Fluid, Electrolyte, Acid-Base Balance

Intracellular (ICF)

fluid within cell, 70%

Extracellular (ECF)

outside cell, 30%, intravascular and interstitial fluid

Solvents

liquids that hold a substance in solution

Solutes

substances that are dissolved in solution

Sodium

controls and regulates volume of body fluids

Potassium

chief regulator of cellular enzyme activity and water content

Calcium

nerve impulse, blood clotting, muscle contraction, B12 absorption

Magnesium

metabolism of carbohydrates and proteins, vital actions involving enzymes

Chloride

maintains osmotic pressure in blood, produces hydrochloric acid

Bicarbonate

buffer system

Phosphate

chemical reactions in body, cell division, and hereditary traits

Isotonic

same concentration of particles as plasma

Hypotonic

less concentration of particles than plasma (swell)

Hypertonic

greater concentration of particles than plasma (shrink)

Acid

substance containing hydrogen ions that can be liberated or released

Base

substance that can trap hydrogen ions

Hypovolemia

deficiency in amount of water and electrolytes in ECF with near normal water/electrolyte proportions

Dehydration

decreased volume of water and electrolyte change

Third space fluid shift

distributional shift of body fluids into potential body spaces

Hypervolemia

excessive retention of water and sodium in ECF

Overhydration

above normal amounts of water in EC spaces

Edema

excessive ECF accumulates in tissue spaces or interstitial spaces

Infiltration

needle or catheter has dislodged from the vein and is in subQ space, insertion site becomes cool, pallor, clammy, swollen and painful

Phlebitis

pain, increased skin temp over the vein, redness traveling along the vein

IV site infection

redness, tender, pain, swollen, warm to the touch

Air embolus

respiratory distress, increased heart rate, change in level of consciousness, decreased BP

The human body is composed of 50-60% water by weight

True

A hypertonic solution has less osmolarity than plasma

False- A hypotonic solution has less osmolarity that plasma

The acidity or alkalinity of a solution is determined by its concentration of oxygen ions

False- The acidity or alkalinity of a solution is determined by its concentration of hydrogen ions

The kidneys are the primary controller of the body's carbonic acid supply

False- The lungs are the primary controller of the body's carbonic acid supply

Excessive retention of water and sodium in ECF results in a condition termed fluid volume excess or hypervolemia

True

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?

A. Start an IV

B. Review the results of serum electrolytes

C. Offer the woman foods that are high in sodium and potassium content

D. Administer an antiemetic

B. Review the results of serum electrolytes

The nurse is determining a site for an IV infusion. What guideline should the nurse consider?

A. Scalp veins should be selected for infants because of their accessibility

B. Antecubital veins should be used for long-term infusions

C. Veins in the leg should be used to keep the arms free for the patient's use

D. Veins in surgical areas should be used to increase the potency of medication.

A. Scalp veins should be selected for infants because of their accessibility

What nursing actions would be performed when preparing an IV solution and tubing when starting and IV infusion? Select all that apply.

A. Maintain aseptic technique when opening sterile packages and IV solution.

B. Clamp tubing, uncap spike and insert into entry site on badge as manufacturer directs

C. Squeeze drip chamber and allow it to fill one-fourth full

D. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing

E. Allow fluid to flow and cap at end of tubing before all air bubbles have disappeared.

F. Apply label to tubing reflecting the day/date for next set change, per facility guidelines

A. Maintain aseptic technique when opening sterile packages and IV solution.

B. Clamp tubing, uncap spike and insert into entry site on badge as manufacturer directs

D. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing

F. Apply label to tubing reflecting the day/date for next set change, per facility guidelines

What signs of complications and their probable causes may occur when administering an IV solution to a patient? Select all that apply

A. Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV

B. Redness, swelling, heat and pain at the site may indicate phlebitis

C. Local or systemic manifestations may indicate an infection is present at the site

D. A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when an air embolus is present

E. Bleeding at he site when the IV is discontinued indicates an infection is present

F. Engorged neck veins, increased blood pressure, and dyspnea occur when a thrombus is present

A. Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV

B. Redness, swelling, heat and pain at the site may indicate phlebitis

C. Local or systemic manifestations may indicate an infection is present at the site

The nurse is assisting with a patient blood transfusion. What type of reactions may occur during this procedure? Select all that apply.

A. Dyspnea, dry cough, and pulmonary edema may occur during a bacterial reaction. B. Hives, itching, and anaphylaxis may occur during an allergic reaction.

C. Fever, chills, headache and malaise may occur during a febrile reaction.

D. Fever, hypertension, abdominal pain and dry, flushed skin may occur during circulatory overload.

E. Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.

F. Shortness of breath and auscultated crackles bilaterally in the bases may occur during a febrile reaction.

B. Hives, itching, and anaphylaxis may occur during an allergic reaction.

C. Fever, chills, headache and malaise may occur during a febrile reaction.

E. Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.

A 28 year old client is admitted with severe bleeding from a fractured femur. Which IV fluid does the nurse anticipate as the most appropriate for use to replace potential fluid losses?

A. 0.9% sodium chloride

B. 3% sodium chloride

C. 5% dextrose in water

D. 5% dextrose in 0.225%% sodium chloride

A. 0.9% sodium chloride

A 17 year old client who sustained a head injury in a motorcycle collision 2 days ago is responsive only to pain. Which intravenous fluid order would the nurse question because it could increase the risk of complications?

A. Ringer's solution

B. 5% dextrose in water

C. 0.9% sodium chloride

D. Lactated Ringers solution

B. 5% dextrose in water

The nurse is instructing a client diagnosed with hyperkalemia about foods to avoid. Which of the following statements by the client indicates to the nurse a need for instruction?

A. "I should avoid eating a lot of bananas."

B. "I guess I can't eat all the tomatoes I want this summer."

C. "I can still use my salt substitute instead of real salt."

D. "No more avocado for me."

C. "I can still use my salt substitute instead of real salt."

The nurse would closely monitor a client with diabetic ketoacidosis(DKA) for which of the following primary acid- base imbalances?

A. Metabolic acidosis

B. Metabolic alkalosis

C. Respiratory acidosis

D. Respiratory alkalosis

A. Metabolic acidosis

A client receiving a transfusion of packed RBCs suddenly sounds hoarse, begins wheezing, is diaphoretic, short of breath and reports palpitations. Blood pressure is 76/52. What is the priority nursing action?

A. Stop the transfusion

B. Infuse the normal saline (NS) rapidly to maintain intravascular volume.

C. Administer epinephrine and steroids.

D. Maintain the client's airway and notify the physician.

A. Stop the transfusion