Acid-Base Imbalances Nursing Care Plan & Management

Notes

Description

Acid–base imbalance is an abnormality of the human body’s normal balance of acids and bases that causes the plasmapH to deviate out of the normal range (7.35 to 7.45).

I. Respiratory Alkalosis

Respiratory Alkalosis is an acid-base imbalance characterized by decreased partial pressure of arterial carbon dioxide and increased blood pH

acid based balance

Contributing Factors:
  • hyperventilation due to anxiety
  • hypoxia
  • improper mechanical ventilation
  • fever
  • salicylate poisoning
Signs and Symptoms/ Clinical Manifestations:
  • light headedness
  • inability to concentrate
  • convulsions
  • positive Chvostek’s sign nausea and vomiting
  • muscle twitching
  • Labs indicated: arterial blood gas (ABG) studies reveal abnormal values: pH above 7.45 and partial pressure of carbon dioxide below 35 mmHg.
Nursing Diagnoses:
  • Impaired gas exchange
  • Ineffective Breathing pattern
  • Ineffective Tissue perfusion
  • Acute confusion
  • Risk for injury
Medical Management / Nursing Interventions:
  • Institute safety measures for the patient with vertigo or the unconscious patient.
  • Encourage the anxious patient to verbalize fears
  • Administer sedation as ordered to relax the patient
  • Keep the patient warm and dry
  • Encourage the patient to take deep, slow breaths or breathe into a brown paper bag (inspire CO2).
  • Monitor vital signs
  • Monitor ABGs, primarily PaCO2; a value less than 35 mmHg indicates too little CO2 (carbonic acid)
 II. Respiratory Acidosis

Respiratory Acidos is is an acid-base imbalance characterized by increased partial pressure of arterialcarbon dioxide and decreased blood pH.

Contributing Factors:
  • chronic obstructive respiratory disorders
  • chest wall trauma, pulmonary edema, atelactasis, pneumothorax, drug overdose, pneumonia, Guillain-Barre syndrome
  • any condition that results in hypoventilation
  • Signs and Symptoms/ Clinical Manifestations:
  • increased pulse and respiratory rate
  • Increased blood pressure
  • mental cloudiness and feeling of fullness in head
  • weakness
  • dull headache
  • Labs indicated: arterial blood gas (ABG) studies reveal abnormal values: pH below 7.35 and partial pressure of carbon dioxide above 45 mmHg.
Nursing Diagnoses:
  • Impaired gas exchange
  • Ineffective Breathing pattern
  • Ineffective Tissue perfusion
  • Acute confusion
  • Risk for injury
Medical Management / Nursing Interventions:
  • Institute safety measures
  • Assist with positioning
  • Monitor I&O and administer fluids as ordered
  • Administer oxygen and medications for order; monitor hourly vital signs and respiratory status (may requires mechanical ventilation)
  • Monitor arterial blood gases (ABGs); pH, PaCO2, HCO3
 III. Metabolic Alkalosis

Metabolic Alkalosis is an acid-base imbalance characterized by excessive loss of acid or excessive gain of bicarbonate.

Contributing Factors:
  • vomiting
  • gastric suctioning
  • excessive intake of alkali (antacids, baking soda)
Signs and Symptoms/ Clinical Manifestations:
  • tingling of fingers
  • dizziness, confusion
  • tetany
  • slow, shallow respirations, possibly apnea
  • Labs indicated: arterial blood gas (ABG) studies reveal abnormal values: pH above 7.45 and HCO3 above 26 mEq/L; urine chloride concentrations help to differentiate between vomiting or diuretic ingestion or one of the causes of mineralocorticoid excess.
IV. Metabolic Acidosis

Metabolic Acidosis is an acid-base imbalance resulting from excessive absorption or retention of acid or excessive excretion of bicarbonate.

Contributing Factors:
  • ketoacidosis
  • lactic acidosis
  • prolonged fasting
  • salicylic poisoning
  • oliguric renal disease
  • abnormal bicarbonate losses, which can occur in loss of fluid from the lower GI tract from surgery, drains or severe diarrhea
Signs and Symptoms/ Clinical Manifestations:
  • headache
  • drowsiness and confusion
  • weakness
  • increased respiratory rate and depth
  • nausea and vomiting
  • diminished cardiac output with pH below 7, which results in hypotension, cold clammy skin and cardiac arrhythmias.
  • Labs indicated: arterial blood gas (ABG) studies reveal abnormal values: pH below 7.35 and HCO3 below 22 mEq/L; serum potassium level reveals hyperkalemia

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Exam

Welcome to your NCLEX Practice Exam for Fluids, Electrolytes & Homeostasis 2! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.

 

Exam Details

  • Number of Questions: 60 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!

 

Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

Consider the physiological effects of magnesium on cardiac function when elevated.

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1. Nurse Riley is assessing Mrs. Johnson, who has recently been diagnosed with hypermagnesemia. The nurse is vigilant for symptoms that could arise due to elevated magnesium levels. What symptoms could Mrs. Johnson potentially display?

💡 Hint

Consider the factors that could lead to an equal loss of water and electrolytes from the body, affecting the isotonic balance.

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2. You're working in the emergency department, and a 33-year-old patient named Mark comes in with symptoms of dehydration. You suspect that he might be experiencing isotonic fluid volume deficit (FVD). To confirm your suspicion, you consider the various ways isotonic FVD can occur. Which of the following could be a reason for Mark's isotonic FVD?

💡 Hint

Focus on the interaction between CO2 and hydrogen ions, and how the lungs play a role in this mechanism to maintain pH balance.

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3. You are precepting a group of nursing students and discussing the respiratory system's role in maintaining acid-base balance. One of the students asks how the lungs participate in this crucial function. How would you explain the lungs' role in regulating acid-base balance?

💡 Hint

Consider which condition is likely to disrupt the body's phosphate balance, possibly due to malabsorption or increased excretion.

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4. You are caring for Martin, a 65-year-old man who has been admitted with muscle weakness and confusion. Blood tests are ordered, and you suspect he may have hypophosphatemia. Which of the following conditions could potentially lead to a decrease in serum phosphate levels like you suspect in Martin?

💡 Hint

Think about how changing breathing patterns can impact the levels of carbon dioxide in the blood, which in turn affects acid-base balance.

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5. During a clinical rotation in the respiratory unit, you're explaining to nursing students the different physiological systems that maintain the body's acid-base balance. One student is curious about the specific role of the respiratory system in this regulation. How does the respiratory system contribute to acid-base balance?

💡 Hint

Consider the part of the renal system that is primarily responsible for the reabsorption and secretion processes of electrolytes and fluids.

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6. Nurse Emily is reviewing a patient's case history, who has chronic electrolyte imbalances. She suspects that a malfunction in one of the renal structures could be affecting electrolyte reabsorption. Which renal structure is most likely to influence electrolyte reabsorption?

💡 Hint

Think about the electrolytes that are lost when you sweat, as they are similar to those lost during vomiting.

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7. You are tending to John, a 45-year-old patient who has been experiencing persistent vomiting due to a gastrointestinal infection. As his nurse, you are concerned about the potential electrolyte imbalances that may arise from frequent vomiting. Which electrolytes are primarily lost due to this condition?

💡 Hint

Focus on the segment of the gastrointestinal tract where a high degree of absorption—both of nutrients and water—takes place. This area is specially adapted for this purpose.

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8. You're caring for Lisa, a 64-year-old patient with chronic gastrointestinal issues that have led to fluid imbalances. Understanding the gastrointestinal tract's role in water absorption will help you manage her care effectively. Where does the majority of water reabsorption occur in the gastrointestinal system?

💡 Hint

The intracellular environment has a specific major cation that plays a vital role in cell function. Consider which cation is essential for actions like muscle contraction and nerve impulse transmission.

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9. You're supervising a group of nursing students in a clinical setting, and the topic of intracellular fluid (ICF) comes up. One of the students is curious about the major cation present in the ICF. As an experienced nurse, how would you answer?

💡 Hint

Think about the hormone responsible for sodium reabsorption in the kidney, as chloride often follows sodium.

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10. You're taking care of Jack, a 62-year-old patient with hypertension who is on diuretic therapy. As part of his electrolyte management, understanding how chloride reabsorption is regulated is vital. Which hormone plays a role in the reabsorption of chloride ions?

💡 Hint

Consider the interplay between two particular electrolytes; when one is low, it may indicate a heightened risk for the other being high.

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11. You're closely monitoring Emily, a 59-year-old patient with multiple health concerns. You're especially attentive to her risk for imbalances in electrolytes. Which among the following medical conditions would heighten Emily's risk for developing an excess of phosphate, also known as hyperphosphatemia?

💡 Hint

The symptoms and behaviors John is displaying point toward an electrolyte imbalance, which could potentially impact a specific cation.

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12. John, a male patient diagnosed with bipolar disorder, has been consuming large amounts of water and urinating often. He is experiencing symptoms like muscle cramps, twitching, and dizziness. As his nurse, what laboratory work would you primarily focus on?

💡 Hint

Intracellular fluid has a unique composition compared to extracellular fluid. Think about which anion is primarily involved in energy storage and transfer within the cell.

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13. You are teaching a group of nursing students about fluid and electrolyte balance. During the discussion, you focus on the intracellular fluid (ICF) composition. One of the students asks which anion is predominantly present in the ICF. How would you answer?

💡 Hint

Think about the implications of fluid accumulating in a compartment that is not in direct exchange with the circulatory system. What effect would this have on the body's overall fluid balance?

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14. You are caring for Henry, a 72-year-old patient who has just undergone abdominal surgery. Post-operatively, you notice signs of third-spacing, a phenomenon where fluid accumulates in compartments that are not easily accessible by the circulatory system. What is the primary concern regarding fluid being sequestered in the third space in Henry's case?

💡 Hint

Think about which component is directly linked to respiratory function and is a gas at room temperature.

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15. You're caring for Emma, a patient in the ICU with severe pneumonia. The physician orders an arterial blood gas (ABG) test to better understand her respiratory status. While reviewing the ABG results, you take note of various components. Which of the following is the gaseous element measured in an ABG?

💡 Hint

Metabolic alkalosis often accompanies a particular electrolyte imbalance. Think about which electrolyte level is commonly affected.

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16. You are conducting a head-to-toe assessment on Lisa, a 45-year-old female who was admitted with complaints of nausea and prolonged vomiting. The admitting physician suspects she might have metabolic alkalosis. As a nurse with a strong understanding of acid-base imbalances, what clinical manifestation would you particularly look out for in assessing Lisa for metabolic alkalosis?

💡 Hint

Consider conditions that would directly affect the gastrointestinal system's ability to absorb nutrients, including essential minerals like magnesium.

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17. You are reviewing the lab results for Clara, a 60-year-old patient in the medical-surgical unit, and notice that her magnesium levels are below the normal range. You start thinking about the potential underlying causes that could lead to her hypomagnesemia. What are the possible etiologies associated with this condition?

💡 Hint

Think about the compartment that consists of all the water inside the cells of the body. This compartment holds more water than any other.

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18. You are caring for Maria, a 78-year-old patient admitted with severe dehydration. As part of educating her family on the importance of fluid balance, you explain the various fluid compartments in the body. You ask them, "Do you know where the majority of the body’s water is primarily contained?"

💡 Hint

Think about the actions of magnesium on the muscular and cardiovascular systems. Magnesium often has an effect opposite to calcium in many physiological processes.

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19. You are working in the cardiology ward and attending to Robert, a 68-year-old patient with coronary artery disease. During your discussion with the medical team, the topic of magnesium and its various physiological functions comes up. Which of the following is NOT a function performed by magnesium in the body?

💡 Hint

Consider what isotonic means in terms of osmolarity. An isotonic solution is one that has the same osmolarity as blood, thus not causing cells to swell or shrink.

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20. You are working in the Emergency Department, and Jennifer, a 38-year-old patient comes in with dehydration. The physician orders an isotonic solution to be administered. Which of the following options is an example of an isotonic solution suitable for Jennifer?

💡 Hint

Consider the medication that has a primary function related to promoting fluid loss via urinary excretion.

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21. Nurse Casey is overseeing the care of Olivia, a 72-year-old patient with a nursing diagnosis indicating a fluid volume deficit. Olivia is on multiple medications for various chronic conditions. Nurse Casey is concerned that one of Olivia's current medications might worsen her fluid imbalance. Which medication could potentially aggravate Olivia's fluid volume deficit?

💡 Hint

Consider the term that describes a state where the number of positive ions equals the number of negative ions, thus maintaining balance across cell membranes.

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22. Lisa, a 28-year-old ICU patient, has been diagnosed with a complex electrolyte imbalance. As a nurse who is responsible for her care, you understand that her cellular processes depend on maintaining a balance of negatively and positively charged ions across the cell membranes. What is this balance termed as?

💡 Hint

Think about the area of the nephron where ion exchange primarily occurs, affecting the levels of various electrolytes, including magnesium.

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23. Nurse Taylor is caring for Mark, a 58-year-old patient who has been diagnosed with hypomagnesemia. Mark's physician has requested that his magnesium levels be closely monitored. Nurse Taylor needs to understand the renal physiology behind magnesium reabsorption to better manage Mark's condition. What anatomical or hormonal element chiefly regulates the reabsorption of magnesium?

💡 Hint

To counteract metabolic alkalosis, the body aims to retain more CO2. Consider what respiratory change would facilitate this process.

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24. Emily, a 58-year-old patient with a history of chronic kidney disease, is admitted to the medical unit for evaluation. Upon reviewing her lab results, you notice signs of metabolic alkalosis. As a nursing professional, you know that the body tries to naturally compensate for such imbalances. What would be the body's physiological response to compensate for Emily's metabolic alkalosis?

💡 Hint

Consider which type of solution would provide free water to help dilute excess solutes, thereby assisting the kidneys in their elimination.

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25. Maria, a 72-year-old patient, has been admitted to the hospital for treatment of fluid volume deficit (FVD) following an episode of severe diarrhea. The medical team is contemplating the use of a hypotonic solution as part of her fluid replacement therapy. As a nursing professional, what rationale would you provide for choosing a hypotonic solution in treating Maria's FVD?

💡 Hint

Think about the roles that body fluids play in both cellular functions and systemic processes, excluding the one that is not directly linked.

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26. As a nurse, you are preparing an educational module about the importance of maintaining fluid balance in the body. To make your point, you plan to include the various functions that body fluids perform. Which of the following is NOT a function of body fluids?

💡 Hint

When monitoring a patient during a blood transfusion, an increase in body temperature could be a red flag. Think about what complications might arise specifically in the context of a blood transfusion.

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27. Keane, a 46-year-old patient with anemia, is undergoing a blood transfusion. About 30 minutes into the transfusion, you notice that Keane's body temperature has risen. As a nurse well-versed in the potential complications associated with blood transfusions, how would you interpret this elevation in body temperature?

💡 Hint

Consider the medications Emily is taking and how they could affect her electrolyte levels, particularly in relation to cardiac function.

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28. Emily, a 68-year-old patient, is on daily digoxin and Lasix. During your shift, she reports feeling nauseous, and you find her apical pulse to be 130 and irregular. As her nurse, what is the most suitable course of action to take?

💡 Hint

Think about which hormone serves as a regulatory mechanism to lower elevated calcium levels in the bloodstream.

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29. You're caring for a patient who recently had a parathyroidectomy. Knowing the interplay of hormones that regulate calcium levels is critical in managing her postoperative care. Which hormone is released when there is an increase in serum calcium levels?

💡 Hint

Think about the specific process that governs the movement of water molecules through a semipermeable membrane based on concentration gradients.

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30. You are caring for a patient who is receiving intravenous fluids following a surgical procedure. The physician explains that the type of fluid chosen is meant to restore cellular hydration. Intrigued by the process, a nursing student with you asks how water moves from one concentration to another across cell membranes. What term describes the net movement of water from a higher concentration to a lower concentration through a semipermeable membrane?

💡 Hint

Consider the physiological process that involves the exchange of chloride and bicarbonate ions, particularly in the context of red blood cells and plasma.

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31. You're assigned to the care of Lisa, a 58-year-old patient who has a history of chronic kidney disease. As you review her lab results, you note a fluctuation in her chloride levels. Understanding the role of chloride in acid-base balance is crucial for her management. What role does chloride play in maintaining acid-base balance?

💡 Hint

Think about the electrolytes that might be imbalanced due to his substantial fluid loss from diarrhea and the need for appropriate supplementation.

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32. Jonas has been admitted to the hospital with a history of substantial diarrhea, losing about 1,000 ml of fluid per day for the past three days. The physician orders an IV of 0.45% NaCl combined with 5% dextrose. As his nurse, what is the most appropriate nursing intervention you should consider?

💡 Hint

Consider the physiological ramifications of Fluid Volume Deficit on cardiac performance and other body systems when selecting the most applicable nursing diagnosis.

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33. Nurse Emily is attending to Mr. Goggins, who has been diagnosed with Fluid Volume Deficit (FVD). Which of the following nursing diagnoses is most appropriate for Mr. Goggins' condition?

💡 Hint

Think about the type of foods that are often recommended for a balanced diet and are rich in essential minerals, including magnesium.

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34. Sara, a patient with chronic fatigue, is advised to increase her magnesium intake. As her nurse, you plan to educate her on dietary sources of magnesium. What foods would you recommend Sara include in her diet for a higher magnesium intake?

💡 Hint

Reflect on which particular vitamin is crucial for boosting the absorption rate of calcium in the digestive system, thereby supporting bone health and various cellular activities.

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35. During a nutritional education session, you're discussing with your patient Sarah about the importance of absorbing essential nutrients for overall health. Sarah is especially keen on optimizing her bone health and queries you on how calcium is absorbed. What specific substance plays a central role in facilitating calcium absorption within the gastrointestinal tract?

💡 Hint

Think about the primary source of energy for cells, as it is also found in extracellular fluid.

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36. As a nurse on the intensive care unit, you are managing Emily, a 50-year-old patient with severe sepsis. Due to her critical condition, maintaining proper extracellular fluid balance is crucial. You are explaining the composition of extracellular fluid to a nursing student. Besides water, electrolytes, and proteins, what else is predominantly found in the extracellular fluid?

💡 Hint

Consider which clinical condition primarily impacts the gastrointestinal system, leading to a loss of bicarbonate.

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37. Nurse Jordan is working in the emergency department and is responsible for Sarah, a 36-year-old woman exhibiting signs of electrolyte imbalance. After assessing Sarah's lab results, Nurse Jordan notes a significant reduction in bicarbonate levels. Which clinical condition is most commonly associated with the depletion of bicarbonate?

💡 Hint

Consider the types of molecules that are more likely to be found inside cells rather than in the extracellular fluid, particularly those that contribute to cellular function and structure.

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38. You're preparing an educational seminar on fluid balance for nursing students. One of the topics is the composition of the intracellular fluid compartment. You ask the students, "Besides water, what else is primarily stored in the intracellular compartment?"

💡 Hint

When the body experiences a fluid volume deficit, the cardiovascular system tries to maintain cardiac output. Think about what heart-related symptom would be likely in this situation.

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39. Katherine, a 50-year-old patient, comes to the emergency department complaining of severe diarrhea and dehydration. As a nurse experienced in identifying fluid imbalances, you are tasked with assessing her for fluid volume deficit (FVD). What clinical manifestation would you specifically anticipate in Katherine?

💡 Hint

Hypertonic fluids generally result in fluid being drawn out of cells. Consider what kind of imbalance this is least likely to cause.

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40. Samantha, a 54-year-old woman, is admitted to the hospital and is receiving hypertonic fluids as part of her treatment plan. As a nurse responsible for her care, you are aware that monitoring for potential complications is crucial. Which of the following is not a potential complication that you need to monitor for while she is on hypertonic fluids?

💡 Hint

Reflect on the physiological changes that occur during high-intensity physical activities like marathon running, particularly those affecting fluid balance.

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41. Nurse Alex is caring for Tim, a marathon runner, who is at a heightened risk for experiencing fluid volume deficit. Which of the following factors contributes to Tim's risk?

💡 Hint

Think about which factors directly contribute to the amount of water in the body. One of these options is less likely to have a significant impact on total body water percentage.

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42. You're conducting a comprehensive health assessment on Mark, a 42-year-old male patient. Part of the assessment involves calculating his total body water percentage. You know that multiple factors influence this calculation. Which of the following elements is not a significant influencer of total body water percentage?

💡 Hint

When considering the regulation of sodium levels, focus on hormones that directly influence water and sodium balance in the kidneys. These hormones play a role in regulating blood volume and pressure.

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43. In assessing the homeostatic control of sodium levels, Nurse Riley recognizes that the regulation of sodium is influenced by the secretion of which of the following hormones?

💡 Hint

Consider situations where there's a direct loss of bodily fluids, including electrolytes, from the internal environment to the external environment.

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44. You're caring for Karen, a 52-year-old patient recovering from abdominal surgery. She has multiple surgical drains in place, and you're closely monitoring her electrolyte levels. Among the options below, which clinical condition is likely to exacerbate the excretion of electrolytes?

💡 Hint

Focus on the physiological effects of angiotensin II that would directly impact blood pressure and fluid regulation within the renal system.

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45. You're caring for Emily, a 48-year-old patient who has been admitted for hypertension and is suspected to have renal impairment. The healthcare team discusses the role of angiotensin II in Emily's renal regulation of water balance. As a nursing student studying renal physiology, what functions would you attribute to angiotensin II in this context?

💡 Hint

Think about the daily sodium intake that is often recommended for adults, especially those with cardiovascular concerns. The answer is usually expressed in grams.

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46. You're consulting with Lisa, a 65-year-old patient with hypertension, about dietary changes to manage her condition. She is interested in knowing what the minimum daily sodium requirement for an adult is. What type of diet would contain this minimum requirement?

💡 Hint

The endocrine system, particularly hormones like aldosterone, plays a role in regulating the balance between two specific electrolytes—one is reabsorbed and the other is excreted.

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47. Nina, a 60-year-old patient with chronic kidney disease, is experiencing electrolyte imbalances. You're explaining to her family that her endocrine system plays a role in maintaining electrolyte homeostasis. Specifically, what does the endocrine system typically regulate when it comes to electrolyte balance in the body?

💡 Hint

Think about the part of the body primarily responsible for absorbing nutrients and electrolytes from digested food. This area plays a crucial role in maintaining electrolyte balance, including chloride levels.

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48. You are providing care for Grace, a patient who recently underwent abdominal surgery. While monitoring her electrolyte levels, you note a decrease in her chloride levels. To make appropriate clinical decisions, you consider where chloride is typically absorbed in the body. Where does this occur?

💡 Hint

Focus on the blood product that is most effective for restoring oxygen-carrying capacity quickly in cases of severe bleeding.

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49. You are working in the emergency department and are responsible for administering blood products to patients as needed. John, a 52-year-old male, has just been admitted with severe bleeding due to a motor vehicle accident. Different blood products are considered for rapid infusion to manage his condition. Which among the following blood products is typically infused quickly to be effective?

💡 Hint

Consider the type of fluid that has the capability to draw fluid back into the vascular system, thus affecting fluid shifts.

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50. Mark, a 50-year-old patient with acute kidney injury, requires manipulation of fluid shifts between intravascular and interstitial compartments. As the attending nurse, you consider the most effective type of fluid to achieve this. What fluid is commonly used for manipulating fluid shifts among compartments?

💡 Hint

Hypocalcemia can lead to a range of symptoms affecting the nervous system. Consider what neurological issue is most likely to place the patient at high risk for injury.

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51. You are reviewing the lab results for Julia, a 65-year-old patient who has just been diagnosed with hypocalcemia. You're considering appropriate nursing diagnoses to address her condition. Which of the following nursing diagnoses is most fitting for a patient experiencing low levels of calcium?

💡 Hint

Focus on the symptoms that point towards fluid imbalance and think about what nursing intervention would most directly address this issue.

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52. Mr. Johnson, an 85-year-old patient with a feeding tube, presents with symptoms of severe diarrhea, lethargy, poor skin turgor, tachycardia, and hyperactive reflexes. As the nurse in charge of his care, what intervention should be your priority?

💡 Hint

Think about the physiological impact of hypertonic FVE on the cardiovascular system, particularly how it may affect the heart's ability to pump effectively.

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53. You're caring for Sarah, a 55-year-old patient in the cardiac unit who has been diagnosed with hypertonic fluid volume excess (FVE). As you evaluate Sarah's condition and plan her nursing care, which nursing diagnosis is most likely relevant to her hypertonic FVE status?

💡 Hint

Consider the characteristics of the wound, specifically the depth of tissue loss and what types of tissue are visible or not visible in the ulcer. Remember that each stage of pressure ulcers represents a different level of tissue damage.

54 / 57

54. Lisa, a registered nurse, is conducting a wound assessment of a patient who has a pressure ulcer on the sacral area. The wound has full-thickness tissue loss in which adipose (fat) is visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. How should Lisa stage this pressure ulcer?

💡 Hint

Think about the electrolyte that often pairs with chloride to help maintain acid-base balance.

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55. Mia, a 74-year-old patient with a history of congestive heart failure, has come in for her regular check-up. Her labs indicate that her chloride levels are below 95 mEq/L. As her nurse, you consider the implications of this on the reabsorption of other electrolytes. When chloride concentration falls below this level, the reabsorption of which electrolyte increases proportionately?

💡 Hint

Consider which electrolyte directly affects the pH level, leading to an acidic environment when in excess.

56 / 57

56. You are managing the care of Robert, a 72-year-old patient who has been admitted with respiratory issues. After reviewing his arterial blood gas (ABG) results, you suspect acidosis. Which electrolyte's presence is a contributing factor to the development of acidosis?

💡 Hint

Think about what other components in the blood can bind to calcium, affecting its measured levels and its biological availability.

57 / 57

57. During morning rounds, you're discussing lab results with Dr. Williams. She emphasizes the importance of interpreting calcium levels in a specific context for accurate diagnosis and treatment. In medical practice, normal calcium levels should generally be considered in conjunction with which of the following?

Nursing Care Plans

Nursing Care Plan for Respiratory Alkalosis

Nursing Diagnosis
  • Impaired Gas Exchange
May be related to
  • Ventilation perfusion imbalance (e.g., altered oxygen supply, altered blood flow, altered oxygen-carrying capacity of blood, alveolar-capillary membrane changes)
Possibly evidenced by
  • Dyspnea, tachypnea
  • Changes in mentation
  • Hypocapnia, tachycardia
  • Hypoxia
Desired Outcomes
  • Demonstrate improved ventilation and adequate oxygenation of tissue as evidenced by ABGs within patient’s acceptable limits and absence of symptoms of respiratory distress.
  • Verbalize understanding of causative factors and appropriate interventions.
  • Participate in treatment regimen within level of ability/situation.
Nursing Interventions
  • Monitor respiratory rate, depth, and effort. Ascertain cause of hyperventilation if possible. Differentiate hyperventilation caused by anxiety, pain, or improper ventilator settings.
    • Rationale: Identifies alterations from usual breathing pattern and influences choice of intervention.
  • Encourage patient to breathe slowly and deeply. Speak in a low, calm tone of voice. Provide safe environment.
    • Rationale: May help reassure and calm the agitated patient, thereby aiding the reduction of respiratory rate. Assists patient to regain control.
  • Assess level of awareness or cognition and note neuromuscular status. Assess strength, tone, reflexes, and sensation.
    • Rationale: Decreased mentation (mild to severe) and tetany or seizures may occur when alkalosis is severe.
  • Demonstrate appropriate breathing patterns, if appropriate, and assist with respiratory aids or rebreathing mask/bag.
    • Rationale: Decreasing the rate of respirations can halt the “blowing off” of CO2, elevating Pco2 level and normalizing pH.
  • Provide comfort measures; encourage use of meditation and visualization. Use tepid sponge bath/cool cloths.
    • Rationale: Promotes relaxation and reduces stress. Control and reduction of fever reduces potential for seizures and helps reduce respiration rate.
  • Provide safety and seizure precautions. Place bed in low position, pad side rails and do frequent observation of the patient.
    • Rationale: Changes in mentation, CNS and neuromuscular hyperirritability may result in patient harm, especially if tetany or convulsions occur.
  • Discuss cause of condition (if known) and appropriate interventions and/or self-care activities.
    • Rationale: Promotes participation in therapeutic regimen and may reduce recurrence of disorder.
  • Assist with identification and treatment of underlying cause.
    • Rationale: Respiratory alkalosis is a complication, not an isolated occurrence; addressing the primary condition (hyperventilation of panic attack, organ failure, severe anemia; drug effect, such as with paraldehyde or epinephrine) promotes correction of the disorder and reduces likelihood of recurrence.
  • Monitor and graph serial ABGs, and pulse oximetry.
    • Rationale: Identifies therapy needs and effectiveness.
  • Monitor serum potassium. Replace as indicated.
    • Rationale: Hypokalemia may occur as potassium is lost (urine) or shifted into the cell in exchange for hydrogen in an attempt to correct alkalosis.
  • Provide sedation and pain medication, as indicated.
    • Rationale: May be required to reduce psychogenic cause of hyperventilation.
  • Administer CO2, or use rebreathing mask as indicated. Reduce respiratory rate and tidal volume, or add additional dead space (tubing) to mechanical ventilator.
    • Rationale: Increasing CO2 retention may correct carbonic acid deficit.

Nursing Care Plan for Respiratory Acidosis

Nursing Diagnosis
  • Impaired Gas Exchange
May be related to
  • Ventilation perfusion imbalance (altered oxygen-carrying capacity of blood, altered oxygen supply, alveolar-capillary membrane changes, or altered blood flow)
Possibly evidenced by
  • Dyspnea with exertion, tachypnea
  • Changes in mentation, irritability
  • Tachycardia
  • Hypoxia, hypercapnia
Desired Outcomes
  • Demonstrate improved ventilation and adequate oxygenation of tissues as evidenced by ABGs within patient’s acceptable limits and absence of symptoms of respiratory distress.
  • Verbalize understanding of causative factors and appropriate interventions.
  • Participate in treatment regimen within level of ability/situation.
Nursing Interventions
  • Monitor respiratory rate, depth, and effort.
    • Alveolar hypoventilation and associated hypoxemia lead to respiratory distress or failure.
  • Auscultate breath sounds.
    • Rationale: Identifies areas of decreased ventilation (atelectasis) or airway obstruction and changes as patient deteriorates or improves, reflecting effectiveness of treatment, dictating therapy needs.
  • Note declining level of consciousness.
    • Rationale: Signals severe acidotic state, which requires immediate attention. Note: In recovery, sensorium clears slowly because hydrogen ions are slow to cross the blood-brain barrier and clear from cerebrospinal fluid and brain cells.
  • Monitor heart rate and rhythm.
    • Rationale: Tachycardia develops early because the sympathetic nervous system is stimulated, resulting in the release of catecholamines, epinephrine, and norepinephrine, in an attempt to increase oxygen delivery to the tissues. Dysrhythmias that may occur are due to hypoxia (myocardial ischemia) and electrolyte imbalances.
  • Note skin color, temperature, moisture.
    • Rationale: Diaphoresis, pallor, cool or clammy skin are late changes associated with severe or advancing hypoxemia.
  • Encourage and assist with deep-breathing exercises, turning, and coughing. Suction as necessary. Provide airway adjunct as indicated. Place in semi-Fowler’s position.
    • Rationale: These measures improve lung ventilation and reduce or prevent airway obstruction associated with accumulation of mucus.
  • Restrict use of hypnotic sedatives or tranquilizers.
    • Rationale: In the presence of hypoventilation, respiratory depression and CO2 narcosis may develop.
  • Discuss cause of chronic condition (when known) and appropriate interventions and self-care activities.
    • Rationale: Promotes participation in therapeutic regimen, and may reduce recurrence of disorder.
  • Assist with identification or treatment of underlying cause.
    • Rationale: Treatment of disorder is directed at improving alveolar ventilation. Addressing the primary condition (oversedation, lung and respiratory system trauma, pulmonary edema, aspiration) promotes correction of the acid-base disorder.
  • Monitor and graph serial ABGs, pulse oximetry readings; Hb, serum electrolyte levels.
    • Rationale:Evaluates therapy need and effectiveness. Note: Bedside pulse oximetry monitoring is used to show early changes in oxygenation before other signs or symptoms are observed.
  • Administer oxygen as indicated. Increase respiratory rate or tidal volume of ventilator, if used.
    • Rationale: Prevents and corrects hypoxemia and respiratory failure. Note: Must be used with caution in presence of emphysema because respiratory depression or failure may result.
  • Assist with ventilatory aids: IPPB in conjunction with bronchodilators. Monitor peak flow pressure.
    • Rationale: Increases lung expansion and opens airways to improve ventilation, preventing respiratory failure.
  • Maintain hydration (IV/PO) and provide humidification.
    • Rationale: Assists in correction of acidity and thinning and mobilization of respiratory secretions.
  • Provide appropriate chest physiotherapy, including postural drainage and breathing exercises.
    • Rationale: Aids in clearing secretions, which improves ventilation, allowing excess CO2 to be eliminated.
  • Administer IV solutions such as lactated Ringer’s solution or 0.6 M solution of sodium lactate.
    • Rationale: May be useful in nonemergency situations to help control acidosis, until underlying respiratory problem can be corrected.
Administer medications as indicated:
  • Naloxone hydrochloride (Narcan)
    • Rationale: May be useful in arousing patient and stimulating respiratory function in presence of drug overdose and sedation, or acidosis resulting from cardiac arrest.
  • Sodium bicarbonate (NaHCO3)
    • Rationale: May be given in small IV doses in emergency situations to quickly correct acidosis if pH is less than 7.25 and hyperkalemia coexists. Note: Rebound alkalosis or tetany may occur.
  • Potassium chloride (KCl)
    • Rationale: Replaces potassium that shifts out of cells during acidotic state. Correction of the acidosis may cause a relative serum hypokalemia as potassium shifts back into cells. Potassium imbalance can impair neuromuscular or respiratory function, causing generalized muscle weakness and cardiac dysrhythmias.
  • Bronchodilators
    • Rationale: Helps open constricted airways to improve gas exchange.
  • Provide low-carbohydrate, high-fat diet (Pulmocare feedings), if indicated.
    • Rationale: Helps reduce CO2 production and improves respiratory muscle function and metabolic homeostasis.

Nursing Care Plan for Metabolic Alkalosis

These are general interventions for patients with Metabolic Alkalosis.

Desired Outcomes
  • Display serum bicarbonate and electrolytes WNL.
  • Be free of symptoms of imbalance, e.g., absence of neurological impairment/irritability.
Nursing Interventions
  • Monitor respiratory rate, rhythm, and depth.
    • Rationale: Hypoventilation is a compensatory mechanism to conserve carbonic acid and represents definite risks to the individual (hypoxemia and respiratory failure).
  • Assess level of consciousness and neuromuscular status, strength, tone, movement; note presence of Chvostek’s or Trousseau’s signs.
    • Rationale: The CNS may be hyperirritable (increased pH of CNS fluid), resulting in tingling, numbness, dizziness, restlessness, or apathy and confusion. Hypocalcemia may contribute to tetany (although occurrence is rare).
  • Monitor heart rate and rhythm.
    • Rationale: Atrial and ventricular ectopic beats and tachy dysrhythmias may develop.
  • Record amount and source of output. Monitor intake and daily weight.
    • Rationale: Helpful in identifying source of ion loss and potassium and HCl are lost in vomiting and GI suctioning.
  • Restrict oral intake and reduce noxious environmental stimuli; use intermittent and low suction during NG suctioning; irrigate gastric tube with isotonic solutions rather than water.
    • Rationale: Limits gastric losses of HCl, potassium, and calcium.
  • Provide seizures and safety precautions as indicated. Pad side rails, protect the airway, put bed in low position and frequent observation.
    • Rationale: Changes in mentation and CNS or neuromuscular hyperirritability may result in patient harm, especially if tetany or convulsions occur.
  • Encourage intake of foods and fluids high in potassium and possibly calcium (dependent on blood level), canned grapefruit and apple juices, bananas, cauliflower, dried peaches, figs, and wheat germ.
    • Rationale: Useful in replacing potassium losses when oral intake permitted.
  • Review medication regimen for use of diuretics, such as thiazides (Diuril, Hygroton),furosemide (Lasix), and ethacrynic acid (Edecrin).
    • Rationale: Discontinuation of these potassium-losing drugs may prevent recurrence of imbalance.
  • Instruct patient to avoid use of excessive amounts of sodium bicarbonate.
    • Rationale: Ulcer patients can cause alkalosis by taking baking soda and milk of magnesia in addition to prescribed alkaline antacids.
  • Assist with identification and treatment of underlying disorder.
    • Rationale: Addressing the primary condition (prolonged vomiting and/or diarrhea, hyper aldosteronism, Cushing’s syndrome) promotes correction of the acid-base disorder.
  • Monitor laboratory studies as indicated: ABGs/pH, serum electrolytes (especially potassium), and BUN.
    • Rationale: Evaluates therapy needs and effectiveness and monitors renal function.

Administer medications as indicated: Correcting sodium, water, and chloride defects may be all that is needed to permit kidneys to excrete bicarbonate and correct alkalosis, but must be used with caution in patients with HF or renal insufficiency.

  • Sodium chloride PO/Ringer’s solution IV unless contraindicated
    • Rationale: Hypokalemia is frequently present. Chloride is needed so kidney can absorb sodium with chloride, enhancing excretion of bicarbonate.
  • Ammonium chloride or arginine hydrochloride
    • Rationale: Although used only in severe cases, ammonium chloride may be given to increase amount of circulating hydrogen ions. Monitor administration closely to prevent too rapid a decrease in pH, hemolysis of RBCs. Note: May cause rebound metabolic acidosis and is usually contraindicated in patients with renal or hepatic failure.
  • Acetazolamide (Diamox)
    • Rationale: A carbonic anhydrase inhibitor that increases renal excretion of bicarbonate.
  • Spironolactone (Aldactone)
    • Rationale: Effective in treating chloride-resistant alkalosis, e.g., Cushing’s syndrome.
  • Avoid or limit use of sedatives or hypnotics.
    • Rationale: If respirations are depressed, may cause hypoxia and respiratory failure.
  • Encourage fluids IV/PO.
    • Rationale: Replaces extracellular fluid losses, and adequate hydration facilities removal of pulmonary secretions to improve ventilation.
  • Administer supplemental O2 as indicated and respiratory treatments to improve ventilation.
    • Rationale: Respiratory compensation for metabolic alkalosis is hypoventilation, which may cause decreased Pao2 levels or hypoxia.
  • Prepare patient for and assist with dialysis as needed.
    • Rationale: Useful when renal dysfunction prevents clearance of bicarbonate.

Nursing Care Plan for Metabolic Acidosis

Here are general interventions for patients with metabolic acidosis.

Desired Outcomes
  • Display serum bicarbonate and electrolytes within normal limits (WNL).
  • Be free of symptoms of imbalance, e.g., absence of neurological impairment; vital signs WNL.
Nursing Interventions
  • Monitor BP.
    • Rationale: Arteriolar dilation or decreased cardiac contractility and hypovolemia occur, resulting in systemic shock, evidenced by hypotension and tissue hypoxia.
  • Assess LOC and note progressive changes in neuromuscular status. Note neuromuscular strength, tone, movement.
    • Rationale: Decreased mental function, confusion, seizures, weakness, flaccid paralysis can occur because of hypoxia, hyperkalemia, and decreased pH of CNS fluid.
  • Provide seizure or coma precautions and bed in low position, use of side rails, frequent observation.
    • Rationale: Protects patient from injury resulting from decreased mentation and convulsions.
  • Monitor heart rate and rhythm.
    • Rationale: Acidemia may be manifested by changes in ECG configuration and presence of brady dysrhythmias as well as increased ventricular irritability such as fibrillation (signs of hyperkalemia). Life-threatening cardiovascular collapse may also occur because of vasodilation and decreased cardiac contractility. Note: Hypokalemia can occur as acidosis is corrected, resulting in premature ventricular contractions (PVCs) and/or ventricular tachycardia.
  • Observe for altered respiratory excursion, rate, and depth.
    • Rationale: Deep, rapid respirations (Kussmaul’s) may be noted as a compensatory mechanism to eliminate excess acid; however, as potassium shifts out of cell in an attempt to correct acidosis, respirations may become depressed. Transient respiratory depression may be the result of overcorrection of metabolic acidosis with sodium bicarbonate.
  • Assess skin temperature, color, capillary refill.
    • Rationale: Evaluates circulatory status, tissue perfusion, effects of hypotension.
  • Auscultate bowel sounds, measure abdominal girth as indicated.
    • Rationale: In the presence of coexisting hyperkalemia, GI distress (distension, diarrhea, and colic) may occur.
  • Monitor I&O closely and weigh daily.
    • Rationale: Marked dehydration may be present because of vomiting, diarrhea. Therapy needs are based on underlying cause and fluid balance.
  • Test and monitor urine pH.
    • Rationale: Kidneys attempt to compensate for acidosis by excreting excess hydrogen in the form of weak acids and ammonia. Maximum urine acidity is pH of 4.0.
  • Provide oral hygiene with sodium bicarbonate washes, lemon, glycerine swabs.
    • Rationale: Neutralizes mouth acids and provides protective lubrication.
  • Assist with identification and treatment of underlying cause.
    • Rationale: Treatment of disorder is directed at mild correction of acidosis until organ(s) function is improved. Addressing the primary condition (DKA, liver or renal failure, drug poisoning, sepsis) promotes correction of the acid-base disorder.
  • Monitor and graph serial ABGs.
    • Rationale: Evaluates therapy needs and effectiveness. Blood bicarbonate and pH should slowly increase toward normal levels.
  • Monitor serum electrolytes, especially potassium.
    • Rationale: As acidosis is corrected, serum potassium deficit may occur as potassium shifts back into the cells.
  • Replace fluids, as indicated depending on underlying etiology: D5W/saline solutions.
    • Rationale: Choice of solution varies with cause of acidosis: DKA. Note: Lactate-containing solutions may be contraindicated in the presence of lactic acidosis.

Administer medications as indicated: 

  • Sodium bicarbonate or lactate or saline IV
    • Rationale: Corrects bicarbonate deficit, but is used cautiously to correct severe acidosis (pH less than 7.2) because sodium bicarbonate can cause rebound metabolic alkalosis.
  • Potassium chloride
    • Rationale: May be required as potassium re-enters the cell, causing a serum deficit.
  • Phosphate
    • Rationale: May be administered to enhance acid excretion in presence of chronic acidosis with hypo phosphatemia.
  • Calcium
    • Rationale: May be given to improve neuromuscular conduction and function.
  • Modify diet as indicated: low-protein, high-carbohydrate diet in presence of renal failure or American Diabetes Association (ADA) diet for the person with diabetes.
    • Rationale: Restriction of protein may be necessary to decrease production of acid waste products, whereas addition of complex carbohydrates will correct acid production from the metabolism of fats.
  • Administer exchange resins and/or assist with dialysis as indicated.
    • Rationale: May be desired to reduce acidosis by decreasing excess potassium and acid waste products if pH less than 7.1 and other therapies are ineffective or HF develops.