Chapter 6 Nursing Care of Patients with Fluid, Electrolyte, and Acid–Base Imbalances

Answers CHAPTER 6 NURSING CARE OF PATIENTS WITH FLUID, ELECTROLYTE, AND ACID–BASE IMBALANCES AUDIO CASE STUDY Grandma Lois Is Dehydrated 1. Grandma Lois was lethargic and had altered mental status; low-grade temperature; concentrated urine; dry, sticky mucous membranes; tachycardia; and poor skin turgor. 2. Shortness of breath with elevated respiratory rate, crackles in lungs, and edema. 3. Older adults have a lower percentage of body water to begin with and so are more easily dehydrated than younger people. Their kidneys also do not work as efficiently as younger people’s. VOCABULARY 1. diffusion 2. isotonic 3. hypertonic 4. hypovolemia 5. cations 6. hypernatremia 7. hypokalemia 8. hypocalcemia 9. Acidosis 10. alkalosis DEHYDRATION Corrections are in boldface. Mrs. White is a 78-year-old woman admitted to the hospital with a diagnosis of severe dehydration. The licensed practical nurse/licensed vocational nurse (LPN/LVN) assigned to Mrs. White is asked to collect data related to fluid status. The LPN/LVN expects Mrs. White’s blood pressure to be low because of fluid loss. The nurse also finds Mrs. White’s skin turgor to be poor, and the nurse notes that the urine output is scant and dark amber. The nurse asks Mrs. White if she knows where she is and what day it is, because severe dehydration may cause confusion. In addition, the nurse initiates taking daily weights because this is the most accurate way to monitor fluid balance. ELECTROLYTE IMBALANCES 1. (4) 2. (5) 3. (2) 4. (3) 5. (1) CRITICAL THINKING 1. Check Mr. James’s vital signs. Elevated blood pressure, bounding pulse, and shallow, rapid respirations are common signs of fluid overload. If he is able to stand, weigh him to see if his weight has increased since yesterday. Auscultation of his lungs may reveal new-onset or worsening crackles. (He may have had crackles on admission related to his bronchitis.) 2. Kidney function declines in the older adult, and the intravenous (IV) fluids may have been too much for him. Regular assessment and caution with IV therapy can prevent overload from occurring. 3. The registered nurse may decide to reduce the IV infusion rate until orders are obtained. The LPN/LVN can do the following: Elevate the patient’s head to ease breathing. Make sure oxygen therapy is being administered as ordered. Stay with him to help him feel less anxious. Anticipate a possible diuretic order. Continue to monitor fluid balance. 4. If a diuretic is administered, urine output should increase, but this does not signal resolution of the problem. It is probably unrealistic to expect Mr. James’s lungs to clear completely because he was admitted with bronchitis. However, return of lung sounds to admission baseline would signal resolution of the acute overload. Other signs would include return to admission vital signs and weight and the ability to walk to the bathroom again without excessive shortness of breath. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (2) is correct. 0.9% is isotonic, making 0.45% hypotonic. (1) is isotonic; (3, 4) are hypertonic. 2. (1) is correct. Antidiuretic hormones retain water. (2, 3, 4) do not affect water balance. 1 2 Chapter 6 Answers 3. (2) is correct. Deli meats are high in sodium. (1, 3, 4) are not high in sodium. 4. (3) is correct. Potatoes are high in potassium. (1, 2, 4) are not high in potassium. 5. (2) is correct. Fluid gains and losses are evidenced in weight gains and losses. (1, 3, 4) are all ways to monitor fluid balance, but they are not as reliable. Intake and output may be inaccurate, vital signs may be affected by other factors, and measurement of skin turgor is subjective. 6. (2) is correct. Vomiting, diarrhea, and profuse sweating can cause dehydration that may manifest itself by thirst, a rapid heartbeat but weak pulse, low blood pressure, dark urine, dry skin and mucous membranes, and elevated blood urea nitrogen and hematocrit levels. Temperature often increases in cases of dehydration but may not be apparent in older people who often have a lower normal body temperature than younger people. (1) is incorrect. Hypervolemia, or overhydration, is the opposite of dehydration. Excess fluid may result in (3) edema in the lower extremities and elevated blood pressure; increased rate of respiration; pale, cool skin; and diluted urine. (4) is incorrect. Hyponatremia, or low sodium level, may occur with dehydration but can be confirmed only by laboratory tests. In any case, the fluid imbalance must be assessed and treated first. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 7. (2) is correct. Failing kidneys cannot effectively excrete water, making the patient at risk for overload. (1, 3, 4) do not cause fluid retention. Influenza can cause fluid loss if vomiting or diarrhea is present. 8. (1, 4, 6) are correct. The patient with an ileostomy loses large amounts of water with continuous liquid stools. Fever is associated with an increased risk of dehydration. Diuretic therapy increases the risk for dehydration. (2) Asthma, (3) diabetes (as long as it is stable), and (5) fractures do not cause fluid loss. 9. (1) is correct. Hyponatremia accompanied by fluid loss results in dehydration and mental status changes. (2, 3, 4) are not as likely to affect fluid balance and mental status. 10. (3) is correct. Ambulation can help prevent bone loss. Because the patient is weak and is at risk for falls and fractures, assistance should be provided. (1) is incorrect. Bedrest promotes bone loss. (2) is incorrect. Fluids will not help bone or calcium levels. (4) is incorrect. The patient needs calcium, not protein. 11. (2) is correct. The patient is probably hyperventilating because of the anxiety. Rebreathing carbon dioxide exhaled into a paper bag can temporarily relieve symptoms of alkalosis until the underlying cause is corrected. (1, 3, 4) all help increase oxygenation, which is not needed at this time. 12. (2) is correct. Hypoventilation related to lung disease leads to retention of carbon dioxide, which causes acidosis. (1) is incorrect. Hyperventilation causes alkalosis. (3) is incorrect. Loss of acid causes alkalosis. (4) is incorrect. Loss of base causes acidosis, but it is not the cause in this case. 13. (3, 4, 6) are correct. Potassium supplements should be taken with food. Slow-K should not be crushed. Diarrhea is not expected and should be reported to the physician. If the patient makes these statements, more teaching is needed. (1, 2, 5) are incorrect.