NR 324-exam 1 fluid and electrolytes and respiratory Questions with 100% accurate solutions - Chamberlain University

paO2

80-100 mm Hg

pH

7.35-7.45

low pH

acidic

high pH

alkalosis

pa CO2

35-45 mm Hg

HCO3

22-26 mEq/L

respiratory acidosis

low pH, high co2, normal bicarbonate

causes of respiratory acidosis

respiratory depression from anesthesia, overdose, increased intracranial pressure, airway obstruction from decreased alveolar capillary diffusion like pneumonia, COPD, ARDS, AND PE

signs/symptoms of respiratory acidosis

hypoventilation (hypoxia), rapid, shallow respirations, decrease in BP, skin/mucous pale to cyanotic, headache, hyperkalemia, dysrhythmias, drowsiness, dizziness, disorientation, muscle weakness, hyperreflexia

Nursing management of respiratory acidosis

ventilator, arterial blood gas, low-dose oxygen in chronic conditions, high-dose oxygen in acute hypoxia with acidosis, I/O, promote the release of CO2, turn/cough/deep breathe, assume semi-high fowlers position, clear respiratory secretions, colors of skin, mucous membranes

respiratory alkalosis

high pH, low co2 and normal bicarbonate

causes of respiratory alkalosis

high pH, low co2 and hyperventilation, initial stages of pulmonary emboli, hypoxia, fever, pregnancy, high altitudes, and anxiety

signs/symptoms of respiratory alkalosis

seizures, deep/rapid breathing, hyperventilation, tachycardia, decrease BP, hypokalemia, numbness/tingling in extremities, lethargy/confusion, light headedness, N/V

nursing management of respiratory alkalosis

kidneys retain H+ ions, use a rebreather mask or paper bag, sedatives, monitor respiratory rate/depth, tachycardia, low BP, serum K+ levels/ECG levels, hydration status I/O, check for toxicities

metabolic acidosis

low ph, normal co2 and low bicarbonate

metabolic acidosis signs/symptoms

compensatory hyperventilation (kussmaul respirations), headache, decreased BP, hyperkalemia, muscle twitching, warm/flushed skin, N/D/V, changes in LOC,

causes of metabolic acidosis

low ph/low bicarbonate, diabetic ketoacidosis, shock, sepsis, severe diarrhea, and renal failure

what goes up in acidosis

potassium

metabolic acidosis nursing management

BUN, creatinine, hemoglobin/hematocrit levels, monitor hydration, turn/cough/deep breathe, ABG's, check K, Ca usually goes down, weights, vitals

metabolic alkalosis

high ph, normal co2, and high hco3

causes of metabolic alkalosis

high ph, high bicarb and severe vomiting, excessive GI suctioning, diuretics, and excessive NaHCO3

metabolic alkalosis signs/symptoms

restlessness (lethargy), confusion, dizzy, irritable, dysrhythmias, compensatory hypoventilation, N/V/D, tremors, muscle cramps, tingling of fingers and toes, dehydration

metabolic alkalosis nursing management

monitor ECG's, ABG's for pH, K, Ca levels, LOC checks for tetany, tremors, muscle cramps, tingling,

what is hyperkalemia frequently associated with

metabolic acidosis

what is a compensatory mechanism for metabolic alkalosis

decreased respiratory rate and depth to retain CO2 and kidney excretion of bicarbonate

excessive intake causes

rapid oral ingestion of water, infusions of D5%W hypotonic fluid at excess, massive replacement of water without NA

decreased output causes

renal failure

fluid volume excess causes

heart failure, water intoxication, liver cirrhosis, SIADH, lung cancer, renal failure, primary polydipsia, long term use of cortiosteroids

fluid volume excess clinical manifestations

headache, JVD, increased weight, edema, ascites, elevated blood pressure, crackles in lungs, confusion, decreased urine specific gravity, pitting edema, high BP, presence of s3, tachycardia, bounding pulse, changes in LOC, seizures, low pulse ox (below 89%), seizures, coma, muscle spasms, dyspnea

fluid volume excess nursing management

frequent respiratory assessments and LOC, watch for edema, cardiovascular checks, daily weights, fluid restriction, measure intake and output, decrease sodium intake, diuretics

fluid volume deficit population

elderly, profuse sweating, v/d, NG tubes, trauma r/t bleeding, pts NPO, AMS, surgical patients, laxativies, diruetics

fluid volume deficit causes

water loss, perspiration, diabetes insipidus, osmotic diuresis, hemorrhage, GI losses like vomiting, NG suctioning, diarrhea, fistula drainage, overuse of diuretics, inadequate fluid intake, third space shifts, burns, intestinal obstruction

fluid volume deficit signs/symptoms

restlessness, drowsiness, lethargy, confusion, thirst, dry mucous membranes, decreased skin turgor, decreased cap refill, postural hypotension, increased pulse 120, decreased CVP, decreased urine output, concentrated urine, increased respiratory rate, weakness, dizziness, seizures, coma, decreased BP 86/50

fluid volume deficit nursing interventions

intake/output, cardiovascular changes, LOC changes, pupillary response, responsiveness, voluntary movement, patient safety, seizure precautions, fall precautions, daily weights, skin assessment for turgor/color/dryness, pitting edema, administer IV fluids

dehydration

loss of water alone without sodium, cell shrinks

hypernatremia causes

sodium greater than 145, intake excessive, IV fluids (hypertonic Nacl, IV sodium bicarbonate), hypertonic tube feedings without water supplements, near-drowning in salt water, inadequate water intake (cog impaired), excessive water loss (heatstroke, high fever), osmotic diuretic therapy, diarrhea, disease states like DI, primary hyperaldosteronism, cushing syndrome, uncontrolled diabetes mellitus

hypernatremia; fluid volume deficit signs/symptoms

signs of thirst, fever, dry mucous membranes, hypotension, tachycardia, low jugular venous pressure and restlessness, weakness, change of LOC, thready pulses

nursing management of hypernatremia

administer hypotonic solution if na known, administer isotonic solution if na is not known, if corrected too quickly can cause cerebral edema

hypernatremia nursing interventions

treat the cause, add water to balance sodium, or replace sodium and water, monitor I/O, urine specific gravity greater than 1.025, pulses, tachycardia, tachypnea, changes in sensorium, daily weights, skin turgor and mucous membranes

which of the follow interventions does the nurse complete when caring for a client admitted with a sodium level of 152 mEq/L

observe and prepare for possible seizures

hyponatremia causes

sodium is less than 135 mEq/L, vomiting, diuretics, gastrointestinal suctioning, diarrhea, inadequate salt intake, fluid shift from the ICF to the ECF by hypertonic solutions which leads to dilutional hyponatremia

two phases of hyponatremia

1 is too much volume, so decrease in sodium to correct give diuretic and 2 is loss of sodium from other sources to correct on individual basis

decreased Na is caused by dilution as a result of

excess water or increased Na loss

hyponatremia signs and symptoms

cell swells, lethargy, headache, confusion, apprehension, seizures, and coma, change in LOC, muscle weakness, stupor, tendon reflexes decreases

hyponatremia interventions

administer hypertonic solutions with known Na value, monitor patients lungs sounds, administer isotonic solutions with unknown sodium level, report LOC changes, fluid restriction if caused by too much water

nursing management of hyponatremia

I/O, check for bounding pulses, bulging neck veins, BP changes, signs of cerebral edema, daily weights, pitting edema with fluid excess, daily weights and goal is to restore na and water balance and prevent complications of cerebral edema

the nurse assigned to a client with hyponatremia would conclude that which of the following factors probably contributed to this electrolyte imbalance

fluid retention and heart failure

potassium imbalances

heart contractions and ECG will guide plan of care

hyperkalemia caused by

life threatening, impaired renal excretion of potassium, excess intake, metabolic acidosis and medications like beta blockers, dehydration

hyperkalemia signs/symptoms (MURDER)

muscle cramps, urine abnormalities, respiratory distress, decreased cardiac contractility, EKG changes, and reflexes

nursing management of hyperkalemia

check for muscle weakness, administer diuretics, monitor renal and respiratory status, restricted diet, increase fluid intake, administer insulin-kayexalate, dialysis, monitor ECG, monitor blood sugar

the nurse anticipates the client with which condition would be most at risk to develop hyperkalemia

chronic renal failure

hypokalemia is caused by

increased excretion of potassium, N/V, sweating, diuretics, dialysis, increased insulin, alkalosis, tissue repair, increased epinephrine, lack of intake

hypokalemia assessment

muscle weakness and cramps, life threatening if not treated, alkalosis on ABG, fatigue, depressed ST with a U wave, arrhythmias, thready pulse

signs/symptoms of hypokalemia (A SIC WALT)

alkalosis, shallow respirations, irritability, confusion and drownsiness, weakness and fatigue, arrhythmias, lethargy, thready pulse

hypokalemia nursing interventions

watch for skeletal muscle weakness, most dangerous drug to administer, on IV pump no more than 10 mEq/hr, causes vein irritation, ice site, lidocaine, monitor, piggyback with normal saline, always on a pump, encourage intake from foods

calcium

controlled by the parathryroid hormone and calcitonin, bones store, regulated with moving in/out of bones which increases GI and renal absorption, calcitonin lowers ca by decreasaing GI absorption and increasing absorption

hypercalcemia causes

results from malignancy, increased production of PTH, hyperparathyroidism, prolonged immobilization, vitamin d overdose, thiazide diuretics

hypercalcemia signs/symptoms

painful bones, renal stones, abdominal groans like N/V, constipation, indigestion and psychiatric moans like lethargy, fatigue, memory loss, psychosis, depression

hypocalcemia causes

any condition decreasing serum calcium levels like cirrhosis, malnutrition, decreased production of PTH like hypoparathryoidism, loop diuretics, alkalosis, vitamin D deficiency

hypocalcemia signs/symptoms (CATS)

convulsions, arrhythmias, tetany, stridor and spasms

clinical signs for hypocalcemia

chvostek sign (contraction of facial muscles that occur when lightly tapping on ear) and trousseau sign (carpal spasm bringing the index finger and thumb together when the BP cuff is inflated above systolic pressure)

nursing management of hypocalcemia

monitor for dysrhythmias, diet high in calcium and vitamin D, assess for discomfort, IV site, IV preparations, oral supplements

when phosphorus is increased

calcium is decreased

when calcium is increased

phosphorus is decreased

normal calcium levels

8-10

magnesium normal range

1.3-2.1 mEq/L for adults

hypermagnesemia causes

renal dysfunction, use of antacids, use of laxatives like MOM, and Mag sulfate

hypermagnesemia signs/symptoms

respiratory depression, lethargy, cardiac arrest, diminished deep tendon reflexes, flushed warm skin, decreased pulse, decreased BP, muscle weakness, dysphagia, N/V

nursing intervention for hypermagnesemia

focus on prevention, decrease intake of foods like bananas, oranges, peanut butter, chocolate

hypomagnesemia causes

inadequate intake (malnutrition, malabsorption), metabolic acidosis, alcoholism, malabsorption from inflammatory bowel diseases, excessive gastric drainage

hypomagnesemia signs/symptoms

confusion, tremors, seizures, hyperactive deep tendon reflexes, insomnia, increased pulse, increased BP, muscle cramps

intervention for hypomagnesemia

administer MG oral or IV, increase food intake

the nurse is educating the client who has a magnesium level of 1.2 mEq/L, what information is most important for the nurse to include in discussions with the client

hypomagnesemia, diet counseling

phosphorus

essential to muscle function, RBC, and nervous system, found in bones and teeth

hyperphosphatemia

renal failure patients, diseases of endocrine system, fleets enema, sickle cell anemia

hyposhoshatemia

rare disorder, malnourished, malabsorption, hypoventilation like respiratory alkalosis

hypertonic solutions

3-5% NS, CHF, Hypervolvemia, edema, pull sodium in vasculature

isotonic solution

0.9% NS, lactated ringers, dehydrated

hypotonic solution

0.45 NS, D5W, dehydrated and hypovolemic, moves to cells, swells, neurologically comprised

nursing care of patient with impaired gas exchange

life the HOB (open airway), give oxygen, asculate, look for sputem, chest x-ray, and give antibiotics also be aware for signs of distress

gas exchange

the process by which oxygen is transported to the cells and carbon dioxide is transported from the cells

impaired oxygenation leads to

ischemia

impaired elimination of carbon dioxide leads to

respiratory acidosis

what impacts gas exchange

diseases

types of impaired ventilation

narrowed airways, obstructed airways, in inadequate muscle/nerve function, poor gas diffusion in alveoli

nursing interventions for impaired ventilation

ventilating and oxygenating

narrowed airways

from asthma, infection, inflammation, pneumonia and sounds like a wheeze or whistle

fluid in lungs

crackles, then rhonchi which leads to secretions and then infections

altered transport of oxygen

anemia and inadequate perfusion

populations at risk

infants/young children, older adult (posture which leads to infection, not moving, neurological impairment), tobacco use, risk for aspiration, bed rest and immobility, immunosuppression, and chronic disease

a patients condition is described as progressing to hypoxemia, how would the nurse interpret this information

there is a abnormally low level of oxygen in the blood

lung sounds

crackles (high pitched, heard during inspiration, discontinuous), rhonchi (rumbling, coarse sounds, like a snore, may clear with coughing/suctioning, continuous), and wheeze (musical noise, continuous)

diagnostic testing for respiratory oxygenations

pulse ox, Allen's test to assess before ABG, x-ray

Narcan

reverses CO2 toxicity like in drug overdoses

pain medications

depress respiratory system

bronchoscopy

aspirate, check CN 9 and 10 every 10 minutes after to make sure gag reflex comes back, NPO after procedure,

asthma CM

cough, increase mucus, sob, wheezing, prolonged expiration, increase in co2 retention, chest tightness, retractions, hypoxemia (tachycardia, restlessness, tachypnea)

asthma is

reactive airway disease, induced by triggers, hypersensitivities, URI, exercise, air pollutants, respiratory infections and GERD and anxiety

management of asthma

adrenergic (beta 2 agonists/albuterol), steroids, theophylline, hydration, mask of o2 and anticholinergic