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The nurse is caring for four clients on a medical unit. Which client's laboratory reports does the nurse review first for an electrolyte imbalance?
- A. A 7-year-old with a fracture tibia
- B. A 65-year-old with a myocardial infarction
- C. A 52-year-old with diarrhea
- D. A 72-year-old with a total knee repair
Correct Answer: C
Rationale: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
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The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur?
- A. Respiratory alkalosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Metabolic acidosis
Correct Answer: B
Rationale: Metabolic alkalosis results in increased plasma $\mathrm{pH}$ because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate- containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more $\mathrm{CO}_2$ than necessary.
The nurse is conducting a lecture on the difference between hypovolemia and dehydration. When completing a verbal comparison, which point needs clarified?
- A. Similar causes are present in both conditions.
- B. Hypovolemia contains only low blood volume.
- C. In dehydration, only extracellular is depleted.
- D. Both conditions result in abnormal laboratory studies.
Correct Answer: C
Rationale: In clients diagnosed with dehydration, all fluid compartments including the intracellular and extracellular compartment are reduced. The other options are correct. Both states can be from similar disease process such as vomiting, fever, diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that hypovolemia relates to low blood volume.
A nurse is caring for a severely burned client who now has elevated hematocrit and blood cell counts. What consequences should the nurse expect in this client?
- A. Slow heart rate
- B. Kidney stones and blood clots
- C. Imbalance in electrolytes
- D. Elevated central venous pressure (CVP)
Correct Answer: B
Rationale: Severe burn injury may cause high fluid loss leading to hypovolemia. Elevated hematocrit levels and blood cell counts indicate hemoconcentration, which means a high ratio of blood components in relation to watery plasma. This increases the potential for blood clots and urinary stones. In hypovolemia, the heart rate tends to be high because the heart tries to compensate for the drop in the circulatory volume. Serum electrolyte levels tend to remain normal because they are depleted in proportion to the water loss. CVP is usually below $4 \mathrm{~cm} \mathrm{H}_2 \mathrm{O}$.
The nursing instructor is talking with the nursing class about fluid and electrolyte balance. What would the instructor tell the students that the average daily fluid intake for an adult is?
- A. 2000 mL
- B. 2500 mL
- C. 3000 mL
- D. 3500 mL
Correct Answer: B
Rationale: In healthy adults, oral fluid intake averages about $2500 \mathrm{~mL} /$ day; however, it can range between 1800 and $3000 \mathrm{~mL} /$ day, with a similar volume of fluid loss. $2000 \mathrm{~mL}, 3000 \mathrm{~mL}$, and $3500 \mathrm{~mL}$ are not the average amounts of fluid a healthy adult takes in daily.
The nurse receives report that a client's $\mathrm{pH}$ level is 7.4. Which nursing action would be most appropriate?
- A. Call the health care provider with the report.
- B. Encourage the client to practice deep breathing.
- C. Finish the head-to-toe assessment.
- D. Obtain an ECG.
Correct Answer: C
Rationale: The nurse realizes that a $\mathrm{pH}$ level of 7.4 is within normal limits. No additional measures need obtained and the nurse would perform a usual head-to-toe assessment.