Fluid Imbalance - keeptrackofkris.weebly.com · Fluid Imbalance . Refer to Chapter 8 in Porth...

UNIT 2 – INTEGRATIVE BODY FUNCTIONS

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Fluid Imbalance . Refer to Chapter 8 in Porth textbook (4th Ed.)

Do You Understand the Difference Between?

-Intracellular and Extracellular Compartment?

-Intravascular and Interstitial Compartment?

What are the forces that MOVE fluid to different

body compartments?

Osmosis: The movement of fluid through a semipermeable membrane, from an area of low solute concentration to an area of higher solute concentration until equilibrium is reached.

Hydrostatic pressure “PUSHES” fluid out of the blood vessel into the tissue on the arterial side of the capillaries.

Osmotic (oncotic) pressure is the “PULL” that attracts fluid out of the tissue back into the blood vessel on the venous side of the capillaries. Molecules with PULLING POWER are Protein, Glucose, and Sodium..

* * * * * * * * * * * *

TONICITY of IV Fluids number/ size of molecules in a solution determines which direction

fluid flows:

Isotonic: MOST COMMONLY USED. This fluid moves equally back and forth across a membrane without increasing or decreasing the cell size. Preferred for fluid replacement since the tonicity (sodium concentration) is similar to blood. To remember that ISOtonic fluids are used for almost all situations, “I SO perfect”. Examples: 0.9% normal saline (NS) and lactated ringers (LR).

Hypertonic: fluid is attracted from the tissue into the blood stream by the high concentration of solutes in hypertonic fluid. molecules like Proteins and Glucose attract water (Examples: Albumin, D50,

hetastarch). High concentrations of sodium (higher than 0.9%) also attract water (“SALT SUCKS!”). Hypertonic solution can be given IV when RAPID FLUID REPLACEMENT is needed (usually in an emergency when there is extreme blood loss and the blood vessels need to be filled up with fluid to keep the person from losing blood pressure and dying); OR, when the TISSUE is OVER - HYDRATED (as in edema or Third Spacing) to “pull” or attract fluid out of the tissue. Examples: 3% saline, 6% saline, etc.

Hypotonic: fluid moves to area of higher concentration so a hypotonic solution (which is low in solutes) moves toward the higher concentration of solutes outside of the blood stream. Hypotonic solution is given IV when the TISSUE is DEHYDRATED (as in diabetes or burns). Examples: 0.45% NS; D5W.

: YouTube video “Fluids and Electrolytes” by

David Woodruff, https://www.youtube.com/watch?v=SDDaqoOKnrA (NOTE: The

Electrolyte discussion begins at minute 43:20) and “Fluid & Electrolytes Part II” (first 4

minutes).

Note to self…

Do a “TEACH-BACK” to someone about these concepts!

https://www.youtube.com/watch?v=SDDaqoOKnrA


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“Causes of Edema, “ chart 8-1

pg 163

Test Yourself: Categorize the following IV solutions as Hypertonic/Isotonic/Hypotonic:

1. 0.9% Saline ___________

2. Albumin ___________

3. 3%, 6% Saline ___________

4. 0.45%, 0.33%, 0.225% Saline ___________

5. D5W ___________

6. Lactated Ringers ___________

7. Hetastarch ___________

Nursing Considerations when giving fluids by IV: It is necessary to use caution because giving too

much fluid or giving fluids too fast can cause – primarily in the lungs (because excess fluid in the blood vessels pushes into the interstitial lung tissue) and will drown a patient. The patient’s lungs and breathing effort must be assessed frequently (by auscultating the lungs with a stethoscope).

A “Fluid Challenge” = 500 mL. This means that IV fluid is given in increments of 500 mL at

a time and the patient is assessed before more fluid is given. Then another 500 mL are infused until the patient’s blood pressure normalizes.

- Swelling in Interstitial tissue 1. Damaging effects of edema include: a. Impaired blood flow (and O2 delivery) b. Reduced local healing of tissue c. Metabolic wastes cannot easily leave cells so toxins build up. d. Increases workload on the heart as it tries to move fluid through the blood veins. More pressure is required to push the excess fluid which raises B/P chronic hypertension.

2. LIFE-THREATENING Edema: a. Laryngeal edema (causes AIRWAY blockage). b. Pleural edema (BREATHING impaired). c. Cerebral edema (fluid crushes the brain inside the skull and then the BRAIN stops working).

3. THIRD-SPACING: too much fluid moves from the intravascular space (blood vessels) into the interstitial or "third" Space - the nonfunctional area between cells. This can cause potentially serious problems such as edema, reduced cardiac output, and hypotension (because fluid has moved out of the blood vessels which results in low blood pressure).


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4. How to “Measure” edema changes in a patient:

Dependent edema (in legs) is a common finding in congestive heart failure. This is not an exact or precise measurement but gives nurses a general method of monitoring the changing condition of edema in a patient.

Daily Weights – Done at the same time every day (after voiding with the same weight clothing on, i.e., hospital gown), gives an indication of water gain/loss. It is normal for everyone to weigh about 2 pounds less in the morning than at bedtime. Water is lost through respiration and skin evaporation during the night, along with the collected urine that is voided in the morning. - OR – to weigh 2 pounds more after eating more than usual the day before.

5. Treatment to reduce edema: Diuretic medications [triggers the kidneys to release more water] and

hypertonic fluids [“pulls” fluid out of the tissue to be excreted by the kidneys].

Mechanisms of Water and Sodium Regulation: Thirst – controlled by the thirst center in the hypothalamus & triggered by:

1. Cellular dehydration (caused by increased ECF osmolality, i.e., blood is thicker

than normal).

2. Hypovolemia (low blood volume) - thirst is one of the earliest s/s of hemorrhage.

Antidiuretic hormone (ADH): also called Vasopressin

Secreted by the posterior pituitary gland.

Released in response to increased osmolality (⬆ blood concentration).

Regulates water in the body by signaling the kidney to retain water and sodium.

Excretion of ADH is caused by: Low blood volume; low sodium; high osmolarity of body fluids

(i.e., dehydration – ADH will cause fluid retention to relieve the dehydration).

Electrolyte Imbalance.

4 Major CATIONS: Na+, K+, Ca++, Mg+ What is the normal range for each of the 4 electrolytes?

What is the function of each electrolyte: Excites or Calms?

What tissues do they affect?

S/S of imbalance with each cation (hyper and hypo).


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Learning Activity – Complete the “Electrolyte Imbalances of the 4 Major Cations” chart using your textbook: Pages 174 – 189. A blank copy of this chart is in the Modules section of Canvas for this unit of study. Look up three major signs of imbalance for each cation (both the Hyper and Hypo S/S). One of the BEST ways to commit this information to memory is to fill out the chart SEVERAL TIMES. So make some extra copies of the blank chart and take 10 – 15 minutes every other day to fill it in!

Functions of the 4 Major Cations [Electrolytes]

EXTRACELLULAR Cations

INTRACELLULAR Cations

Exc

ites

Sodium “Excites” Nervous Syst. -Affects BRAIN and nerves. BOTH and

Na+

cause changes in LOC and seizures.

- Na+

same s/s as fluid overload

- Na+

same s/s as dehydration

135 – 145

Potassium - Cardiac tissue -Affects heart, muscles, GI tract. BOTH and

K+ cause dysrhythmias, N/V, paresthesia, SZs.

K+

causes diarrhea (excites GI)

K+

causes constipation

(calms GI)

3.5 – 5.0

Ca

lms

Calcium “Calms” muscle & nerves -Also can affect heart & B/P

- Ca++

Causes tetany because muscle cannot

calm down [positive Chvostek’s sign;

Severe Ca= laryngeal spasm.

-Ca++

muscle weakness

8.5 - 10.5

Magnesium “Calms” smooth muscle and DTRs - Smooth muscle = lungs/ uterus/

heart/ intestines)

- Mg+ hyperreflexia [DTRs cannot relax].

- Mg+ Resp. failure.

- Milk of Magnesia =

laxative

1.5 – 3.0

Match to the Electrolyte: Chvostek’s sign _________; DTRs _________; Seizures: _________:

Dysrhythmias _________; Hyperreflexia _________; Tetany _________; LOC Change ________;

How does HYPONATREMIA cause Seizures?* _____________________________________________ How does HYPERNATREMIA cause Seizures?* ___________________________________________________

(*HINT: Think about how sodium affects H2O movement in and out of cells in the brain – read section in textbook)

*Note to VISUAL and TACTILE dominant learners: It may be helpful to draw a picture of the associated body system to help remember what parts of the body these electrolyte imbalances affect the most.


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Recommended:

“Acid/Base Imbalances”

PowerPoint available in Canvas,

Unit 2 Module, for a mini review of

Acid/Base concepts.

This background information will help you

answer test questions.

Acid/Base Imbalance.

PH is balanced by 3 Mechanisms:

Mechanism Mechanism Action Rates of Acid/Base Correction

Chemical Buffers

Bicarbonate buffer, Phosphate buffer, and Protein buffers

Buffers function almost instantaneously

Respiratory System

Uses respiration to “blow off” excess carbon dioxide (an acid) to normalize low pH

Respiratory mechanisms take several minutes to hours

Renal System:

Controls excretion of Hydrogen ions (acid control) and Bicarbonate (base control)

Renal mechanisms may take several hours to days

Respiratory regulation – First Response by lungs

If Acidotic: The lungs try to compensate - raises pH by “blowing off” CO2 (which makes a weak acid in the body – carbonic acid). This results in a KUSSMAUL breathing pattern - deep rapid breathing).

If Alkalotic: The body will try to compensate by reducing ventilations to conserve CO2. Hyperventilation (which causes respiratory alkalosis) can occur with fever, anxiety, pain, or as a result of ventilator providing too much oxygen.

Metabolic regulation – Slower response by kidneys

If Acidotic: The kidneys will excrete hydrogen ions [H+] to get rid of acid and retain Bicarbonate (a base) to neutralize acid.

If Alkalotic: The kidneys will retain H+ excrete bicarb.

Causes of Acid/Base Imbalances.

Respiratory ~ Acidosis – RETAINED CO2 (lung insult/illness/injury – infection, COPD, trauma to lungs, etc.) ~Alkalosis - CO2 is too low (caused by hyperventilation)

Metabolic ~Acidosis – Retained H

+ or other acid (Chronic Renal Failure or Diabetic Ketoacidosis-DKA), crush

injury that releases potassium into the blood stream (K+ becomes an acid), or in diarrhea (“base-out-the–butt”).

~Alkalosis – Loss of H+ or other acid as in vomiting.

pH

7.35 - 7.45

PCO2 (respiratory) 35 - 45

HCO3- (renal) 22 - 26 PaO2 80 - 100


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Acid Base Mnemonic video (2:23 min.) https://www.youtube.com/watch?v=rLaPJjXQvec

Effects of Acid/Base Imbalances.

Principal effect of ACIDOSIS is DEPRESSION of the Central Nervous System (decrease in synaptic transmission).

Deranged CNS function is the greatest threat Generalized weakness

Severe acidosis causes: Disorientation - Coma - Death

Principal effect of ALKALOSIS is EXCITATION of the Central Nervous System.

S/s initially are numbness/lightheadedness Severe Alkalosis causes: Muscle spasms or tetany - Convulsions - Death

Interpreting Arterial Blood Gas Results STEP 1: Determine from the pH if the condition is ACIDOSIS or ALKALOSIS

Below 7.35 = ACIDOSIS Above 7.45 = ALKALOSIS

STEP 2: Determine from the CO2 and Bicarb if the condition is RESPIRATORY or METABOLIC

If the pH and abnormal value [could be either CO2 or HCO3] are pointing in the same direction

(both high or both low) then the condition is pH ⬆, PaCO2 ⬌, HCO3 ⬆

If the pH and abnormal value [CO2 or HCO3] are opposite from each other (one is high, the other

low or vice versa) then it is pH ⬇, PaCO2 ⬆, HCO3 ⬌

How to determine if / / :

= pH is NORMAL and other two values are abnormal

= pH and one other value is abnormal

= all values are abnormal

PRACTICE READING ABGs: Interpret the following ABG Values to determine what type of Acid-Base

Imbalance is present. Examples: ⬇ = low, ⬆= high, ⬌ = normal range

pH 7.32, PaCO2 55, HCO3 25 pH ⬇, PaCO2 ⬆, HCO3 ⬌ Respiratory (pH and PaCO2 are opposite) Acidosis (low pH) pH 7.50 , PaCO2 30, HCO3 23 pH ⬆, PaCO2 ⬇, HCO3 ⬌ Respiratory (pH and PaCO2 are opposite) Alkalosis (high pH) pH 7.29, PaCO2 39, HCO3 20 pH ⬇, PaCO2 ⬌, HCO3 ⬇ Metabolic (pH and HCO3 are the same) Acidosis (low pH) pH 7.50, PaCO2 42, HCO3 32 pH ⬆, PaCO2 ⬌ , HCO3 ⬆ Metabolic (pH and HCO3 are the same) Alkalosis (high pH)

https://www.youtube.com/watch?v=rLaPJjXQvec


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Uncompensated Acid/Base Examples (Determine if Acidosis/Alkalosis, then determine if Respiratory/Metabolic)

1) pH: 7.30, PaCO2: 38, HCO3: 18 ________________________________________________________________

2) pH: 7.25; PaCO2: 50; HCO3: 23 ________________________________________________________________

3) pH: 7.49; PaCO2: 33; HCO3: 25 ________________________________________________________________

4) pH: 7.48; PaCO2: 47; HCO3:30 ________________________________________________________________

5) pH: 7.33; PaCO2: 52; HCO3: 26 ________________________________________________________________

6) pH: 7.52; PaCO2: 40; HCO3: 33 ________________________________________________________________

7) pH: 7.52; PaCO2: 27; HCO3: 25 ________________________________________________________________

8) pH: 7.31; PaCO2: 48; HCO3: 22 ________________________________________________________________

9) pH: 7.29; PaCO2: 36; HCO3: 15 ________________________________________________________________

Determine if Uncompensated/Partially Compensated/ or Compensated

1) pH: 7.32; PaCO2: 33; HCO3: 20 ________________________________________________________________

2) pH: 7.49; PaCO2: 30; HCO3: 25 ________________________________________________________________

3) pH: 7.32; PaCO2: 47; HCO3: 30 ________________________________________________________________

4) pH: 7.43; PaCO2: 48; HCO3: 35 ________________________________________________________________

5) pH: 7.38; PaCO2: 43; HCO3: 24 ________________________________________________________________

EXAMPLE: Patient who is developing pneumonia 1. Beginning stages of pneumonia – pH is NORMAL:

2. As pneumonia worsens CO2 increases , this Results in an UNCOMPENSATED ABG

2 arrows abnormal

3. Kidney starts to help to neutralize acid

3 arrows abnormal

4. Kidneys are able to neutralize acid on a continuous basis by retaining bicarbonate

pH is NORMAL but other values abnormal

Metabolic Alkalosis- Partial Compensation pH , PCO2 , HCO3 Arrows saME direction as pH = MEtabolic Metabolic Acidosis- Partial Compensation pH , PCO2 , HCO3

Respiratory Alkalosis- Partial Compensation pH , PCO2 , HCO3 Arrows REverse direction of pH = REspiratory Respiratory Acidosis- Partial Compensation pH , PCO2 , HCO3

See the

answers

at the

end of

the

outline


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What ABG lab values would you expect to find given the symptoms in the scenario?

1) Patient has been nauseous & vomiting. What ABG values might you expect, and why?

2) Client is in Acute Renal Failure due to prolonged hypovolemia. What ABG values

might you expect, and why?

3) Client reports that he ate some really spicy hot wings last night, and has been

having diarrhea ever since. What ABG values might you expect, and why?

4) You realize that the mechanical ventilation for a comatose client has been set at

too high a rate. What ABG values might you want to check for, and why?

5) Client has COPD. What ABG values might you want to watch for, and why?

See answers at end of outline.

Stress and Adaptation.

Stress, whether mental or physical, triggers an identifiable

physiological response. The body’s response to short term

stress is intended to return the body to normal. The effects of

prolonged stress, however, result in many disease states that

bring people to the doctor!

Hans Seyle - General Adaptation Syndrome

1. Alarm stage--> aware of the stress, CNS aroused. Body defenses mobilized, cortisol response--> SNS or flight or fight phenomena. Release of catecholamine and cortisol. 2. Resistance/Adaptation – full mobilization of all body resources allow the individual to cope (maintain homeostasis) despite being in a stressed condition. 3. Stage of Exhaustion - continuous stress causes the progressive breakdown of compensatory mechanisms & homeostasis. This stage marks the onset of certain diseases.

Body Chemistry Involved in the Stress Response (NOT an all-inclusive list)

Catecholamines (epinephrine/norepinephrine) prepare the body to act & cortisol mobilizes energy (glucose) and other substances needed to fuel the action.

1-Epinephrine-- exerts its chief effects on the cardiovascular system. This occurs through vasodilation of blood vessels that supply these organs

Increases cardiac output to maintain blood pressure

Increases blood flow to the brain

Increases blood flow to the skeletal muscles

Dilation of the airways-- increases delivery of O2 to the bloodstream

2-Norepinephrine-- the effects complement those of epinephrine. Works through vasoconstriction

It constricts blood vessels of the viscera and skin-->this shifts blood flow to the vessels dilated by epinephrine.

Also increases mental alertness

Test Material


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Cortisol – Corticosteroid that acts as both a mediator and an inhibitor of the stress response to prevent over activation of SNS

Mobilizes glucose, amino acids, lipids and fatty acids and delivers them to the bloodstream

Suppresses immune and inflammatory function

Antagonizes the effects of insulin

Enhances the effects of catecholamine on the cardiovascular system

Suppresses osteoblast activity, hematopoiesis, protein and collagen synthesis.

Glucose increases with stress. Prolonged and unrelenting stress causes a chronic elevation of glucose levels that leads to Diabetes Mellitus

Antidiuretic Hormone (ADH) – Excreted from the pituitary gland; stimulates the kidneys to RETAIN fluid thereby increasing blood

pressure.

Also causes VASOCONSTRICTION which helps to increase blood pressure.

Participates in the Renin-Angiotensin-Aldosterone pathway (to be discussed in the Renal System Unit).

Effects of Prolonged Stress: Cardiovascular – Sympathetic Nervous System (SNS) increases heart rate and blood pressure. Prolonged stress can be a cause of chronic hypertension and cardiovascular disease. Immune system – Decreased Lymphocyte production. Decreased T cell activity prone to infections.

Increase in proinflammatory processes (via cytokines). Suppresses Natural Killer cell function (NK cells are responsible for killing tumors). Reactivates latent viruses (i.e., herpes virus; Epstein Barr virus).

Gastrointestinal system – is deactivated by the SNS (because the GI tract is not needed for “Fight or Flight” activities. slow peristalsis, ulcers, constipation, serious bowl problems.

Endocrine system – Release of cortisol from the adrenal glands increases blood sugar for energy needs

Hyperglycemia (Diabetes Mellitus Type 2)

Hypothalamic/Pituitary Axis effects on reproductive system (in particular the female)

Responsible for the "hypothalamic" amenorrhea of stress, depression and eating disorders, and the hypogonadism of Cushing's syndrome. Effects lipid alterations (a cause of obesity).

Central Nervous system Fatigue & lethargy: protein catabolism

Depression, anxiety, insomnia: activity of neurotransmitters & neurohormones

Cancer A. Decreased natural killer cell activity B. Poor repair of damaged DNA C. Alterations in the rates of apoptosis of immune and cancer cells D. Psychosocial interventions extended the lives of women with breast cancer.

Autoimmune disorders - Diseases impacted by increased humoral activity. Inflammatory process is triggered – damage to tissue caused by proinflammatory chemicals that then triggers the immune system to fight against the body in genetically susceptible individuals.


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ANSWERS - TO “What ABG lab values would you expect to find given the symptoms in the scenario?”

1) Patient has been nauseous & vomiting. (What ABG values might you expect, and why?)

Metabolic Alkalosis pH: high (alkaline) PaCO2: normal or increasing HCO3: high

Vomiting rids the body of stomach acid, decreasing the total amount of acid in the body. So acid would decrease, which causes the pH to increase (become more alkaline). Reduced amounts of acid means that more free bicarb will be available, which makes the HCO3 value higher. Since the problem is found in the GI system and HCO3 is the abnormal value, then this imbalance is considered a Metabolic type. The PaCO2 would be normal because there is not a respiratory cause, or it might begin increasing (trying to make the body more acidic) if the respiratory system is starting to compensate.

2) Client is in Acute Renal Failure due to prolonged hypovolemia. (What ABG values might you expect, and why?) Metabolic Acidosis pH: low (acidic) PaCO2: normal or decreasing HCO3: low

Normally, the kidneys resorb bicarbonate and excrete acid. Since the kidneys are in failure, they can’t do either job effectively, especially resorbing bicarb. With the kidneys losing bicarb, we can expect the HCO3 to be low, which also lowers pH and makes the body more acidic. Since the problem is in the kidneys and the Imbalance s primarily r/t bicarb, then this imbalance is considered Metabolic. The PaCO2 would be normal because there is not a respiratory cause, or it might begin decreasing (trying to make the body more alkaline) if the respiratory system is starting to compensate.

3) Client reports that he ate some really spicy hot wings last night, and has been having diarrhea

ever since. Metabolic Acidosis pH: low (acidosis) PaCO2: normal or decreasing HCO3: low

The pH would be acidosis because diarrhea makes you lose bicarbonate, making the body become more acidic. So the HCO3 would be low. Since the problem is in the GI system and the imbalance is r/t the HCO3, then cause of the imbalance is considered Metabolic. The PaCO2 would be normal because this is not a respiratory cause, or it might begin decreasing (trying to make the body more alkaline) if the respiratory system is starting to compensate.

4) You realize that the mechanical ventilation for a comatose client has been set at too high a

rate. (What ABG values might you expect, and why?)

Respiratory Alkalosis pH: high (alkalosis) PaCO2: low HCO3: normal or decreasing

The client is breathing too fast (the equivalent of hyperventilation) and therefore is “blowing off” too much Carbon Dioxide (CO2), so the PaCO2 will be low. Acid “follows” the carbon dioxide, so acid is also leaving the body, making the pH high (more basic/alkaline). Since the cause of the imbalance is in the airway and r/t the PaCO2 level, then this imbalance is considered Respiratory. The HCO3 would be normal because this imbalance does not have a metabolic cause, or it might begin decreasing if the metabolic system is starting to compensate.

5) Client has COPD. (What ABG values might you expect, and why?) Respiratory Acidosis pH: low (acidosis) PaCO2: high HCO3: normal or increasing

Clients with COPD tend to “trap” carbon dioxide (CO2) in the lungs. Since acid follows carbon dioxide, this causes the body’s pH to decrease and become more acidic. Since the cause of this imbalance is in the lungs, and the PaCO2 level is abnormal, then it is considered a Respiratory imbalance. The HCO3 would be normal because this imbalance does not have a metabolic cause, or it might begin increasing if the metabolic system is starting to compensate for the extra acid in the body.


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NOTE: There is another Acid/Base practice sheet in the Canvas Modules for Unit 2 ANSWERS to – “Interpret the following ABG Values to determine what type of Acid-Base Imbalance is present”

Uncompensated examples

1) pH: 7.30, PaCO2: 38, HCO3: 18 = Metabolic Acidosis

2) pH: 7.25; PaCO2: 50; HCO3: 23 = Respiratory Acidosis

3) pH: 7.49; PaCO2: 33; HCO3: 25 = Respiratory Alkalosis

4) pH: 7.49; PaCO2: 44; HCO3: 30 = Metabolic Alkalosis


6) pH: 7.52; PaCO2: 40; HCO3: 33 = Metabolic Alkalosis

7) pH: 7.52; PaCO2: 27; HCO3: 25 = Respiratory Alkalosis


9) pH: 7.29; PaCO2: 36; HCO3: 15 = Metabolic Acidosis

Practice Questions for Unit 2 1--Which of the following would not be an appropriate use of hypertonic saline?

A. A patient with cerebral edema B. A trauma patient who is hemorrhaging

C. A patient in diabetic ketoacidosis D. A patient with severe hyponatremia

2--A nursing order, “Increase fluid intake” is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? A. Urinary output of 1,500 mL in 24 hours. B. Serum hematocrit 52%.

C. Oral fluid intake of 900 mL in 24 hours. D. Blood pressure of 95/82.

3-- An elderly postoperative patient is demonstrating lethargy, confusion, & a respiratory rate of 8 per minute. The nurse sees that the last dose of pain medication was given 30 minutes ago. Which of the following acid-base disorders might this patient be experiencing? A. respiratory alkalosis B. metabolic alkalosis C. respiratory acidosis D. metabolic acidosis 4. __________________ is the dominant cation that helps maintain osmotic balance in the ECF. A. Potassium B. Sodium C. Calcium D. Magnesium 5--Fill in the blanks: Sodium (excites/calms) ______________ tissue. Calcium (excites/calms) ________________________ tissue 6--A primary cause of hyperkalemia is: A. Liver Failure B. Anorexia C. Renal Failure D. Emesis 7-- The most significant effect of serum potassium alterations is: A. Dehydration B. Muscle weakness C. Nausea and vomiting D. Cardiac dysrhythmias 8 -- The nurse cares for a client diagnosed with a compound fracture of the left femur. The client’s vital signs are BP 80/60, pulse 120, respirations 26, temperature 99.0°F (37.2°C). Which IV fluid order should the nurse question?

A. Lactated Ringer’s (LR) C. 0.9% sodium chloride (normal saline) B. 0.45% sodium chloride (half normal saline) D. Hetastarch (Hespan) 9--The health care provider orders an IV with 5% dextrose in water (D5W) started for an 86-year-old client. Which action by the nurse is BEST?

A. Assess for bilateral pretibial edema. C. Obtain daily weights. B. Measure the hourly urine output. D. Auscultate lung sounds.

Uncompensated/Partially compensated/Compensated

1) pH: 7.32; PaCO2: 33; HCO3: 20 = Partially Compensated

2) pH: 7.49; PaCO2: 30; HCO3: 25 = Uncompensated

3) pH: 7.32; PaCO2: 47; HCO3: 30 = Partially Compensated

4) pH: 7.43; PaCO2: 48; HCO3: 35 = Compensated

5) pH: 7.38; PaCO2: 43; HCO3: 24 = Normal…no imbalance!

1-C, 2-A, 3-C, 4-B, 5-excites/nerve; calms nerve & muscle, 6-C, 7-D, 8-B, 9-D

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