NR 324-exam 1 fluid and electrolytes and respiratory 2023 with complete solution

paO2 80-100 mm Hg pH 7.35-7.45 low pH acidic high pH alkalosis pa CO2 35-45 mm Hg HCO3 22-26 mEq/L respiratory acidosis low pH, high co2, normal bicarbonate causes of respiratory acidosis respiratory depression from anesthesia, overdose, increased intracranial pressure, airway obstruction from decreased alveolar capillary diffusion like pneumonia, COPD, ARDS, AND PE signs/symptoms of respiratory acidosis hypoventilation (hypoxia), rapid, shallow respirations, decrease in BP, skin/mucous pale to cyanotic, headache, hyperkalemia, dysrhythmias, drowsiness, dizziness, disorientation, muscle weakness, hyperreflexia Nursing management of respiratory acidosis ventilator, arterial blood gas, low-dose oxygen in chronic conditions, high-dose oxygen in acute hypoxia with acidosis, I/O, promote the release of CO2, turn/cough/deep breathe, assume semi-high fowlers position, clear respiratory secretions, colors of skin, mucous membranes respiratory alkalosis high pH, low co2 and normal bicarbonate causes of respiratory alkalosis high pH, low co2 and hyperventilation, initial stages of pulmonary emboli, hypoxia, fever, pregnancy, high altitudes, and anxiety signs/symptoms of respiratory alkalosis seizures, deep/rapid breathing, hyperventilation, tachycardia, decrease BP, hypokalemia, numbness/tingling in extremities, lethargy/confusion, light headedness, N/V nursing management of respiratory alkalosis kidneys retain H+ ions, use a rebreather mask or paper bag, sedatives, monitor respiratory rate/depth, tachycardia, low BP, serum K+ levels/ECG levels, hydration status I/O, check for toxicities metabolic acidosis low ph, normal co2 and low bicarbonate metabolic acidosis signs/symptoms compensatory hyperventilation (kussmaul respirations), headache, decreased BP, hyperkalemia, muscle twitching, warm/flushed skin, N/D/V, changes in LOC, causes of metabolic acidosis low ph/low bicarbonate, diabetic ketoacidosis, shock, sepsis, severe diarrhea, and renal failure what goes up in acidosis potassium metabolic acidosis nursing management BUN, creatinine, hemoglobin/hematocrit levels, monitor hydration, turn/cough/deep breathe, ABG's, check K, Ca usually goes down, weights, vitals metabolic alkalosis high ph, normal co2, and high hco3 causes of metabolic alkalosis high ph, high bicarb and severe vomiting, excessive GI suctioning, diuretics, and excessive NaHCO3 metabolic alkalosis signs/symptoms restlessness (lethargy), confusion, dizzy, irritable, dysrhythmias, compensatory hypoventilation, N/V/D, tremors, muscle cramps, tingling of fingers and toes, dehydration metabolic alkalosis nursing management monitor ECG's, ABG's for pH, K, Ca levels, LOC checks for tetany, tremors, muscle cramps, tingling, what is hyperkalemia frequently associated with metabolic acidosis what is a compensatory mechanism for metabolic alkalosis decreased respiratory rate and depth to retain CO2 and kidney excretion of bicarbonate excessive intake causes rapid oral ingestion of water, infusions of D5%W hypotonic fluid at excess, massive replacement of water without NA decreased output causes renal failure fluid volume excess causes heart failure, water intoxication, liver cirrhosis, SIADH, lung cancer, renal failure, primary polydipsia, long term use of cortiosteroids fluid volume excess clinical manifestations headache, JVD, increased weight, edema, ascites, elevated blood pressure, crackles in lungs, confusion, decreased urine specific gravity, pitting edema, high BP, presence of s3, tachycardia, bounding pulse, changes in LOC, seizures, low pulse ox (below 89%), seizures, coma, muscle spasms, dyspnea fluid volume excess nursing management frequent respiratory assessments and LOC, watch for edema, cardiovascular checks, daily weights, fluid restriction, measure intake and output, decrease sodium intake, diuretics fluid volume deficit population elderly, profuse sweating, v/d, NG tubes, trauma r/t bleeding, pts NPO, AMS, surgical patients, laxativies, diruetics fluid volume deficit causes water loss, perspiration, diabetes insipidus, osmotic diuresis, hemorrhage, GI losses like vomiting, NG suctioning, diarrhea, fistula drainage, overuse of diuretics, inadequate fluid intake, third space shifts, burns, intestinal obstruction fluid volume deficit signs/symptoms restlessness, drowsiness, lethargy, confusion, thirst, dry mucous membranes, decreased skin turgor, decreased cap refill, postural hypotension, increased pulse 120, decreased CVP, decreased urine output, concentrated urine, increased respiratory rate, weakness, dizziness, seizures, coma, decreased BP 86/50 fluid volume deficit nursing interventions intake/output, cardiovascular changes, LOC changes, pupillary response, responsiveness, voluntary movement, patient safety, seizure precautions, fall precautions, daily weights, skin assessment for turgor/color/dryness, pitting edema, administer IV fluids dehydration loss of water alone without sodium, cell shrinks hypernatremia causes sodium greater than 145, intake excessive, IV fluids (hypertonic Nacl, IV sodium bicarbonate), hypertonic tube feedings without water supplements, near-drowning in salt water, inadequate water intake (cog impaired), excessive water loss (heatstroke, high fever), osmotic diuretic therapy, diarrhea, disease states like DI, primary hyperaldosteronism, cushing syndrome, uncontrolled diabetes mellitus hypernatremia; fluid volume deficit signs/symptoms signs of thirst, fever, dry mucous membranes, hypotension, tachycardia, low jugular venous pressure and restlessness, weakness, change of LOC, thready pulses nursing management of hypernatremia administer hypotonic solution if na known, administer isotonic solution if na is not known, if corrected too quickly can cause cerebral edema hypernatremia nursing interventions treat the cause, add water to balance sodium, or replace sodium and water, monitor I/O, urine specific gravity greater than 1.025, pulses, tachycardia, tachypnea, changes in sensorium, daily weights, skin turgor and mucous membranes which of the follow interventions does the nurse complete when caring for a client admitted with a sodium level of 152 mEq/L observe and prepare for possible seizures hyponatremia causes sodium is less than 135 mEq/L, vomiting, diuretics, gastrointestinal suctioning, diarrhea, inadequate salt intake, fluid shift from the ICF to the ECF by hypertonic solutions which leads to dilutional hyponatremia two phases of hyponatremia 1 is too much volume, so decrease in sodium to correct give diuretic and 2 is loss of sodium from other sources to correct on individual basis decreased Na is caused by dilution as a result of excess water or increased Na loss hyponatremia signs and symptoms cell swells, lethargy, headache, confusion, apprehension, seizures, and coma, change in LOC, muscle weakness, stupor, tendon reflexes decreases hyponatremia interventions administer hypertonic solutions with known Na value, monitor patients lungs sounds, administer isotonic solutions with unknown sodium level, report LOC changes, fluid restriction if caused by too much water nursing management of hyponatremia I/O, check for bounding pulses, bulging neck veins, BP changes, signs of cerebral edema, daily weights, pitting edema with fluid excess, daily weights and goal is to restore na and water balance and prevent complications of cerebral edema the nurse assigned to a client with hyponatremia would conclude that which of the following factors probably contributed to this electrolyte imbalance fluid retention and heart failure potassium imbalances heart contractions and ECG will guide plan of care hyperkalemia caused by life threatening, impaired renal excretion of potassium, excess intake, metabolic acidosis and medications like beta blockers, dehydration hyperkalemia signs/symptoms (MURDER) muscle cramps, urine abnormalities, respiratory distress, decreased cardiac contractility, EKG changes, and reflexes nursing management of hyperkalemia check for muscle weakness, administer diuretics, monitor renal and respiratory status, restricted diet, increase fluid intake, administer insulin-kayexalate, dialysis, monitor ECG, monitor blood sugar the nurse anticipates the client with which condition would be most at risk to develop hyperkalemia chronic renal failure hypokalemia is caused by increased excretion of potassium, N/V, sweating, diuretics, dialysis, increased insulin, alkalosis, tissue repair, increased epinephrine, lack of intake hypokalemia assessment muscle weakness and cramps, life threatening if not treated, alkalosis on ABG, fatigue, depressed ST with a U wave, arrhythmias, thready pulse signs/symptoms of hypokalemia (A SIC WALT) alkalosis, shallow respirations, irritability, confusion and drownsiness, weakness and fatigue, arrhythmias, lethargy, thready pulse hypokalemia nursing interventions watch for skeletal muscle weakness, most dangerous drug to administer, on IV pump no more than 10 mEq/hr, causes vein irritation, ice site, lidocaine, monitor, piggyback with normal saline, always on a pump, encourage intake from foods calcium controlled by the parathryroid hormone and calcitonin, bones store, regulated with moving in/out of bones which increases GI and renal absorption, calcitonin lowers ca by decreasaing GI absorption and increasing absorption hypercalcemia causes results from malignancy, increased production of PTH, hyperparathyroidism, prolonged immobilization, vitamin d overdose, thiazide diuretics hypercalcemia signs/symptoms painful bones, renal stones, abdominal groans like N/V, constipation, indigestion and psychiatric moans like lethargy, fatigue, memory loss, psychosis, depression hypocalcemia causes any condition decreasing serum calcium levels like cirrhosis, malnutrition, decreased production of PTH like hypoparathryoidism, loop diuretics, alkalosis, vitamin D deficiency hypocalcemia signs/symptoms (CATS) convulsions, arrhythmias, tetany, stridor and spasms clinical signs for hypocalcemia chvostek sign (contraction of facial muscles that occur when lightly tapping on ear) and trousseau sign (carpal spasm bringing the index finger and thumb together when the BP cuff is inflated above systolic pressure) nursing management of hypocalcemia monitor for dysrhythmias, diet high in calcium and vitamin D, assess for discomfort, IV site, IV preparations, oral supplements when phosphorus is increased calcium is decreased when calcium is increased phosphorus is decreased normal calcium levels 8-10 magnesium normal range 1.3-2.1 mEq/L for adults hypermagnesemia causes renal dysfunction, use of antacids, use of laxatives like MOM, and Mag sulfate hypermagnesemia signs/symptoms respiratory depression, lethargy, cardiac arrest, diminished deep tendon reflexes, flushed warm skin, decreased pulse, decreased BP, muscle weakness, dysphagia, N/V nursing intervention for hypermagnesemia focus on prevention, decrease intake of foods like bananas, oranges, peanut butter, chocolate hypomagnesemia causes inadequate intake (malnutrition, malabsorption), metabolic acidosis, alcoholism, malabsorption from inflammatory bowel diseases, excessive gastric drainage hypomagnesemia signs/symptoms confusion, tremors, seizures, hyperactive deep tendon reflexes, insomnia, increased pulse, increased BP, muscle cramps intervention for hypomagnesemia administer MG oral or IV, increase food intake the nurse is educating the client who has a magnesium level of 1.2 mEq/L, what information is most important for the nurse to include in discussions with the client hypomagnesemia, diet counseling phosphorus essential to muscle function, RBC, and nervous system, found in bones and teeth hyperphosphatemia renal failure patients, diseases of endocrine system, fleets enema, sickle cell anemia hyposhoshatemia rare disorder, malnourished, malabsorption, hypoventilation like respiratory alkalosis hypertonic solutions 3-5% NS, CHF, Hypervolvemia, edema, pull sodium in vasculature isotonic solution 0.9% NS, lactated ringers, dehydrated hypotonic solution 0.45 NS, D5W, dehydrated and hypovolemic, moves to cells, swells, neurologically comprised nursing care of patient with impaired gas exchange life the HOB (open airway), give oxygen, asculate, look for sputem, chest x-ray, and give antibiotics also be aware for signs of distress gas exchange the process by which oxygen is transported to the cells and carbon dioxide is transported from the cells impaired oxygenation leads to ischemia impaired elimination of carbon dioxide leads to respiratory acidosis what impacts gas exchange diseases types of impaired ventilation narrowed airways, obstructed airways, in inadequate muscle/nerve function, poor gas diffusion in alveoli nursing interventions for impaired ventilation ventilating and oxygenating narrowed airways from asthma, infection, inflammation, pneumonia and sounds like a wheeze or whistle fluid in lungs crackles, then rhonchi which leads to secretions and then infections altered transport of oxygen anemia and inadequate perfusion populations at risk infants/young children, older adult (posture which leads to infection, not moving, neurological impairment), tobacco use, risk for aspiration, bed rest and immobility, immunosuppression, and chronic disease a patients condition is described as progressing to hypoxemia, how would the nurse interpret this information there is a abnormally low level of oxygen in the blood lung sounds crackles (high pitched, heard during inspiration, discontinuous), rhonchi (rumbling, coarse sounds, like a snore, may clear with coughing/suctioning, continuous), and wheeze (musical noise, continuous) diagnostic testing for respiratory oxygenations pulse ox, Allen's test to assess before ABG, x-ray Narcan reverses CO2 toxicity like in drug overdoses pain medications depress respiratory system bronchoscopy aspirate, check CN 9 and 10 every 10 minutes after to make sure gag reflex comes back, NPO after procedure, asthma CM cough, increase mucus, sob, wheezing, prolonged expiration, increase in co2 retention, chest tightness, retractions, hypoxemia (tachycardia, restlessness, tachypnea) asthma is reactive airway disease, induced by triggers, hypersensitivities, URI, exercise, air pollutants, respiratory infections and GERD and anxiety management of asthma adrenergic (beta 2 agonists/albuterol), steroids, theophylline, hydration, mask of o2 and anticholinergic rescue inhaler short acting, beta 2 agonist and can increase time for patient peak flow meter establishes baseline and assesses severity of symptoms for patient, red with peak flow less than 50% call 911, yellow with peak flow 50-80% give medication, and green with peak flow greater than 80% is good pharmacologic treatment options for asthma reliever which are short acting bronchodilators (quick) and controllers which are daily medications taken on long term basis used for controlling persistent asthma and includes anti-inflammatory agents and long acting bronchodilators COPD CM easily fatigued, frequent respiratory infections, use of accessory muscles to breathe, orthopenic, tripod position, cor pulmonale, thin in appearance, wheezing, pursed lip breathing, chronic cough, barrel chest, dyspnea prolonged expiratory time, increased sputum, and digital clubbing COPD risk factors smoking, genetic factors, prolonged exposure to dust and chemicals, secondhand smoke, air pollution collaborative care of COPD venturi mask or non-rebreather mask, self-management education and smoking cessation, bronchodilators, inhaled corticosteroids, pulmonary rehabilitation, and oxygen COPD teaching infection prevention, flu/pneumonia vaccines, avoid triggers, allergens, smoke/air pollutants, exercise and to increase quality of life pneumonia is obstruction of bronchioles, decreased gas exchange, and increase exudate, hospital acquired or community acquired, opportunistic pneumonia CM productive cough with yellow, blood-streaked sputum, malaise, fever, chills, tachycardia, tachypnea, dyspnea, pleural pain, respiratory distress, decreased breath sounds pneumonia orders sputum culture, chest x-ray and ABG's pneumonia population over age 65, respiratory infections, COPD, bedridden patients, immunocomprised and smoking nursing management for pneumonia ambulate, incentive spirometer, cough, turn and deep breathe aspiration pneumonia priority heads up, positioning t the side aspiration pneumonia who is at risk tube feedings, altered LOC, neurological impairments, impaired swallowing the nurse provides discharge instructions to a pt. who has hospitalized for pneumonia, which statement indicated a good understanding of the instructions I will continue to do the deep breathing and coughing exercises at home populations for TB homeless, immunocompromised, immigrants, Asians tuberculosis is diagnosed by positive sputum studies (3 specimens collected on different days), TB skin test, chest x-ray tuberculosis nursing cautions airborne precautions, N95 mask tuberculosis CM bloody sputum, night sweats, progressive fatigue, malaise, anorexia, weight loss, chronic cough (productive), pleuitic chest pain, low grade temperature tuberculosis treatment medications that are 6-12 months, decreased activity, isolation until negative sputum, frequently out patient basis nurse specific for TB public health nurse who does direct observed therapy at sites a pt with active TB contines to have positive sputum cultures after 6 months of treatment, she says she can't remember to take the medication all the time, what is the best action for the nurse to take arrange for directly observed therapy by a responsible family member or public health nurse pneumothorax causes (who is at risk) trauma, gun shot, quick growing boys, ruptured BLEB from COPD, thoracentesis, secondary infection pneumothorax Immediate nursing management check for unequal expansion, listen for no sound, feel if bouncy (air), chest tube (equalizes pressure), oxygen pneumothorax is air in the pleural cavity, resulting in lung collapse pneumothorax diagnosed by chest x-ray, ABG pneumothorax CM unequal expansion, decreased breath sounds, pleural pain, dyspnea, anxiety, tachycardia tension pneumothorax assessment tracheal deviation when the trachea goes to the unaffected side from chest tube disrupting airflow leading to air build up leads to increased pressure on affected side and severe dyspnea, call for help to determine whether a tension pneumothorax is developing in a pt with chest trauma, for what does the nurse assess the patient severe respiratory distress and tracheal deviation pleural effusion is, assessment and population fluid build up in lungs, assess for unequal lung expansion, dull, the degree of patient distress depends on the degree of effusion, no sound on lung, fluid volume excess and cancer patients pleural effusion nursing management thoracentesis nursing care of patient with chest tube check drainage device, site secure, sutured in, skin assessment, vitals, pan chest drainage device water to and forms a seal which allows air/fluid to move out but not back in, tidiling which is going up and down with inspiration is normal, has to be below the level of the lung when should the nurse check for leaks in the chest tube and pleural drainage system there is continuous bubbling in the water-seal chamber thoracentesis outside and in, inserting the needle between the ribs, in the space around the lung and not into the lung, assess for composition of pneumothorax pulmonary embolus risk factors immobility, obesity, DVT, postoperative, decreased pco2, decreased oxygen, increase pH, venous stasis pulmonary embolus CM sudden sharp chest pain, bloody sputum, respiratory distress, tachypnea (decreased co2), hypoxia (decreased o2), dyspnea, tachycardia pulmonary embolus nursing management thrombolytic therapy remember to separate the lines/do not mix, blood thinners, and removing the embolus two days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety, what is the first action that the nurse should take raise the head of bed atelectasis collapse of the alveoli, increases the risk for pneumonia, and affects many populations atelectasis nursing management use of incentive spirometer, watch for infections, cough, turn, deep breathe, ambulate nurse can give the most oxygen using non-rebreather mask for severe hypoxia which method of oxygen administration is the safest system to use for a patient with exacerbation of COPD venture mask obstructive sleep apnea (OSA) risk factors hypertension, diabetes, heart disease, driving and work related accidents and strokes OSA CM snoring, excessive daytime sleepiness, pauses in breathing while sleeping, and decreased sex drive, having no neck, overweight CPAP therapy potential life saving and changing option for the treatment of sleep apnea OSA nursing management sit up, oxygen, sleep study, educate on diet/lifestyle tracheostomy is an artificial airway recent tracheostomy doctor orders do not change it, always have TT (new trach kit near patient) nursing care of a tracheostomy suction, clear sections, patient comfort if can ease at all possible, do not remove ties unless doctor order