water loss greater |
| Hypotonic | electrolyte loss greater |
| Nurising diagnoses of dehydration | deficient fluid volume, decreased cardiac output, impaired oral mucosa membrane, potential for dysrhtymia |
| A nurse should ask a pt that is dehydrated what? | If they are on a diuretic, N&V, elderly, cognitive impaired, trauma, extreme exercise |
| S/S decreased reflexes, skin turger, dry skin, mucus membranes dry, urine specific gravity up, fisisure in tongue | dehydration |
| Interventions of dehydration | Oral fluid/IV repalcement, O2 therapy (reduced blood volume), Monitor vitals (BP low, heart rate and breathing high, pursed lips), monitor level of conciousness (decreased), I&O, electrolytes and provide oral care |
| Overhydration | too much water |
| Overhydration-isotonic | expansion of ECF only |
| Overhydration-hypotonic | expansion of ECF and ICF |
| Overhydration-hypertonic | expansion of ECF and contraction of ICF |
| a pt with overhydration can have poor IV control, over diluting baby formula, renal pt, heart failure pt, some drugs make them really thirsty | true |
| Nursing diagnoses of overhydration | Excess fluid volume; potential for electrolyte imbalances, HTN, Pulomanry edema |
| S/S puffy, edema pitting in periferal (ankles) Bounding pulse | Overhydration |
| Intervention of ___: administer diuretics; fluid/sodium restrictions; monitor I&O & urine specific gravity (low); Administer controleed IV therapy, monitor fluid overload (venous distention, crackles, periphearl edema); crackles in lower lobes; daily wt | OVERLOAD |
| Potassium is regulated by | the sodium-potassium pump and kidney function |
| ___regulates glucose use and storage; mantains action potentials in excitable membranes; 98% of total ___ inside the cell, very minor changes change the membrane excitability | potassium |
| S/S: thirst, fever, tachycardia, dry mucous membranes, restlessness, agitation, convulsions, hyperreflexia, twitching, weakness, confusion, lethargy, coma, flushed skin, oliguria, anuria, hyperventilation | Hypernatremia |
| Increased cell excitability results in excitable tissues responding to less intense stimui is an Sx of | Hyperkalemia |
| Hyperkalemia ECG | Tall Tentented T waves, widened QRS, Prolonged PR, flat P waves. Pt could have heart block, v fib..crash cart needed |
| Excessive dietary or IV sodium intake, Diaphoresis, fluid loss related to burns or other causes, Diabetes insipidus, Osmotic diuresis, Cushings syndrome, Hyperaldosteronism, Infants, Elderly, Drugs (steroids), antiacids, salt tablets are risk factors for | Hypernatremia |
| Therapeutic Nursing Management of Hypernatremia | BP and Pulse, I&O, wt, Dietary sodium intake, capillary refill, skin turgor, neurological status |
| complications of Hypernatremia | Convulsions, Death, Permanaent neurological damage |
| Sodium is regulated by | the kidney |
| Vital functions of Sodium | Skeletal muscle contraction, cardiac contractions, and Nerve impulse transmission |
| slower membrane depolarization (less than 136), cellular swelling. Changes in cerebral function (brain swells and increase cellular pressure) personality changes headache... | hyponatremia |
| water moves from the ICF to the ECF and causes cellular dehydration | Hypernatremia |
| in the early stages of hypernatremia excitable tissues _____ to stimuli | over respond |
| In the late stages of Hypernatremia tissues ___ respond to stimuli | fail to respond |
| Pt tend to be agitated have cesuries and can lead to lethargy and coma | Hypernatremia |
| Risk factors for hyponatremia | Excessive oral water intake, deficient dietary sodium intake, vomiting or diarrhea, nasogastric suctioning, diuretics, peripheral edema, bowel obstruction, ascites, CHF |
| S/S: lethargy, confusion, disorientation, stupor or coma, muscle weakness, anorexia, N&V, headache, abdominal cramping, decreased deep tendeon reflexes, Hypothermia, orthostatic HTN, seizures | Hyponatremia |
| Therapeutic Nursing Assesment/Monitoring for Hyponatremia | Daily wt, I&O, BP, Pulse, Orthostatic BP & pulse, skin turgor, neurological status, restrict water intake, high in sodium foods encouraged, |
| Complications of hyponatremia | Seizures, Coma, Respiratory arrest |
| 0.9 % NaCl solution, 3% hypertonic, NaCl soln in severe cases or Lactated Ringer's soln is given to pt with | hyponatremia |
| IV isotonic salt-free solution (D5 in water), prepare for possible dialysis if >200 mEq/L, Diuretics, Ca may be need to be given as balance corrects, and sodium bicarbonate-may need to be given for severe metabolic acidosis | Hypernatremia |
| is caused by excessive intake, decreased excretion, or movement of potassium out of the cell in response to injury, sepsis, fever, or surgery. | Hypercalemia |
| T/F rapid increases in potassium may be lethal, whereas slow, chronic elevations are better tolerated | true |
| S/S: N&V, diarrhea, paresthesis, numbness; muscle weakness, flaccid paralysis, ECG changes, dysrhythmias, restlessness and fatigue, oliguria, anuria | Hyperkalemia |
| Theraputic Nursing Management of Hyperkalemia | Vital signs, Serum potassium levels, cardiac status continually |
| Complications of Hyperkalemia | Ventricular fibrillation, Cardiac arrest, Death |
| T/F a nurse should give potassium by IV push or as a bolus. | FALSE Never give potassium by IV push or as a bolus. It can cause death by increasing the potassium level too rapidly |
| Sx are diminished deep tendon reflexes, paresthesias, dysrhythmias (such as frequent, premature, ventricular contractions and cardiac arrest) or paralytic ileus | Hypokalemia |
| T/F Potassium directly affects the excitability of muscles and nerves | True |
| T/F Potassium excess is associated with acid excess (acidosis) | True |
| T/F severe hyperkalemia is a life-threatening emergency | true due to prolonged Tall Tented T waves/decreased cardiac output |
| Where is the majority of potassium contained? | In the intracellular spaces |
| Sodium is found where? | in extreacellular fluid |
| ___ occurs with fluid volume deficits in which both fluid and sodium are lost from the body or from fluid volume excess. it also occurs when the blood vessels contain more water and less sodium. | Hyponatremia |
| Occurs with fluid volume deficit or sodium excess | Hypernatremia |
| Antidiuretic hormone (ADH) is secreated by the posterior pituitary to help maintain this sodium balance | hypernatremia |
| ADH allows water to be retained, which helps loer serum sodium levels in | hypernatremia |
| When the solute concentration in the blood increases, the hypothalamus triggers the thirst mechanism which helps gaurd against the development of | hypernatermia |
| Metabolic alkalosis, insulin excess, reduced intake of potassium, failure to replace potassium loss, renal disorders, liver disease, excessive use of laxatives, non-potaisum sparing diuretics, corticosteroids, starvation, NG suction, vomiting: risk factor | Hypokalemia |
| Lethargy, diminished deep-tendon reflexes, faint pulse, confusion, mental depression, weakness, flaccid paralysis, respiratory muscle weakness, Cardiac dysrhythmias, anorexia N&V, Abs distention, paralytic ileus, ECG changes, increase dilute output urine | Hypokalemia |
| Therapeutic Nursing Management for Hypokalemia | Vital signs, I&O, wt, Cardiac Dysrhythmias, Bowel sounds and abdominal distention are monitored |
| Complications of Hypokalemia | REspiratory arrest, Cardiac arrest, Death |
| T/F an increased risk of hypokalemia is realted to the increased intake of diuretics and laxative by older adults | true |
| Vital functions of Calcium | Bone strength and density, activation of enzymes or reactions, skeletal/cardiac muscle contraction, nerve impulse transmission, blood blotting |
| calcium is regulated by | parathyroid and thyroid gland |
| Positive trousseau's 9when BP cuff arm inflate for 1-4 mins if spasms occur then +) and chvostek's sign; ECG changes prolonged ST, QT, at risk for bleeding, Siezures, Diarehea | Hypocalcemia |
| T/F phosporous has an inverse effect against Ca | True |
| Can't Pee Can't Poo | Hypercalcemia |
| ___causes excitbale tissues to be less sensitive to norm stimuli (heart, muscle, nerves, & intestinal smooth muscles), ECG changes shortened ST, Widened T, Excessive blood clotting, bradycardia so severe it can cause cardiac arrest | Hypercalecmia |
| Medications (calcium salts); Vit D, Seizure precaustions and fracture precautions are interventions for | hypocalcemia |
| Calcium chelators (binders), Dialysis, ECG monitoring and clotting monitoring are interventions for | Hypercalcemia |
| The nurse determines the intravenous (IV) administration of calcium gluconate to a client with hyperkalemia has been effective when | Cardiac dysrhythmia is corrected |
| A person on corticosteroid therapy is at high risk for developing a | sodium imbalance.the use of corticosteroids can lead to the development of hypernatremia because they cause sodium to be retained and potassium to be excreted. |
| is usually administered rectally and binds potassium in exchange for sodium in the gastrointestinal tract. | Kayexalate (cation exchange resin) for hyperkalemia |
| T/Fthe thirst mechanism is decreased in the elderly and would normally serve as a compensatory mechanism to provide water intake. | True |
| The results of a client's laboratory tests show an elevated ionized calcium and parathyroid hormone (PTH). The nurse suspects that the cause is: | hyperparathyroidism |
| T/F Cerebral cells are especially sensitive to fluid gains from hypotonic fluids. If infused too rapidly, the cerebral cells will be the first to gain fluid too quickly, resulting in neurological changes. | True. so monitor pt mental status if giving 1/4 NS which is a hypotonic solution that provides free water to the cells |
| A client presents with complaints of fatigue, headache, and increasing muscle weakness and has blood work drawn to evaluate the serum calcium level. The nurse anticipates medical management for an abnormal value to include: | Symptoms of fatigue, headache, and increasing muscle weakness are clinical manifestations of hypercalcemia. Increased hydration is needed to reduce the serum concentration and aid in elimination. |
| Which of the following serum electrolyte imbalances would the nurse assess for in a client admitted with a high fever and severe dehydration? | Hypernatremia and hyperchloremia |
| normal Bun is | 8-22 mg/dL |
| Hct normally is | 38-45% |
| Potassium suplement tablets should be taken when? | After you have eaten breakfast to prevent gastric irritation |
| T/F Prolonged NGT suctioning leads to metabolic alkalosis | True |
| T/F SIADH is caused by excessive production of ADH or an ADH-like substance, resulting in decreased serum sodium and hypervolemia. Loop diuretics are given to promote diuresis. | True |
| T/F Many malignant tumors produce chemicals that are carried in he blood to cause release of calcium from the bones, most commonly in association with ovarian cancer, renal cell carcinoma, and breast cancer, among others. | true |
| HCTZ and Lasix are diuretics that increase the excretion of potassium, so clients should | be taught to increase their intakes of potassium in their diet |
| Shortening of the QT interval is an ECG change of | hypercalcemia |
| to estimate serum osmolality one mulitpiles sodium level by | 2 |
| The nurse evaluates that the discharge teaching has been effective when the cl w/ hypocalcemia states: | I should notify my healthcare provider if I start to feel thingling or numbness around my mouth. Cl should increase protein in the diet |
Created by:
cgwayland