Fluid and electrolytes Active Transport

Intracellular Fluid
Fluid within cell. Most of body's fluids are found within the cell
Extracellular Fluid
Found in the blood vessels in the form of plasma or serum. Intravascular. Interstitial: lymph fluid, digestive
secretions, sweat, csf. Mainly responsible for the transport of nutrients and wastes.
Requires expenditure of energy from an area of lower conc. to and areo of higher conc. Ex. Carrier proteins
can transport substances from lower to higher area.
Filtration
transfer of water & solutes through a membrane from an area of high pressure to and area of low pressure.
filtration is necessary process of moving fluid out of the capillaries into the tissue & for filtering plasma through
the kidneys.

Water Osmosis

Composes 50 -60% of human body The movement of water across a membrane from a less concentrated solution to a more concentrated
solution.
Explain Homeostasis
Osmolality
a tendency to equilibrium or stability in the normal physiological states of the organism.
The concentration of a solution determined by the number of dissolved particles per kilogram of water;
Ions controls water movement and distribution in the body fluid compartments.

Dissolved electrolytes that develop an electric charge when dissolved in water. Main regulators of fluid balance

Sodium ...Kidneys & Circulatory system

the most abundant electrolyte in the body and the primary electrolyte in the extracellular fluid. Name the hormones that have a major effect on fluid vol. & balance

Potassium ...Renin & ADH....?

found in the intracellular fluid. Major intracellullar cation. Plays an important role in maintaining fluid osmo & Increased Plasma Osmo stimulates the osmoreceptors in the hypothalmus to triggger this regulatory
volume within the cell. K+ is essential for normal membrane excitability & nerve impulses. Needed for protein mechanism
synthesis & breakdown of glycogen & maintain plasma acid_base balance.
...The sensation of thirst
Selective permeable membrane
A good indicator of fluid loss or retention
Selective permeablility maintains the unique composition of the body while allowing for the transport of
nutrients & wastes to & from cells. . SPM surrounds cells to separate fluid in the cells from fluid in the tissues. ...Body weight

Calcium Condition in the pt's health history that might put pt. at risk for fluid & electorlyte imbalance.

Ca+ /phos to form the mineral salts of the bones & teeth. 99% concentrated in bones & teeth. Ca+ promotes ...Vomiting, diarrhea,kidney diseases,diabetes, salicylate poisoning,burns, congestive heart failure, cerebral
normal transmission of nerve impulses & helps regulate normal muscle contraction & relaxation. injuries, ulcerative colitis, and hormonal imbalance

Magnesium (Mg+) Characteristics of Urine that we observe include these.

Second most abundant cation in the intracellular fluid; involved in the metabolism of carbs & proteins; also ...pH, specific gravity, osmolality, creatinine clearance, urine sodium, urine potassium.
important in functioning of heart, nerves & muscles
Skin characteristics that we look for in our pt.
Electrolyes
...color, moisture, turgor, temperature, puffy or sunken eyes, edema
A substance that develops an electrical charge when dissolved in water.
H2O & Na retention in the tissues; results from excessive reabsorption or inadequate secretion of of
Diffusion Na.

the random movement of particles in all directions. A substance that moves from an area of higher conc to an ...Edema AEB kidney failure...test by pitting, rate 1+ - 4+, if severe and greater than this, it is called brawny
area of lower conc. EX. O2 moving from the alveoli to the pulmonary capillaries. edema (or hard)

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Typical care for a pt. with edema includes what? ...fresh fruits, grains; unsalted pasta, oatmeal, unsalted popcorn, ruffed rice, shredded wheat. Meats: fresh,
chicken, fish
...Weight & I.O. monitoring.....
Can be caused by vomiting, diarrhea, nasogastric suction, inadequate intake of K+ & K= wasting
Indicator of H+ ions in the urine. diuretics.
...pH ...HypoKalemia
Indicator of fluid balance; it it is high, the urine is highly concentrate as in fluid vol. deficit; it is low, Signs & Symptoms of Hypokalemia
the urine is dilute as in fluid vol. excess.
...anorexia,abd distention, vomiting, diarrhea, muscle cramps, weakness, dysrhythmias, postural hypotension,
...specific gravity. reflects concentration of urine and renal function.
List the causes of hypoCalemia.
Used to detect glomerular damage in the kidneys
...vomiting,diarrehea, nasogastric suction, inadequate dietary intake of K+, diabetic acidosis, excessive
...Creatininine clearance. Normal range: male 85 -125 ml/min & female 75 - 115 ml/min aldosterone secretions, drugs such as K+ wasting diurectics and corticosteroids.
Used to measure renal tubular function. Normal blood pH. Acid, alkaline?
...urine K+ 25-123 mEq/24h ...7.35 -7.45 acid < 7.35 and alkaline > 7.45
Normal is 8 - 20 mg/dl. Provies a measurement of renal function. Acid base imbalance that occurs when the respiratory system fails to eliminate the appropriate
amount of CO2
BUN > high BUN = associated with fluid vol. deficit & low BUN with fluid vol. excess.
respiratory acidosis.....low pH....high pCO2
A plasma protein that maintains blood volume by creating colloid osmotic pressure.
When excessive amounts of CO2 are eliminated via the lungs.
Albumin > normal range = 3.5 - 5.5 g/dl
respiratory alkalosis.....high pH.....low pCO2
Causes of fluid vol. deficit
Occurs when the body retains too many H+ ions & losses too many bicarb ions.
...Hypovolemia> abn. fld losses, excessive bleeding, vomiting, diarrhea, burns
Dehydration ...metabolic acidosis...low pH....low HCO3
Indicator of dehydration in the elderly. S&S of metabolic acidosis
...decreasing urine output, heart rate increases, bp may fall. ...changing levels of consciousness, ranging from fatigue & confusion to stupor & coma, headache, vomiting,
diarrhea, muscle weakness and cardiac dysrhythmias.
Causes of fluid volume excess.
Effects of Hypotonic solutions on the cell.
...extracellular fluid excess ( isotonic fluid excess )
intracellular water excess (hypotonic fluid excess) ...cells will swell up
Sodium deficit caused by vomiting, diarrhea, diaphoresis. Effects of Hypertonic solutions on the cell.
...excessive water intake without na+, vomiting, diarrhea or diaphoresis with only water replacement; use of ...cells will shrink
distilled water to irrigate body cavities; and excess secretion of ADH.
Effect of isotonic solutions
Symptoms of hyponatremia
...Normal concentration of fluids
...headache, muscle weakness, fatigue, apathy, confusion, abd. cramps, & orthostatic hypotension.
Solutions that have the same conc. as body fluids & the same osmotic pressure as plasma are called
Symptoms of hypernatremia this.
...thirst, flushed skin, dry mucous membranes, low urine output, restlessness, increased heart rate, ...Tonicity, a measure of the concentration of electrolyes in the fluid.
confulsions & postural hypotention. Solutions that have the same conc. as body fluids are called istonic.
Foods included in a low sodium diet.
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Signs of IV infiltrations. Kidneys regulate pH by:

...pain or burning sensation, the site may be pale & puffy. If a lot of fluid is in the tissue, it may feeel hard & Excreting acid or bases as needed. Kidneys produce & reobsorb bicarb. Regulation of HCO3 & excretion of
cool. H+ ions regulate acid-base balance through the kidneys.

Signs of inflammation & infection of an iv site. Respiratory acidosis occurs when respiatory system fails to:

...Irritation by the cannula or by medications. Redness, swelling, warmth, & tenderness near the insertion site Eliminate the appropriate amt. of CO@ to maintain the a-b balance.CO2 retained with resultant accumulation
suggest phlebitis. An infected site may have purulent drainage and the patient might have a fever. oc carbonic acid and decrese in blood pH.
Inflammation may be mild or severe & carries the possibility of the formation of blood clots in the vein
(thromobphlebitis). Acute respiratory acidosis is caused by:

signs of fluid overload related to IV infusion too fast. Resp. diseases i.e. pneumonia, drug overdoses, head injury, chest wall injury, obesity, asphyxiation, drwning
or acute respiratory failure.
...rising blood pressure, bounding pulse, and edema. Severe fluid volume excess produces congestive heart
failure & pulmonary edema. S& S of Respiratory acidosis:

Results from an increase in Bicarb. levels or a loss of H+ ions. Rapid heart rate, headache, sweating, lethargy, & confusion.

...Metabolic alkalosis....increase in bicaronate levels or a los of H+ ions.

Signs of metabolic acidosis

...changing levels of consciousness, ranging from fatigue & confusion to stupor & coma, headache, vomiting, Respiratory Alkalosis
diarrhea, muscle weakness and cardiac dysrhythmias.
Marked by low PaCO2 with risultant rise in pH. Characterized by rapid or deep respirations that cause
Metabolic alkalosis excessive amounts of CO2 to be eliminated through the lungs. A cause can be anxiety. Others; decreased O2
by pneumonia, adult respiratory distress syndrome, anemia, severe blood loss by trauma, congestive blood
High pH.....High HCO3 failure. Pain, drugs (aspirin overdose)head trauma, & gram -Neg septicemia.

Acid-base balance S&S of Resipratory Alkalosis

refers to homeostasis of the hydrogen ion (H+) concentration in the body fluids. A solution containing a higher Increased respiratory and heart rates. Anxious appearance, irritability, dizziness, lighjtheadedness, muscle
number of H+ ions is acid, and opposite, i.e., low number of H+ ions = alkaline or base. weakness, & tingling or numbness of fingers. Confusion, fainting, or seizures.

Acid-base balance is maintained by 3 mechanisms: Metabolic Acidosis

1. buffers Body retains too many H+ ions or loses too many bicarb ions. With too many H+ or too little bicarb, pH will fall.
2. respiatory control of CO2 Met. Acid leads to hyperventilation because the lungs try to compensate by blowing off CO2 & lowering O2
3. renal regulation of bicarb, HCO-3 levers which raises the pH.

Principle buffers in renal tubular fld Causes of Metabolic Acidosis:

Ammonia and phosphate>>> others are proteins and hgb. Starvation, dehydration, diarrhea, shock, renal failure, and diabetic ketoacidosis.

Buffers systems comprise S&S of Metabolic Acidosis:

A weak acid and a salt. Changing leves of consciousness, ranging from fatigue, & confusion to stupor & coma, headache, vomiting &
diarrhea, anorexia, muscle weakness & cardiac dysrhythmias.
Lungs are primarily responsible for regulation of:
Metabolic Alkalosis
Carbon dioxide (CO2) in the blood, controlled by rate & depth of respirations.
Opposite of Metabolic acidosis. Increase in HCO3 or a loss of H+ ions. Loss of H+ ions may be caused by
Carbonic acid is broken down into: prolonge nasogastric suctioning, vomiting, diuretics, & electrolyte disturbances. Retention of HCO3 may be
result from admin of HCO3 or massive blood transfusions.
H2O & CO2, & eliminated by exhalation.
S&S of Metabolic Alkalosis:
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headache, irritability, lethargy, changes in lvevel on consciousness, confusion, changes in heart rate, slow hibited. The body naturally attempts to conserve fluid internally specifically for the brain & heart.
shallow resp. with periods of apnea; nausea & vomiting, hyperactive reflexes and numbness of extremities. Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output.
Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.

A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of
diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most
What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is appropriate?
intermittently confused? 1. Risk for Imbalanced Fluid Volume
1. risk of dehydration 2. Excess Fluid Volume
2. risk of kidney damage 3. Imbalanced Nutrition
3. risk of stroke 4. Ineffective Tissue Perfusion
4. risk of bleeding
Answer: 1
Answer: 1
Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabetes insipidus is at
Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can increase the serum levels of
consciousness, there is an increased risk of dehydration & high serum osmolality. sodium.
Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & electrolyte issues. Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially during the early
Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues. stages of treatment.
Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues. Rationale 3: Imbalanced Nutrition does not apply.
The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for Rationale 4: Ineffective Tissue Perfusion does not apply
developing? A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the pt's
1. intracellular fluid deficit primary healthcare provider with which of the following 24-hour urine output volumes?
2. intracellular fluid overload 1. 600 mL
3. extracellular fluid deficit 2. 750 mL
4. interstitial fluid deficit 3. 1000 mL
4. 1200 mL
Answer: 1
Answer: 1
Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished, leading to an Rationale 1: A urine output of less than 30 mL per hour must be reported to the primary healthcare provider.
intracellular fluid deficit. This indicates inadequate renal perfusion, placing the pt at increased risk for acute renal failure & inadequate
Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus. Because this pt tissue perfusion. A minimum of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals
was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. 720 mL per 24 hours).
Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between
the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an
intracellular fluid deficit.
Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments
the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an should focus on which postoperative complication?
intracellular fluid deficit. 1. fluid volume excess
2. fluid volume deficit
A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, 3. seizure activity
& decreased urine output. The nurse realizes these findings are most likely a direct result of which of 4. liver failure
the following?
1. the body's natural compensatory mechanisms Answer: 1
2. pharmacological effects of a diuretic Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following the stress response
3. effects of rapidly infused intravenous fluids before, during, & immediately after surgery. This increase leads to sodium & water retention. Adding more
4. cardiac failure fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system.
Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, &
Answer: 1 stress upon the heart & circulatory system.
Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances.
Rationale 1: The internal vasoconstrictive compensatory reactions within the body are responsible for the Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid administration.
symptoms ex

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A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of further due to dilution.
the following precautions implemented? Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit &
1. seizure hypernatremia.
2. infection Rationale 3: Kayexalate is used in pts with hyperkalemia.
3. neutropenic Rationale 4: The administration of normal saline with furosemide is used to increase calcium secretion.
4. high-risk fall
When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse
Answer: 1 additionally assess in the pt?
Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, 1. other electrolyte disturbances
raised side rails, & having an oral airway at the bedside would be included. 2. hypertension
Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia. 3. visual disturbances
Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia. 4. drug toxicity
Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.
Answer: 1
A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the Rationale 1: The pt diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium
following might have contributed to the pt's health problem? levels.
1. corticosteroid Rationale 2: The pt with hypocalcemia may exhibit hypotension, & not hypertension.
2. thiazide diuretic Rationale 3: Visual disturbances do not occur with hypocalcemia.
3. narcotic Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.
4. muscle relaxer
A pt with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following
Answer: 1 interventions should the nurse include in this pt's plan of care?
Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as corticosteroids, 1. Request a dietitian consult for selecting foods high in phosphorous.
potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics. 2. Provide aluminum hydroxide antacids as prescribed.
Rationale 2: Excessive sodium is lost with the use of thiazide diuretics. 3. Instruct pt to avoid poultry, peanuts, & seeds.
Rationale 3: Narcotics do not typically affect electrolyte balance. 4. Instruct to avoid the intake of sodium phosphate.
Rationale 4: Muscle relaxants do not typically affect electrolyte balance.
Answer: 1
A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause & promoting a high
The nurse realizes this pt is exhibiting signs of which of the following? phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans & peas, eggs,
1. hyperkalemia fish, organ meats, Brazil nuts & peanuts, poultry, seeds & whole grains.
2. hypokalemia Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided.
3. hypercalcemia Rationale 3: Poultry, peanuts, & seeds are part of a high phosphate diet.
4. hypocalcemia Rationale 4: Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate.

Answer: 1 When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse
Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion anticipates that compensation will develop through which of the following mechanisms?
is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are 1. The kidneys retain bicarbonate.
muscle weakness & ECG changes. 2. The kidneys excrete bicarbonate.
Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide. 3. The lungs will retain carbon dioxide.
Rationale 3: Hypercalcemia has been associated with thiazide diuretics. 4. The lungs will excrete carbon dioxide.
Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is not associated
with diuretic use. Answer: 1
Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate.
The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following Rationale 2: Excreting bicarbonate causes acidosis to develop.
should be included in this pt's plan of care? Rationale 3: Retaining carbon dioxide causes respiratory acidosis.
1. Restrict fluids. Rationale 4: Excreting carbon dioxide causes respiratory alkalosis
2. Administer intravenous fluids.
3. Provide Kayexalate. The nurse is caring for a pt diagnosed with renal failure. Which of the following does the nurse
4. Administer intravenous normal saline with furosemide. recognize as compensation for the acid-base disturbance found in pts with renal failure?
1. The pt breathes rapidly to eliminate carbon dioxide.
Answer: 1 2. The pt will retain bicarbonate in excess of normal.
Rationale 1: The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids to 3. The pH will decrease from the present value.
1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from dropping 4. The pt's oxygen saturation level will improve.
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Answer: 1
Rationale 1: In metabolic acidosis compensation is accomplished through increased ventilation or "blowing
off" C02. This raises the pH by eliminating the volatile respiratory acid & compensates for the acidosis.
Rationale 2: Because compensation must be performed by the system other than the affected system, the pt
cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal
bicarbonate value.
Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease
process, not the compensation.
Rationale 4: Oxygenation disturbance is not part of the acid-base status of the pt with renal failure.
When caring for a group of pts, the nurse realizes that which of the following health problems
increases the risk for metabolic alkalosis?
1. bulimia
2. dialysis
3. venous stasis ulcer
4. COPD
Answer: 1
Rationale 1: Metabolic alkalosis is cause by vomiting, diuretic therapy or nasogastric suction, among others. A
pt with bulimia may engage in vomiting or indiscriminate use of diuretics.
Rationale 2: A pt receiving dialysis has kidney failure, which causes metabolic acidosis.
Rationale 3: A venous stasis ulcer does not result in an acid-base disorder.
Rationale 4: The pt diagnosed with COPD typically has hypercapnea & respiratory acidosis.
The nurse is caring for a pt who is anxious & dizzy following a traumatic experience. The arterial
blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, & HCO3 24. The nurse would anticipate
which initial intervention to correct this problem?
1. Encourage the pt to breathe in & out slowly into a paper bag.
2. Immediately administer oxygen via a mask & monitor oxygen saturation.
3. Prepare to start an intravenous fluid bolus using isotonic fluids.
4. Anticipate the administration of intravenous sodium bicarbonate.
Answer: 1
Rationale 1: This pt is exhibiting signs of hyperventilation that is confirmed with the blood gas results of
respiratory alkalosis. Breathing into a paper bag will help the pt to retain carbon dioxide & lower oxygen levels
to normal, correcting the cause of the problem.
Rationale 2: The oxygen levels are high, so oxygen is not indicated, & would exacerbate the problem if given.
Intravenous fluids would not be the initial intervention.
Rationale 3: Not enough information is given to determine the need for intravenous fluids.
Rationale 4: Bicarbonate would be contraindicated as the pH is already high.
A pt is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the pt is receiving
this replacement is
1. to sustain respiratory function.
2. to help regulate acid-base balance.
3. to keep a vein open.
4. to encourage urine output.
Answer: 2
Rationale 1: Potassium does not sustain respiratory function.
Rationale 2: Electrolytes have many functions. They assist in regulating water balance, help regulate &
maintain acid-base balance, contribute to enzyme reactions, & are essential for neuromuscular activity.
Rationale 3: Intravenous fluids are used to keep venous access not potassium.
Rationale 4: Urinary output is impacted by fluid intake not potassium.
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An elderly pt does not complain of thirst. What should the nurse do to assess that this pt is not
dehydrated?
1. Ask the physician for an order to begin intravenous fluid replacement.
2. Ask the physician to order a chest x-ray.
3. Assess the urine for osmolality.
4. Ask the physician for an order for a brain scan.
Answer: 3
Rationale 1: It is inappropriate to seek an IV at this stage.
Rationale 2: There is no indication the pt is experiencing pulmonary complications thus a cheat x-ray is not
indicated.
Rationale 3: The thirst mechanism declines with aging, which makes older adults more vulnerable to
dehydration & hyperosmolality. The nurse should check the pt's urine for osmolality as a 1st step in
determining hydration status before other detailed & invasive testing is done.
Rationale 4: There is no data to support the need for a brain scan.
An elderly pt who is being medicated for pain had an episode of incontinence. The nurse realizes that
this pt is at risk for developing
1. dehydration.
2. over-hydration.
3. fecal incontinence.
4. a stroke.
Correct Answer: 1
Rationale 1: Functional changes of aging also affect fluid balance. Older adults who have self-care deficits, or
who are confused, depressed, tube-fed, on bed rest, or taking medications (such as sedatives, tranquilizers,
diuretics, & laxatives), are at greatest risk for fluid volume imbalance.
Rationale 2: There is inadequate evidence to support the risk of over-hydration.
Rationale 3: There is inadequate evidence to support the risk of fecal incontinence.
Rationale 4: There is inadequate evidence to support the risk of a stroke.
The nurse assesses a pt's weight loss as being 22 lbs. How many liters of fluid did this pt lose?
Correct Answer: 10
Rationale: Each liter of body fluid weighs 1 kg or 2.2 lbs. This pt has lost 10 liters of fluid.
A postoperative pt with a fluid volume deficit is prescribed progressive ambulation yet is weak from
an inadequate fluid status. What can the nurse do to help this pt?
1. Assist the pt to maintain a standing position for several minutes.
2. This pt should be on bed rest.
3. Assist the pt to move into different positions in stages.
4. Contact physical therapy to provide a walker.
Answer: 3
Rationale 1: The pt should avoid prolonged standing.
Rationale 2: Bed rest can promote skin breakdown.
Rationale 3: The pt needs to be taught how to avoid orthostatic hypotension which would include assisting &
teaching the pt how to move from one position to another in stages.
Rationale 4: A physician referral is needed for physical therapy intervention & is not indicated in this situation.
A postoperative pt is diagnosed with fluid volume overload. Which of the following should the nurse
assess in this pt?
1. poor skin turgor
2. decreased urine output
©SGT XENIIA MARIE RAZALO LAWAN PAFR
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4. concentrated hemoglobin & hematocrit levels
Answer: 3
Rationale 1: Poor skin turgor is associated with fluid volume deficit.
Rationale 2: Decreased urine output is associated with fluid volume deficit.
Rationale 3: Circulatory overload causes manifestations such as a full, bounding pulse; distended neck &
peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs;
pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by
excess fluid causes a decreased hematocrit & blood urea nitrogen (BUN); & possible cerebral edema.
Rationale 4: Increased hemoglobin & hematocrit values are associated with fluid volume deficit.
An elderly pt is at home after being diagnosed with fluid volume overload. Which of the following
should the home care nurse instruct this pt to do?
1. Wear support hose.
2. Keep legs in a dependent position.
3. Avoid wearing shoes while in the home.
4. Try to sleep without extra pillows.
muscle cramps are manifestations of a low serum sodium level.
Rationale 3: This pt is more likely to develop clinical manifestations associated with fluid volume deficit.
Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias.
A pt is admitted with hypernatremia caused by being str&ed on a boat in the Atlantic Ocean for five
days without a fresh water source. Which of the following is this pt at risk for developing?
1. pulmonary edema
2. atrial dysrhythmias
3. cerebral bleeding
4. stress fractures
Answer: 3
Rationale 1: Pulmonary edema is not associated with dehydration.
Rationale 2: Atrial dysrhythmias are not a factor for this pt.
Rationale 3: The brain experiences the most serious effects of cellular dehydration. As brain cells contract, the
brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, & lead to
cerebral vascular bleeding.
Rationale 4: There have been no activities to support the development or occurrence of stress fractures.

Answer: 1 The nurse is admitting a pt who was diagnosed with acute renal failure. Which of the following
Rationale 1: The home care nurse should instruct this pt about ways to decrease dependent edema, which electrolytes will be most affected with this disorder?
include wearing support hose, elevating feet when in a sitting position, & resting in a recliner or bed with extra 1. calcium
pillows. 2. magnesium
Rationale 2: The pt should elevate the legs. 3. phosphorous
Rationale 3: As long as the shoes are well fitting, there is not reason to avoid wearing them. 4. potassium
Rationale 4: It is appropriate for the pt to use extra pillows to keep the head up while sleeping.
Answer: 4
A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that Rationale 1: This pt will be less likely to develop a calcium imbalance.
this pt could possibly have which of the following electrolyte imbalances? Rationale 2: This pt will be less likely to develop a magnesium imbalance.
1. hypokalemia Rationale 3: This pt will be less likely to develop a phosphorous imbalance.
2. hypernatremia Rationale 4: Because the kidneys are the principal organs involved in the elimination of potassium, renal
3. carbon dioxide failure
4. magnesium
A pt who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following
Answer: 2 does the nurse realize might occur with this pt?
Rationale 1: The kidneys are the principal organs involved in the elimination of potassium. Renal failure is 1. Digoxin toxicity may occur.
often associated with elevations potassium levels. 2. A higher dose of digoxin (Lanoxin) may be needed.
Rationale 2: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with 3. A diuretic may be needed.
hypernatremia. 4. Fluid volume deficit may occur.
Rationale 3: Carbon dioxide abnormalities are not normally seen in this type of pt.
Rationale 4: Magnesium abnormalities are not normally seen in this type of pt. Answer: 1
Rationale 1: Hypokalemia increases the risk of digitalis toxicity in pts who receive this drug for heart failure.
An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with Rationale 2: More digoxin is not needed.
abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the Rationale 3: A diuretic may cause further fluid loss.
following? Rationale 4: There is inadequate information to assess for concerns related to fluid volume deficits.
1. hypernatremia
2. hyponatremia A pt is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement
3. fluid volume excess should be administered
4. hyperkalemia 1. directly into the venous access line.
2. mixed in the prescribed intravenous fluid.
Answer: 2 3. via a rectal suppository.
Rationale 1: Hypernatremia is associated with fluid retention & overload. FVE is associated with 4. via intramuscular injection.
hypernatremia.
Rationale 2: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The abdominal &
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Answer: 2 A 28-year-old male pt is admitted with diabetic ketoacidosis. The nurse realizes that this pt will have a
Rationale 1: Never administer undiluted potassium directly into a vein. need for which of the following electrolytes?
Rationale 2: The intravenous route is the recommended route for diluted potassium. 1. sodium
Rationale 3: The nurse should administer diluted potassium into the pt's intravenous line. 2. potassium
Rationale 4: The nurse should administer diluted potassium into the pt's intravenous line. 3. calcium
4. magnesium
An elderly pt with a history of sodium retention arrives to the clinic with the complaints of "heart
skipping beats" & leg tremors. Which of the following should the nurse ask this pt regarding these Answer: 4
symptoms? Rationale 4: One risk factor for hypomagnesaemia is an endocrine disorder, including diabetic ketoacidosis.

1. "Have you stopped taking your digoxin medication?" An elderly pt with peripheral neuropathy has been taking magnesium supplements. The nurse realizes
2. "When was the last time you had a bowel movement?" that which of the following symptoms can indicate hypomagnesaemia?
3. "Were you doing any unusual physical activity?" 1. hypotension, warmth, & sweating
4. "Are you using a salt substitute?" 2. nausea & vomiting
3. hyperreflexia
Answer: 4 4. excessive urination
Rationale 1: Although this pt may be prescribed digoxin this is not the primary focus of this question.
Rationale 2: The pt's bowel habits are not of concern at this time. Answer: 1
Rationale 3: The cardiac & musculoskeletal discomforts being reported are not consistent with physical Rationale 1: Elevations in magnesium levels are accompanied by hypotension, warmth, & sweating.
exertion. Rationale 2: Lower levels of magnesium are associated with nausea & vomiting.
Rationale 4: The pt has a history of sodium retention & might think that a salt substitute can be used. Advise Rationale 3: Lower levels of magnesium are associated & hyperreflexia.
pts who are taking a potassium supplement or potassium-sparing diuretic to avoid salt substitutes, which Rationale 4: Urinary changes are not noted.
usually contain potassium.
A pt is admitted with burns over 50% of his body. The nurse realizes that this pt is at risk for which of
A 35-year-old female pt comes into the clinic postoperative parathyroidectomy. Which of the following the following electrolyte imbalances?
should the nurse instruct this pt? 1. hypercalcemia
1. Drink one glass of red wine per day. 2. hypophosphatemia
2. Avoid the sun. 3. hypernatremia
3. Milk & milk-based products will ensure an adequate calcium intake. 4. hypermagnesemia
4. Red meat is the protein source of choice.
Correct Answer: 2
Answer: 3
Rationale 1: This pt should avoid alcohol. Rationale 1: Pts who experience burns are not at an increased risk for developing increased blood calcium
Rationale 2: This pt can benefit from sun exposure. levels.
Rationale 3: This pt is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk Rationale 2: Causes of hypophosphatemia include stress responses & extensive burns.
& milk-based products. Rationale 3: Pts who experience burns are not at an increased risk for developing increased blood sodium
Rationale 4: Protein monitoring is not indicated. levels.
Rationale 4: Pts who experience burns are not at an increased risk for developing increased blood
A pt is admitted for treatment of hypercalcemia. The nurse realizes that this pt's intravenous fluids will magnesium levels.
most likely be which of the following?
1. dextrose 5% & water A pt is diagnosed with hyperphosphatemia. The nurse realizes that this pt might also have an
2. dextrose 5% & ? normal saline imbalance of which of the following electrolytes?
3. dextrose 5% & ? normal saline 1. calcium
4. normal saline 2. sodium
3. potassium
Answer: 4 4. chloride
Rationale 1: If isotonic saline is not used, the pt is at risk for hyponatremia in addition to the hypercalcemia.
Rationale 2: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by Answer: 1
calcium excretion through the kidneys. Rationale 1: Excessive serum phosphate levels cause few specific symptoms. The effects of high serum
Rationale 3: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by phosphate levels on nerves & muscles are more likely the result of hypocalcemia that develops secondary to
calcium excretion through the kidneys. an elevated serum phosphorus level. The phosphate in the serum combines with ionized calcium, & the
Rationale 4: Isotonic saline is used because sodium excretion is accompanied by calcium excretion through ionized serum calcium level falls.
the kidneys.

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The nurse is reviewing a pt's blood pH level. Which of the systems in the body regulate blood pH? 3. respiratory alkalosis
Select all that apply. 4. metabolic alkalosis
1. renal
2. cardiac Answer: 4
3. buffers Rationale 1& 2: Respiratory acidosis & metabolic acidosis are both consistent with pH less than 7.35.
4. respiratory Rationale 3: Respiratory alkalosis is associated with a pH greater than 7.45 & a PaCO2 of less than 35
mmHG. It is caused by respiratory related conditions.
Answer: 1,3 Rationale 4: Arterial blood gases (ABGs) show a pH greater than 7.45 & bicarbonate level greater than 26
Rationale 1: Three systems work together in the body to maintain the pH despite continuous acid production: mEq/L when the pt is in metabolic alkalosis.
buffers, the respiratory system, & the renal system.
Rationale 2: The cardiac system is responsible for circulating blood to the body. It does not help maintain the An elderly postoperative pt is demonstrating lethargy, confusion, & a resp rate of 8 per minute. The
body's pH. nurse sees that the last dose of pain medication administered via a pt controlled anesthesia (PCA)
Rationale 3: Three systems work together in the body to maintain the pH despite continuous acid production: pump was within 30 minutes. Which of the following acid-base disorders might this pt be
buffers, the respiratory system, & the renal system. experiencing?
Rationale 4: Three systems work together in the body to maintain the pH despite continuous acid production: 1. respiratory acidosis
buffers, the respiratory system, & the renal system. 2. metabolic acidosis
3. respiratory alkalosis
The nurse observes a pt's respirations & notes that the rate is 30 per minute & the respirations are 4. metabolic alkalosis
very deep. The metabolic disorder this pt might be demonstrating is which of the following?
1. hypernatremia Answer: 1
2. increasing carbon dioxide in the blood Rationale 1: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or
3. hypertension sedative medications can lead to this condition.
4. pain Rationale 2: The pt condition being described is respiratory not metabolic in nature.
Rationale 3: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or
Answer: 2 sedative medications can lead to this condition.
Rationale 1: Hypernatremia is associated with profuse sweating & diarrhea. Rationale 4: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or
Rationale 2: Acute increases in either carbon dioxide or hydrogen ions in the blood stimulate the respiratory sedative medications can lead to this condition. The pt condition being described is respiratory not metabolic
center in the brain. As a result, both the rate & depth of respiration increase. The increased rate & depth of in nature.
lung ventilation eliminates carbon dioxide from the body, & carbonic acid levels fall, which brings the pH to a
more normal range. The pt has been placed on a 1200 mL daily fluid restriction. The pt's IV is infusing at a keep open rate
Rationale 3: The respiratory rate in a pt exhibiting hypertension is not altered. of 10 mL/hr. The pt has no additional IV medications. How much fluid should the pt be allowed from
Rationale 4: Pain may be manifested in rapid, shallow respirations. 0700 until 1500 daily?

The blood gases of a pt with an acid-base disorder show a blood pH outside of normal limits. The Answer: 540
nurse realizes that this pt is Rationale: Fluid allowed is calculated by figuring the total daily IV intake (in this case 10 mL/hr × 24 hours =
1. fully compensated. 240 mL/day), subtracting that total from the daily allowance (in this case 1200mL - 240 mL = 960mL). The
2. demonstrating anaerobic metabolism. amount calculated is then distributed as 50% for the traditional day shift, 25%-35% for the traditional evening
3. partially compensated. shift, & the remainder for the traditional night shift. In this case, 50% of 960 is 540 mL.
4. in need of intravenous fluids
The pt is receiving intravenous potassium (KCL). Which nursing actions are required? Select all that
Answer: 3 apply.
1. Administer the dose IV push over 3 minutes.
Rationale 1: If the pH is restored to within normal limits, the disorder is said to be fully compensated. 2. Monitor the injection site for redness.
Rationale 2: Anaerobic metabolism results when the body's cells become hypoxic. 3. Add the ordered dose to the IV hanging.
Rationale 3: If the pH is restored to within normal limits, the disorder is said to be fully compensated. When 4. Use an infusion controller for the IV.
these changes are reflected in arterial blood gas (ABG) values but the pH remains outside normal limits, the 5. Monitor fluid intake & output.
disorder is said to be partially compensated.
Rationale 4: Although the pt may be in need of intravenous fluids, this is not the most correct or definitive Answer: 2,4,5
answer.
Which pts are at risk for the development of hypercalcemia? Select all that apply.
A pt's blood gases show a pH greater of 7.53 & bicarbonate level of 36 mEq/L. The nurse realizes that 1. the pt with a malignancy
the acid-base disorder this pt is demonstrating is which of the following? 2. the pt taking lithium
1. respiratory acidosis 3. the pt who uses sunscreen to excess
2. metabolic acidosis
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4. the pt with hyperparathyroidism
5. the pt who overuses antacids
Correct Answer: 1,2,4,5
Rationale 1: Pts with malignancy are at risk for development of hypercalcemia due to destruction of bone or
the production of hormone-like substances by the malignancy.
Rationale 2: Lithium & overuse of antacids can result in hypercalcemia. Hypercalcemia can result from
hyperparathyroidism which causes release of calcium from the bones, increased calcium absorption in the
intestines & retention of calcium by the kidneys.
Rationale 3: The pt who uses sunscreen to excess is more likely to have a vitamin D deficiency which would
result in hypocalcemia.
Rationale 4: Hypercalcemia can result from hyperparathyroidism which causes release of calcium from the
bones, increased calcium absorption in the intestines & retention of calcium by the kidneys.
Rationale 5: Lithium & overuse of antacids can result in hypercalcemia.
Answer: 2,3,4
Rationale: Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general
malaise, decreased level of consciousness, warm flushed skin, & Kussmaul's respirations.
Rationale: These ABG results, coupled with the pt's recent diagnosis of diabetes mellitus & history of vomiting
would lead the nurse to suspect metabolic acidosis. Further assessment findings of this condition are
weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin,
& Kussmaul's respirations.
What is the body water content of Infants?
73% or more water (low body fat, low bone mass).
What is the body water content of adult males?

The pt who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. ~60% water.
Which foods should the nurse suggest for this pt? Select all that apply.
What is the body water content of females?
1. bananas
2. seafood ~50% water (higher fat content, less skeletal muscle mass).
3. white rice
4. lean red meat What does water content decline too in old age?
5. chocolate
~45%.
Answer: 1,2,5
Rationale: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this pt should be
counseled to eat foods high in magnesium. Foods high in magnesium include green leafy vegetables,
seafood, milk, bananas, citrus fruits, & chocolate. White rice & lean red meat are not included. What do each fluid compartment have?

A distinctine pattern of electrolytes.

What are the distinctive pattern of electrolytes in ECF?

The pt has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse Major Cation: Na+, Major anion: Cl- (chloride).
expect for this pt? Select all that apply.
What are the distinctive pattern of electrolytes in ICF?
1. IV normal saline
2. calcium containing antacids Low Na+ and Cl-. Major Cation: K+, Major anion: HPO42- (hydrogen phosphate).
3. IV potassium phosphate
4. encouraging milk intake What in extra- and intracellular fluids are nearly opposites?
5. increasing vitamin D intake
Sodium and potassium concentrations.
Answer: 1,2
Rationale: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes Why are sodium and potassium nealry opposite in ECF and ICF?
renal excretion of phosphate.
Reflects the activity of cellular ATP- dependent sodium -potassium pumps.
The pt, newly diagnosed with diabetes mellitus, is admitted to the emergency department with nausea,
vomiting, & abdominal pain. ABG results reveal a pH of 7.2 & a bicarbonate level of 20 mEq/L. Which What is the driving force for water intake?
other assessment findings would the nurse anticipate in this pt? Select all that apply.
1. tachycardia Thirst.
2. weakness What are the hypothalamic thirst center osmoreceptors stimulated by?
3. dysrhythmias
4. Kussmaul's respirations Declined plasma osmolality of 2 - 3%, Angiotension II or Baroreceptor input, Dry Mouth, Substantial decrease
5. cold, clammy skin in blood volume or pressure.

What creates inhibition of thirst center?

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Drinking water. Net osmosis into tissue cells.

What are the inhibitory feedback signals of water intake? What does net osmosis into tissue cells lead too?

Relief of dry mouth, activation of stomach and intestinal stretch receptors. Swelling of cells.

What is Obligatory water losses? What does swelling of cells lead too?

Insensible water loss from lungs and skin, feces, and minimum daily sensible water loss of 500 ml in urine to Severe metabolic disturbancea such as nausea, vomiting, muscular cramping, cerebral edema - possible
excrete wastes. death.

What is water reabsorption in collection ducts proportional too? What is Edema?

ADH release. Atypical accumulation of IF fluid - tissue swelling.

What does decreased ADH lead too? What is Edema due too?

Dilute urine and decrease volume of body fluids. Anything that increases flow of fluids out of the blood or hinders its return - high blood pressure, capillary
permeability (usually due to inflammatory chemicals), incompletant venous valves, localized blood vessel
What does increased ADH lead too? blockage, congestive heart failure, hypertension, high blood volume.
Concentrated urine. What does Edema result from?
What do Hypothalamic osmoreceptors trigger or inhibit? Protein malnutrition, liver disease, or glomerulonephritis.
ADH release. What does hindered fluid return occur with in Edema?
What other facts may trigger ADH release via large changes in blood volume or pressure? An imbalance in colloid osmotic pressures - hypoporteinemia (decreased plasma proteins).
Fever, sweating, vomiting, dirrhea, blood loss, and traumatic burns. How can blocked (or surgically removed) lymph vessesl result in Edema?
What is a Negative Fluid Balance: Dehydration? Cause leaked proteins to accumulate in IF, increased colloid osmotic pressure of IF draws fluid from the
blood, results in low blood pressure and severly imparied circulation.
ECF water loss due to hemmorrpahge severe burns, prologned vomiting or diarrhea, profuse sweating, water
deprivation, diurectic abuse. What are Electroylytes?
What are the signs and symptoms of Dehydration? Salts, acids and bases.
Thirst, dry flushed skin, oliguria (decreased production of urine). What does Electrolyte balance usually refer too?
What can dehydration lead too? Only salt balance.
Weight loss, fever, mental confusion, hypovolemic shock, and loss of electrolytes. What are salts important for?
What is Hypotonic Hydration? Neuromuscular excitability, secretory activity, membrane permeability, controlling fluid movements.
Cellular overhydration, or water intoxication. What do sodium salts account for in solutes of the ECF?
When does Hypotonic Hydration occur? 90 - 95%.
With renal insufficiency or rapid water ingestion. What is the single most abundant cation in ECF?
What happens if the ECF is diluted? Sodium.
Hyponatremia (no enough sodium in the body fluids outside the cells). What is the only cation exerting significant osmotic pressure?
What does Hyponatremia lead too? Sodium.

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How is Na+ moved? Increased excitability and muscle tetany.

Pumped out against its electrochemical gradiant and leaks into cells. What is Hypercalcermia?

How is Na+ reabsorbed? Inhibits neurons and muscle cells, may cause heart arrhythmias.

65% in proximal tubules, 25% is reclaimed in loops of henle. What is Calcium balance controlled by?

Parathyroid hormone (PTH) and calcitonin.

What does Aldosterone do? How does PTH promote increase in calcium level?

Active reabsorption of remaining Na+. Targets Bones, Small Intestine, and Kidneys.

What follows Na+ if ADH is present? What does PTH do to bones?

Water. Activates osetoclases to break down bone matrix.

What is the main trigger for aldosterone release? What does PTH do to Small Intestines?

Renin-angiotensin. Enhances intestinal absorption of calcium (indirect through vitamin D).

What secretes renin-angiotensin? What does PTH do to Kidneys?

JGA (Justaglomerular apparatus). Enhances calcium reabsorption and decreases phosphate reabsorption.

What does JGA secrete Renin in response too? What does Calcium reabsorption go hand in hand with?

Sympathetic nervous system stimulation - decreased filtrate osmolality, decrease stretch due to low blood Phosphate excretion.
pressure.
What inhibits PTH secretion?
What does renin do to angiotensin II?
High or normal ECF calcium levels.
Catalyzes it, which prompts aldosterone release from the adrenal cortex.
What does inhibited PTH secretion result in?
What can also trigger the release of Aldosterone?
Release of calcium from bone is inhibited, larger amounts of calcium are lost in feces are urine, more
Elevated K+ levels in the ECF. phosphate is retained.

How long does it take for Aldosterone to take effect? What does pH affect?

Slowly - hours to days. All functional proteins and biochemical reactions.

What is ANP released by? What is the normal pH of Arterial Blood?

Atrial cells in response to stretch and high blood pressure. 7.4.

What are the effects of ANP? What is the normal pH of Venous Blood and Iterstitial fluid?

Decreases blood pressure and blood volume. Decreases ADH, Renin and Aldosterone production. Increases 7.35.
excretion of Na+ and water. Promotes vasodilation directly and also by decreasing production of angitensin II.
What is the normal pH of ICF?
What is Calcium ion Ca2+ in ECF important for?
7.0.
Neuromuscular excitability, blood clotting, cell membrane permeability, secretory activities.
What is the pH in Alkolosis or Alalemia?
332r tWhat is Hypocalcemia?
Arterial blood pH > 7.45.
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What is the pH in Acidosis or Acidemia (physiological acidosis)? Bicarbonate ties up Hydrogen and froms carbonic acid. pH of solution decerases only slightly.

Arterial pH < 7.35. What happens if a strong base is added to Bicarbonate buffer system?

What is H+ produced by? Causes Carbonic Acid to dissociate and donate Hydrogen, pH of the solution rises only slightly.

Metabolism. - Phosphoric acid from breakdown of phosphorous containing proteins, lactic acid from anaerobic What is the Phosphate Buffer System?
respiration of glucose, fatty acids and ketone bodies from fat metabolism, H+ liberated with C02 is converted
to HC03 in blood. Nearly identical to Bicarbonate buffer.

What is the concentration of hydrogen ions regulated by? What are the components of Phosphate Buffer System?

Chemical buffer systems, respiratory centers, and renal mechanisms. Sodium salts of Dihydrogen phosphate (H2P04-) [weak acid], Monohydrogen phosphate (HP042-) [weak
base].
What is the Chemical Buffer Systems?
What is an effective buffer in urine and ICF where phosphate concentrations are high?
Rapid; first line of defense.
Phosphate Buffer System.
What is the Respiratory centers (brain stem)?
What are the most plentiful and powerful buffers?
Act within 1 - 3 min.
Intracellular proteins.
What is the Renal Mechanism?
What are protein molecules?
Most potent, but requires hours to days to effect pH changes.
Amphorteric (can function as both a weak acid and a weak base).
What do Strong acids do to pH?
What happens when pH rises?
Dissociate completely in water; dramatically affects.
Organic acid of Carboxyl groups (COOH) [weak acids] release H+.
What do Weak Acids do to pH?
What happens with pH falls?
Dissociate partially in water; are efficient are prevent changes.
Amino groups (NH2) [weak bases] bind H+.
What do Strong Bases do to pH?
What do Lungs eliminate?
Dissociate easily in water; quickly tie up H+.
Volatile carbonic acid by eliminating C02.
What do Weak bases do to pH?
What do Kidneys eliminate?
Accept H+ more slowly.
Other fixed metabolic acids (phosphoric, uric, lactic acids, and ketones) and prevent metabolic acidosis.
What is a Chemical Buffer?
What are the ultimate acid-base regulatory organs?
System of one or more compounds that act to resist pH changes when strong acid or base is added.
The Kidneys.

What is Bicarbonate Buffer System?

What are the most important renal mechanisms?
Mixture of H2C03 (weak acid) [carbonic acid] and salts of HC03- (e.g., NaHC03, a weak base) [sodium
bicarbonate]. Buffers ICF and ECF. Conserving (reabsoring) or generating new HC03-, Excreting HC03-.

What is the only important ECF buffer? What is generating or reabsoring one HC03- the same as?

Bicarbonate Buffer. Losing one H+.

What happens to bicarbonate buffer system if a strong acid is added? What is excreting one HC03- the same as?
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Gaining one H+. Answer: 4

What is Respiratory Acidosis?
Most common cause of acid-base imbalance. Occurs when a person breathes shallowly, or gas exchange is
hampered by diseases such as pneumonia, cystic fibrosis, or emphysema. - HYPOVENTILATION.
What is Respiratory Alkalosis?
Hyperventiation! Can occur from stress, anxiety, panic attack, bleeding, heart or lung disorder, infection.
A nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30,
and HCO3- of 22. The nurse analyzes these results as indicating which condition?
1) Metabolic Acidosis, compensated
2) Respiratory Alkalosis, compensated
3) Metabolic Alkalosis, compensated
4) Respiratory Acidosis, compensated
Answer: 2
Rational: The normal pH is 7.3-7.45. In a respiratory condition, an opposite effect will be seen between the pH
and the Pco2. In this condition, the pH is a the high end of normal and the Pco2 is low. In an alkalotic
condition, the pH is elevated. Therefore the values identified in the question indicated a respiratory alkalosis.
When the pH returns to a normal value, compensation has occurred.
Rational: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis
resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the
client would include hypventilation and tachycardia. Option 2 reflects a respiratory acidotic condition. Option 2
reflects a respiratory alkalotic condition. Option 3 reflects a metabolic acidotic condition.
A nurse caring for a client with an ileostomy understands the the client is most at risk for developing
which acid-base disorder?
1) Metabolic Acidosis
2) Metabolic Alkalosis
3) Respiratory Acidosis
4) Respiratory Alkalosis
Answer: 1
Rational: Metabolic Acidosis is defined as total concentration of buffer base that is lower than normal, with a
relative increase in the hydrogen ion concentration. This results from loss of buffer bases or the retention of
too many acids without sufficient bases, and occurs in conditions such as renal failure, diabetic ketoacidosis,
from the production of lactic acid, from the ingestion of toxins (such as acetylsalicylic acid -aka- aspirin),
malnutrition, or severe diarrhea. Intestinal secretions are high in bicarbonate and may e lost through enteric
drainage tubes or an ileostomy, or with diarrhea. These conditions result in metabolic acidosis. Options 2, 3, &
4 are incorrect interpretations and do not occur in the client with an ileostomy.
**(Base/Bicarbonate is lost through an ileostomy)

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse A nurse is caring for a client with diabetic ketoacidosis and documents the the client is experiencing
monitors the client, knowing that the client is at risk for which acid-base disorder? Kussmaul's respirations. Based on this documentation, which of the following did the nurse observe?

1) Metabolic Acidosis 1) Respirations that cease for several seconds

2) Metabolic Alkalosis 2) Respirations that are regular but abnormally slow
3) Respiratory Acidosis 3) Respirations that are labored and increased in depth and rate
4) Respiratory Alkalosis 4) Respirations that are abnormally deep, regular, and increased in rate

Answer: 2 Answer: 4

Rational: Metabolic Alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base
(bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of
base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive
bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via
nasogastric suction or vomiting causes Metabolic Alkalosis as a result of the loss of hydrochloric acid. Options
1, 3, & 4 are incorrect interpretations.
Rational: Kussmal's respirations are abnormally deep, regular, and increased in rate. Apnea is described as
repirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In
hyperpnea, respirations are labored and increased in depth and rate.
A client who is found unresponsive has arterial blood gases drawn and the results indicate dthe
following: pH is 7.12, Pco2 is 90, and HCO3- is 22. the nurse interprets the results as indicating which
condition?

1) Metabolic Acidosis with compensation

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client 2) Respiratory Acidosis with compensation
is hypoventilating and has a respiratory rate of 10 breaths/min. Arterial blood gases are drawn and the 3) Metabolic Acidosis without compensation
nurse reviews the results, expecting to note which of the following? 4) Respiratory Acidosis without compensation

1) A decreased pH and an increased CO2 Answer: 4

2) An increased pH and a decreased Co2
3) A decreased pH and a decreased HCO3- Rational: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35-
4) An increased pH with an increased HCO3- 7.45. The normal Pco2 is 32-48. In respiratory acidosis the pH is decreased and the pco2 is elevated. The
normal bicarbonate (HCO3-) level is 22-27. Because the bicarbonate is still within normal limits, the kidneys
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have not had time to adjust for this acid-base disturbance. Additionally, the pH is not within normal limits. Select all the apply:
Therefore the condition is without compensation. Options 1, 2, & 3 are incorrect interpretations. 1) Nausea
2) Confusion
The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding 3) Bradypnea
that the client is most likely to experience what type of acid-bases imbalance: 4) Tachycardia
5) Hyperkalemia
1) Metabolic Acidosis 6) Lightheadedness
2) Metabolic Alkalosis
3) Respiratory Acidosis Answer: 1, 2, 4, 6
4) Respiratory Alkalosis
Rational: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion
Answer: 3 concentrations that results from the accumulations of base or from a loss of acid without a comparable loss of
base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical
Rational: Respiratory Acidosis is most often caused by hypoventilation in a client with COPD. Other acid-base manifestations of repirtory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias
disturbances can occur in a client with COPD during exacerbation of the disease but the most likely related to hypokalemai, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hy
imabalance is respiratory acidosis. Option 1, 2,& 4 are incorrect options.

A nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and
determines that the client is experiencing respiratory acidosis. Which of the following validates the What is an acid?
nurse's findings?
a substance that donates (gives) Hydrogen Ions
1) pH 7.25, Pco2 50,
2) pH 7.35, Pco2 40 What is a base?
3) pH 7.50, Pco2 52
a substance that can accept (receive) Hydrogen Ions
4) pH 7.52, Pco2 28
How do you measure Acid-Base in the body?
Answer: 1
Via ARTERIAL BLOOD GAS ANALYSIS or ABG Blood Test
Rational: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory
exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35-7.45. The normal Pco2 How can you measure ABG?
is 32-48. In respiratory acidosis, the pH is decreased and the Pco2 is elevated. Option 2 identifies normal
values. Option 3 identifies an alkalotic condition. Option 4 identifies respiratory alkalosis. ABG is blood measured in the artery not the vein.
Need either the Radial or Ulnar Artery
A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicated a pH of
7.50 and a Pco2 of 30. The nurse has determines that the client is experience respiratory alkalosis. Who is able to take measurement of ABG?
Which laboratory value would most likely be noted in this condition?
SPECIAL TECH
1) Sodium level of 145 RESPIRATORY THERAPIST
2) Potassium level of 3 TRAINED NURSE
3) Magnesium level of 2
Normal pH?
4) Phosphorus level of 4
7.35-7.45
Answer: 2
What is pH and How does it work?
Rational: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion
concentrations that results from the accumulations of base or from a loss of acid without a comparable loss of Arterial pH measures hydrogen (H+) concentration in blood.
base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical Function: Identifies whether the body is in acidic or alkaline state
manifestations of repiratory alkalosis include headache, tachypnea, paresthesias, tetany, vertigo, convusions,
hypkalemia, and hypocalcemia. Options 1, 3, & 4 identify normal laboratory values. Option 2 identifies the
presence of hypokalemia.
What are the Regulators of H+ in the body?
A nurse notes that a client's arterial blood gas reults reveal a pH of 7.50 and a Pco2 of 30. The nurse
monitors the client for which clinical manifestations associated with these arterial blood gas results? LUNGS & KIDNEYS

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What is a BUFFER SYSTEM? How do the kidneys regulate?

Present in all body fluids ** Release bicarb = alkalosis

Act immediately (< 1 sec) after ABN pH ** Release H+ = acidosis
Doesn't have endurance (starts quick but doesn't last) ** Retain (keep) bicarb = acidosis
** Retain (keep) H+ = alkalosis
What is RESPIRATORY REGULATION?
Factors that Affect Acid-Base Balance
Lungs responsible (CHEETAH)
H+ signals respiratory center in brain to adjust respiratory rate Age: Elderly * Infants/Children
Starts fast but doesn't endure pace - Elderly may have renal & respiratory issues
Analogy: Think of Cheetah: is able to run fast quick but can't continue for a long period of time. - Infants/Children renal * respiratory not well developed
Gender/Body size
What is RENAL REGULATION? Environmental: temp - too hot breathing changes (shallow)
Lifestyle: exercise
Kidneys responsible (ELEPHANT)
Increases or decreases HCO3 (bicarb) in body fluids to regulate acid-base What Imbalances pH?
Starts out slow but endures longer & finishes the job of balancing pH
Analogy: think of the Elephant: Slow & sluggish at 1st but once started can walk for days. Respiratory - regulated by lungs - retention or excretion of CO2
Metabolic - regulated by kidney - via release/retain bicarbs & H+ ions
How do the lungs & kidneys work together to maintain acid-base balance?
What is RESPIRATORY ACIDOSIS and what CAUSES it?
Lungs start process while kidneys turn on; then kidneys take over
** Retained CO2 = increased carbonic acid levels causing pH to fall below 7.35
What is the major Buffer System of the body and what does it do? ** Hypoventilation; serious lung diseases (COPD, asthma)
Major BS: Bicarbonate (HCO3) - carbonic acid (H2CO3) (Chemical Buffer) What is METABOLIC ACIDOSIS and what CAUSES it?
Function: prevents major swings in pH by removing or releasing H+
** Low bicarb levels compared to carbonic acid levels cause pH to fall below 7.35
What is the major Respiratory Regulator and what does it do? ** DKA (Diabetic Keto-acidosis), renal failure
* PaCO2 = controlled by LUNGS What is RESPIRATORY ALKALOSIS and what CAUSES it?
* PaCO2: pressure exerted by dissolved CO2 gas in arterial blood
* CO2 is an acid; dissolved in H2O = carbonic acid (H2CO3) ** Carbonic acid falls = pH rises above 7.45
* Lungs put either out CO2 or retain CO2 to balance pH in body ** Hyperventilation (anxiety, fever, infection)

What PT is vulnerable to Respiratory Regulator malfunctioning & why? What is METABOLIC ALKALOSIS and what CAUSES it?

COPD patients ** Increased levels of bicarb ions cause pH to fall

lack of O2 is more powerful than CO2 - can shut down respiratory drive by putting too much O2 ** prolonged vomiting, excessive suctioning, increased bicarb intake (antacids)
** why vomiting or suctioning? - getting rid of HCL acid
What intervention can nurse do for COPD patients?
NURSING ASSESSMENTS
** Monitor levels of O2 when they are on O2 intake
* complete pt history (PMH)
What is the major RENAL regulator & what does it do? * complete PA (VS, WEIGHT, I/O, MENTAL STATUS)
* labs: Lytes, CBC, Urinalysis - pH, osmolality, SG, ABG
Major Renal Regulator = KIDNEYS **Note: ER nurses have standing order for ABG for emergency situations
Regulates body chemically (deals with both CO2 & HCO3)
Function: regulate the bicarb (HCO3) level in ECF; they regenerate & reabsorb the bicarb ions from RENAL NURSING DX
TUBULAR CELLS
Compensation: slow; hours or days * Fluid Volume Deficit
* Fluid Volume Excess
* Risk for Fluid Volume Imbalance
* Impaired Gas Exchange

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NURSING INTERVENTIONS
* Restore/Maintain Normal Fluid balance (I/O)
* Treat/prevent underlying cause (anxiety, hyperventilation)
- 1st choice = talk w/pt don't give meds immediately
NURSING INTERVENTIONS
* Maintain patent airway via positioning, suctioning, chest physiotherapy
* Monitor HR & rhythm, ABGs, lytes level, VS
NURSING INTERVENTIONS
* Administer meds, treatments per order
* Irrigate GI Suction w/Isotonic solution
What are the Components of ABG Arterial Blood Gas Analysis
4) Examine pH/PCO2 relationship: is it respiratory or metabolic
5) Examine HCO3: Confirms Step 4
6) Examine pH/HCO3 relationship: Reconfirms Step 4
7) Look for Evidence of Compensation: when body begins to correct itself after Tx given
What is the difference between Uncompensated & Compensated ABG results?
Uncompensated = no Tx yet given; body still in state of ABN
Compensated = Tx given; body adjusting to Tx & correcting itself to balance pH but ABN still present; must
monitor
ABG - RESPIRATORY ACIDOSIS UNCOMPENSATED vs COMPENSATED COMPARISON
Uncompensated
pH: Below < 7.35 = Acidosis
PCO2: Above > 45 = Acidosis
HCO3: Normal = Confirms Respiratory & NOT Metabolic

*PO2 = 80-100 mmHg Compensated

*pH = 7.35-7.45 pH: Normal (results very close to origin)
*PCO2 = 35-45 PCO2: Above > 45
*HCO3 = 22-26 HCO3: Above > 26
CO2 still high; Bicarb trying to compensate
What is PO2?
ABG - RESPIRATORY ALKALOSIS
* NOT the same as Pulse Ox UNCOMPENSATED vs COMPENSATED COMPARISON
* Amount of O2 dissolved in Blood
* <80 O2 Deficit Uncompensated
>100 O2 Excess pH: above > 7.45 = Alkalosis
PCO2: below < 35 = Alkalosis
What is pH? HCO3: Normal = Confirms Resp & NOT Metabolic

* INDICATOR of Blood Acid or Alkaline levels Compensated

*< 7.35 = acidic (acidosis) excess acid pH: Normal (results close to original)
* > 7.45 = alkalotic (alkalosis) too basic PCO2: below < 35
HCO3: below < 22
What is PCO2 CO2 still low: Bicarb trying to compensate
* INDICATOR of Respiratory Function ABG - METABOLIC ACIDOSIS
* CO2 = Acid UNCOMPENSATED vs COMPENSATED COMPARISON
* pH < 7.35 & PCO2 > (above) 45 = RESPIRATORY ACIDOSIS
*pH > 7.45 & PCO2 < (below) 35 = RESPIRATORY ALKALOSIS Uncompensated
pH: below < 7.35 Acidosis
What is HCO3 PCO2: Normal = NOT respiratory
HCO3: below < 22 = Confirms Metabolic
* Base (Blood Buffer)
* pH < 7.35 & HCO3 < 22 = METABOLIC ACIDOSIS
Compensated
* ph > 7.45 & HCO3 > 26 = METABOLIC ALKALOSIS
pH: Normal (close to original levels)
STEPS TO INTERPRET ABG PCO2: below < 35 = Lungs Helping Out
HCO3: below < 22
1) Examine PO2=determines O2 levels Note: when CO2 falls below in Met Acid = lungs helping kidneys to rid body of excess CO2 (acid)
2) Examine pH = determines acid/base
3) Examine PCO2 = determines CO2 respiration
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ABG - METABOLIC ALKALOSIS RESPIRATORY ACIDOSIS
UNCOMPENSATED vs COMPENSATED COMPARISON pH < 7.35, PACO2 > 45
HCO3 > 26 = kidneys retaining HCO3 to minimize acidosis (renal compensation)
Uncompensated
pH: above > 7.45 = Alkalosis EVIDENCE OF COMPENSATION
PCO2: Normal = NOT respiratory
HCO3: above > 26 Confirms Metabolic RESPIRATORY ALKALOSIS
pH > 7.45, PACO2 > 45
Compenasated HCO3 < 22 = kidneys excreting HCO3 to minimize alkalosis (renal compensation)
pH: Normal (close to original level)
PCO2: above > 45 = Lungs helping
HCO3: above > 25 EVIDENCE OF COMPENSATION
Note: when CO2 rises above in Met Acid = lungs helping kidneys to rid body of excess bicarb (base) by
retaining more CO2 (acid) METABOLIC ACIDOSIS
pH < 7.35, HCO3 < 22
INTERPRETATION OF LABS
PACO2 < 35, lungs blowing off CO2 to minimize acidosis (respiratory compensation)
PO2 = 90 (normal)
EVIDENCE OF COMPENSATION
pH = 7.52 (alkalosis)
PCO2 = 43 (normal) METABOLIC ALKALOSIS
HCO3 = 30 (metabolic) pH > 7.45, HCO3 > 26
PACO2 > 45, lungs retaining CO2 to minimize alkalosis (respiratory compensation)
Result: Metabolic Alkalosis
substance that yeilds H ions in solution
INTERPRETATION OF LABS
acid
PO2 = 94 (normal)
pH = 7.61 (alkalosis) substance that yields OH ions in solution
PCO2 = 27 (respiratory)
HCO3 = 26 (normal) base

Result: Respiratory Alkalosis combination of a weak acid or base and its salt that resists changes in pH

INTERPRETATION OF LABS buffer

PO2 = 85 (normal) -log of H concentration

pH = 7.21 (acidosis)
pH
PCO2 = 39 (normal)
HCO3 = 15 (metabolic) normal H concentration in the body is _______ nmol/l
Result: Metabolic Acidosis 36-44
INTERPRETATION OF LABS what is the normal pH of the body
PO2 = 95 (normal) 7.35-7.45
pH = 7.20 (acidosis)
PCO2 = 49 (respiratory) how does the body maintain a nomal pH
HCO3 = 24 (normal)
chemical blood buffers, physiologic buffering systems (lungs and kidneys)
Results: Respiratory Acidosis
buffer systems work to maintain acid/base ___________
EVIDENCE OF COMPENSATION
homeostasis

buffer systems prevents __________, when pH goes below 7.35

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acidosis pH- 7.513, PCO2- 28.3, HCO3 22.9

buffer systems prevent ________, when pH goes above 7.45 respiratory alkalosis

alkalosis pH 7.33, PCO2 49, HCO3- 25

chemical blood buffers go to work on the cellular level ________, while physiologic buffers may work a little RESPIRATORY ACIDOSIS
more ________
pH 7.36, PCO2- 32, HCO3 17
immediately, slowly
compensated metabolic acidosis
what are the chemical blood buffers
if both the pH and the HCO3 are going up or down guess
HCO3, H2CO3, hemoglobin, phosphate, and plasma proteins
metabolic
what is the reaction that yeilds bicarbonate
if the pH and the PCO2 are seesawing guess
CO2 + H2O<----> H2CO3 <---> H + HCO3
respiratory
the majority of plasma CO2 is in the form of
_______ works along with the bicarb/carbonic acid system to remove acid in the form of CO2 in respiration
bicarbonate
lungs
what is the normal value for HCO3
_________ respiration will increase pH (hyperventilation)
22-26 mmol/L
increased
carbonic acid dissociates into CO2 and H2O which are eliminated by the what?
_________ respiration or faulty exchange will decrease pH (not getting rid of CO2 at the rate of production)
lungs
decreased
HCO3 is regulated by the what?
the _____ is slower to responed but is very powerful
kidneys
kidney
in normal plasma where the lungs and kidneys are functioning normally the ratio of bicarb to carbonic acid is
the kidneys main job is to reabsorb what
20:1
bicarbonate
the ratio of bicarb to carbonic acid is called the
normal value for PCO2
Henderson Hasselbach
35-45 mmHg
the Henderson Hasselbach equation is
normal value for HCO2
pH= 6.1 + log of HCO3(kidney) /H2CO3 (Lung)
22-26 mmol/L
to assess acid/base balance you need what values
normal value for PO2
pH, PCO2, HCO3
80-110mmHg
hemoglobin is responsible for _______% of buffering capacity of blood
normal value for total CO2
30%
23-27mmol/L
__________ combines with secreted H+ ions and is eliminated in the urine
normal value for O2 saturation
phosphate
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>95% how will your body compensate for metabolic acidosis

normal value for O2 Hgb you would hyperventilate to decrease H2CO3

>95% another name for the partial pressure PCO2 electrode

what pH's are not compatable with life severing house electrode

6.8 or 7.8 another name for the O2 electrode

if the problem is respiratory then compensation = clark

metabolic primary CO2 excess

if the problem is metabolic the compensation = respiratory acidosis

respiratory in respiratory acidosis pH is ____, HCO3 is ______, and the CO2 is ________

what are the four types of acid/base disturbances decreased, normal, increased,

metabolic acidosis, metabolic alkalosis, respiratory acidosis, respiratory alkalosis what are some causes for respiratory acidosis

a disorder in ventilation is called hypoventilation, alcohol piosoning

respiratory how will our bodys compensate for respiratory acidosis

a disorder of bicarbonate level is called your kidneys will reabsorb more HCO3

metabolic primary CO2 deficit

primary bicarbonate deficit respiratory alkalosis

metabolic acidosis in respiratory alkalosis pH is _______, HCO3 is ________, CO2 is ________-

in metabolic acidosis pH is ________, HCO3 is _________, and CO2 is ________ (before compensation) increased, normal, decreased

decreased, decreased, normal what are some causes for respiratory alkalosis

in metabolic acidosis CO2 will _______ in order to compensate (Hyperventilate) hyperventilation, PCP, anxiety, pain

decrease how would our bodies compensate for respiratory alkalosis

what are some causes of metabolic acidosis the kidney would excrete more HCO3

aspirin overdose, starvation, diabetic ketoacidosis

in metabolic alkalosis ph is ______, HCO3 is _________, and CO2 is ________ SURGERY

increased, increased, normal 1. How does palliative surgery differ from any other type of surgery?
A. The main purpose is cosmetic in nature rather than functional repair or comfort.
primary bicarbonate excess
B. There are fewer risks associated with palliative surgery than with any other type of surgery.
metabolic alkalosis C. The outcomes of palliative surgery cannot be ensured to produce the desired effect or restoration of
functional ability.
in order to compensate for metabolic alkalosis your body will D. Palliative surgery is performed to provide temporary relief of distressing symptoms rather than to cure a
problem or condition.
decrease respirations and increase kidney HCO3 excretion

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ANS: D
The purpose of palliative surgery is to improve the client's quality of life by reducing or eliminating
distressing symptoms. It does not cure a health problem and, often, does not prolong life. Although
the exact outcomes of palliative surgery cannot be ensured, neither can the outcomes of any other
type of surgery.
2. The client tells the nurse during the preoperative history that he is a three-pack a day cigarette
smoker. This information alerts the nurse to which potential complication during the intraoperative
and postoperative periods?
A. A decreased tolerance to pain
B. A decreased clotting ability
C. An increased risk for atelectasis and hypoxia
D. An increased risk for excessive scar tissue formation
ANS: C
Smoking increases the level of circulating carboxyhemoglobin, which decreases oxygen delivery to the
tissues. In addition, cigarette smoking damages the cilia of mucous membranes, decreasing transport of
secretions and increasing the risk of pulmonary infection and atelectasis.
3. The client receiving preoperative medication tells the nurse that all of the following medications
(drugs or herbs) were ingested yesterday. Which one should the nurse report to the surgical team?
A. Acetaminophen (Tylenol)
B. Vitamin C
C. Motherwort
D. Diphenhydramine (Benadryl)
ANS: C
Motherwort interferes with coagulation, increasing the client's risk for bleeding during and after the surgical
procedure.
4. When the nurse brings the preoperative medication to the client about to have abdominal surgery,
she tells the nurse that she does not need the injection because she had a good night's sleep last
night. What is the nurse's best first action?
A. Tell the client that her surgeon has ordered the medication; therefore, she should go ahead and take the
medication because the surgeon knows what is best.
B. Tell the client that the preoperative medication is ordered to reduce the risk of some problems during
surgery rather than to ensure adequate rest.
C. Appropriately discard the preoperative medication and notify the surgeon.
D. Document the client's statement and notify the charge nurse.
ANS: B
The preoperative medication is prescribed to prevent a vagal response during intubation and surgery, reduce
the amount of anesthetic needed during induction, and reduce anxiety.
5. The client who is scheduled to have surgery cannot read or write. The surgeon obtaining the
consent wants to have the client's spouse sign the consent instead. What is the nurse's best action?
A. Nothing; a signed informed consent statement does not need to be obtained from this client.
B. Locate the spouse, because the informed consent statement must be signed by the client's closest relative.
C. Inform the surgeon that the client may sign the informed consent statement with an X in front of two
witnesses.
D. Notify the administration because the court must appoint a legal guardian to represent the client's best
interests and give consent for all surgical procedures.
21
ANS: C
The lack of ability to read or write does not constitute incapacity to give legal consent. If the client meets all
other legal and clinical aspects of competence, he or she may use an X to demonstrate consent if the act is
witnessed by two persons.
6. Twenty minutes after the client has received a preoperative injection of atropine and midazolam
(Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry
and his heart seems to be beating faster than normal. What is the nurse's best first action?
A. Document the findings as the only action.
B. Check the client's pulse and blood pressure.
C. Prepare to administer epinephrine and diphenhydramine (Benadryl).
D. Explain to the client that these symptoms are normal responses to the medication.
ANS: B
Although these are the expected physiologic responses to the preoperative medication, any time the client
states that he or she can feel a change in normal cardiac function, the system should be assessed. If the
client's pulse and blood pressure are within normal limits, the nurse should
7. Which nursing action or statement is most likely to reduce anxiety in a client being brought to the
surgical suite?
A. Asking the client if he or she has talked with the hospital chaplain
B. Asking the client what specific surgery he or she is having done today
C. Asking the client if he or she wants family members to be with them in the holding area
D. Explaining to the client that the surgical area is the most technologically advanced in the city
ANS: C
Most anxious clients would feel some relief by having one or more familiar persons waiting with them until
surgery begins. In addition, asking the client what he or she wants allows the client to have more control over
the situation. Asking the client if he or she has visited with the hospital chaplain and telling the client about the
advanced technology can imply to the client that the procedure is dangerous. Although the client must be
asked what procedure he or she is having (to ascertain that the client does know what is to be done), this
question may make the client worry about the competency of the staff.
8. All of the members of the surgical team must perform a "surgical scrub" except which of the
following?
A. Anesthetist/anesthesiologist
B. Surgical technologist
C. Scrub nurse
D. Surgeon
ANS: A
The anesthetist or anesthesiologist does not enter the sterile field. Caps, masks, scrub clothing, and scrub
jackets are worn to prevent shedding of microorganisms, but sterile gloves and surgical scrubbing are not
needed.
9. In the operating room, the client tells the circulating nurse that he is going to have the cataract in
his left eye removed. The nurse notes that the consent form indicates that surgery is to be performed
on the right eye. What is the nurse's best first action?
A. Assume that the client is a little confused because he is older and has received midazolam intramuscularly.
B. Check to see if the client has received any preoperative medications.
C. Notify the surgeon and anesthesiologist.
D. Ask the client his name.
©SGT XENIIA MARIE RAZALO LAWAN PAFR
ANS: D A. The electrocardiogram (ECG) shows tall, peaked T waves and wide QRS complexes.
Ensuring proper identification of the client is a responsibility of all members of the surgical team. Especially in B. The client only arouses in response to light shaking.
a specialty surgical setting, where many people undergo the same type of surgery each day, such as cataract C. The pulse pressure has increased from 28 to 40 mm Hg.
removal, it is possible that the client and the record do not match. The nurse identifies the client and the D. The dorsalis pedis pulses are not palpable bilaterally.
client's consent form before the physicians are notified.
ANS: D
10. The anesthetized client with an open abdomen suddenly develops malignant hyperthermia. What The lithotomy position can compromise the client's peripheral circulation in the lower extremities.
intervention should the nurse be prepared to initiate or assist with?
A. Discontinue mechanical ventilation. 15. Which client is at greatest risk for respiratory complications after surgery under general
B. Administer intravenous potassium chloride. anesthesia?
C. Administer intravenous calcium chloride. A. 65-year-old woman taking a calcium channel blocker for hypertension
D. Administer intravenous dantrolene (Dantrium). B. 55-year-old man with chronic allergic rhinitis
C. 45-year-old woman with diabetes mellitus type 1
ANS: D D. 35-year-old man who smokes two packs of cigarettes daily
Dantrolene is a skeletal muscle relaxant and can help lower body temperature by reducing metabolic heat
production by the muscles. Clients become hyperkalemic and hypercalcemic; therefore, neither of these ANS: D
electrolytes should be administered. The client's gas exchange is severely compromised. If the client is not Cigarette smoking greatly increases the risk for pulmonary problems following general anesthesia because
already receiving mechanical ventilation, it is initiated. the cilia of the mucous membranes may be absent or hypoactive, the lining of the airways may be
hypertrophied, and the alveoli may be less compliant. Age and gender are not significant in this case.
11. What is the priority nursing diagnosis for the client under general anesthesia during surgery?
A. Acute Pain related to surgical procedure 16. Two hours after abdominal surgery, the nurse auscultates the client's abdomen. No bowel sounds
B. Risk for Infection related to surgical wound are present. What is the nurse's best first action?
C. Risk for Impaired Skin Integrity related to prolonged static position A. Position the client on the right side with the bed flat.
D. Disturbed Body Image related to presence of surgical wound or scar B. Check the dressing and apply an abdominal binder.
C. Palpate the bladder and measure abdominal girth.
ANS: C D. Document the finding as the only action.
The problem that nursing is most responsible for with this client is ensuring maintenance of skin integrity.
ANS: D
12. The client who has received ketamine hydrochloride during a surgical procedure has all of the Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that should be documented.
following manifestations and behaviors. Which one alerts the nurse to a dissociative reaction? No intervention specific to this finding is needed at this time.
A. Hypoventilation and decreased oxygen saturation
B. Presence of hives on the skin around the IV site 17. Calculate the actual amount of nasogastric (NG) tube drainage during an 8-hour shift (3 PM to 11
C. Crying because the pain at the surgical site has increased PM) from the client who has a drainage container with 200 mL marked at 3 PM and 840 mL at 11 PM,
D. Pulling out the IV because he sees bugs in the solution bag and who received NG irrigations (flushings) of 60 mL three times during the 8-hour shift.
A. 840 mL
ANS: D B. 660 mL
Ketamine hydrochloride induces dissociative reactions such as hallucinations, distorted images, and irrational C. 460 mL
behavior during emergence from the anesthesia. D. 420 mL

13. Who is responsible for accompanying the surgical client to the postanesthesia recovery area after ANS: C
surgery and for giving a report of the client's intraoperative experience to the PACU nurse? The initial volume of 200 mL is subtracted from the 840 mL, leaving 640 mL. The irrigation fluid is not drainage
A. The surgeon and scrub nurse and also must be subtracted (60 3 = 180 mL). The total drainage from this client's NG tube during the 8-hour
B. The surgeon and circulating nurse shift was 460 mL (640 180 = 460 mL).
C. The anesthesiologist and scrub nurse
D. The anesthesiologist and circulating nurse 18. The client who is 24 hours postoperative from abdominal surgery has light brown fluid with small
particles that look like coffee grounds in the NG tube drainage. What is the nurse's best action?
ANS: D A. Notify the physician.
The anesthesiologist (or certified registered nurse anesthetist) and the circulating nurse are responsible for B. Irrigate the tube with normal saline.
accompanying the client to the postoperative recovery area and giving a report of the client's intraoperative C. Clamp the tube and advance it 1 to 2 inches.
experience. D. Document the finding as the only action.

14. The client is admitted to the postanesthesia care unit (PACU) after surgery that took place with the ANS: A
client in the lithotomy position. Which change in assessment findings alerts the nurse to a possible This type of drainage indicates possible gastrointestinal bleeding and should be explored further as soon as
complication of this surgical position? possible.

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19. The nurse empties 80 mL of sanguineous drainage from the Jackson-Pratt drain in the client's hip Reason for Surgery, Restorative:
after hip surgery. What other actions regarding the drain should the nurse take?
A. Flush the tubing with urokinase to ensure patency. Description: Performed to improve a patient's functional ability.
B. Compress and close the drain to ensure suction. Condition of Surgical Procedure: Total knee replacement, finger re-implantation.
C. Advance the tubing ½ inch from the insertion site.
D. Clamp the drain for 2 hours and release the clamp for 2 hours. Reason for Surgery, Palliative:

ANS: B
The Jackson-Pratt drain removes fluid from the wound through closed suction. The drain must be compressed
and closed to create suction as it slowly re-expands.
20. The client is postoperative from surgery performed to determine whether a growth in her colon is
cancerous. She asks the nurse what the pathology report shows. The pathology report indicates that
the growth is benign. What is the nurse's best response?
A. "Congratulations! The growth was not cancerous."
B. "You will have to wait for your doctor to tell you the results."
C. "You shouldn't worry. Most tumors of this sort are benign."
D. "I will call your doctor to let her know you are awake and are concerned about the results."
Perioperative Care refers to the time:
-When the patient is scheduled for surgery until the patient's condition stabilizes and patient is d/c from facility.
-Preoperative, intraoperative, and perioperative
What 3 things will you, as a nurse, function as to the patient in parioperative process?
An educator, advocate, and a promoter of health.
The peri operative emphasis on:
Safety, advocacy, patient education, and a culture of safety.
Description: Performed to relieve symptoms of a disease process, but does not cure.
Condition of Surgical Procedure: Colostomy, nerve root resection, tumor de-bulking, ileostomy.
Reason for Surgery, Cosmetic:
Description: Performed primarily to alter or enhance personal appearance.
Condition of Surgical Procedure: Liposuction, revision of scars, rhinoplasty, blepharoplasty.
Urgency of Surgery, Elective:
Description: Planned for correction of a nonactive problem.
Condition of Surgical Procedure: Cataract removal, hernia repair, hemorrhoidectomy, total joint replacement.
Urgency of Surgery, Urgent:
Description: Requires prompt intervention; may be life threatening if treatment is delayed more than 24-
48hrs.
Condition of Surgical Procedure: Intestinal obstruction, bladder obstruction, kidney or ureteral stones, bone
fracture, eye injury, acute cholecystitis.
Urgency of Surgery, Emergent:
Description: Requires immediate intervention because of life-threatening consequences.
Condition of Surgical Procedure: Gunshot or stab wound, severe bleeding, abdominal aortic aneurysm,
compound fracture, appendectomy.

Degree of Risk of Surgery, Minor:

Objective to Perioperative Care:
Description: Procedure without significant risk; often done with local anesthesia.
-Provide care for the perioperative client Condition of Surgical Procedure: Incision and drainage (I&D), implantation of a venous access device (VAD),
-Provide nursing care for clients experiencing signs and symptoms of commonly occurring complications, muscle biopsy.
shock, and hemorrhage.
Degree of Risk of Surgery, Major:
-Manage the pain of the perioperative client
-Develop age-related teaching/learning strategies for the perioperative client. Description: Procedure of greater risk; usually longer and more extensive than a minor procedure.
Condition of Surgical Procedure: Mitral valve replacement, pancreas transplant, lymph node dissection.
The preoperative period begins when:
Extent of Surgery, Simple:
The patient is scheduled for surgery and ends at the time of transfer to the surgical suite.
Description: Only the most overtly affected areas involved in the surgery.
Reason for Surgery, Diagnostic:
Condition of Surgical Procedure:Simple/partial mastectomy.
Description: Performed to determine the origin and cause of a disorder or the cell type for cancer.
Extent of Surgery, Radical:
Condition of Surgical Procedure: breast biopsy, exploratory laparotomy, arthroscopy.
Description: Extensive surgery beyond the area obviously involved; is directed at finding a root cause.
Reason for Surgery, Curative:
Condition of Surgical Procedure: Radical prostatectomy, radical hysterectomy.
Description: Performed to resolve a health problem by repairing or removing the cause.
Extent of Surgery, Minimally Invasive Surgery (MIS):
Condition of Surgical Procedure:Cholecystectomy, appendectomy, hysterectomy.

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Description: Surgery performed in a body cavity or body area through one or more endoscopes; can correct
problems, remove organs, take tissue for biopsy, re-route blood vessels and drainage systems; is a fast-
growing and ever-changing type of surgery.
Condition of Surgical Procedure: Arthroscopy, tubal ligation, hysterectomy, lung lobectomy, coronary artery
bypass, cholecystectomy.
-Patient must be mentally competent. If patient just received medications that affect comprehensive
neuro status, cannot sign consent.
-If the patient is a minor, a guardian, parent or court order will sign the permit; the state dictates that age.
The Patient Self-Detemination Act allow the patient to:

Risk Factors the Acknowledge In The Preoperative Phase:
Age (older than 65), nutritional, health status, fluid and electrolyte imbalances, radiation,
cardiopulmonary, chemotherapy, meds(antihypertensives, tricyclic antidepressants, anticoagulants,
NSAIDs), family history(malignant hyperthermia, cancer, bleeding disorder), prior surgical experience (less
than optimal emotional reaction, anesthesia reactions or complications, postoperative complications), type of
surgery (neck, oral, or facial procedures [airway complications], chest or high abdominal procedures
[pulmonary complications], abdominal surgery [paralytic ileus, DVT).
Risk Factors the Acknowledge In The Preoperative Phase Con't:
Medical history (decreased immunity, diabetes, pulmonary disease, cardiac disease, hemodynamic
instability, multisystem disease, coagulation defect or disorder, anemia, dehydration, infection, HTN,
hypotension, any chronic disease), health history (malnutrition or obesity, drug, tobacco, alcohol, or illicit
substance use or abuse, altered coping ability).
The Preoperative Nurse:
-Validates & clarifies information
-Assess to identify problems that warrant further patient assessment or intervention before the procedure
-Obtains baseline vital signs
-Have the right to have or to initiate advance directives, such as living will or durable power of attorney.
-Advance directives provide legal instructions to the health care providers about the patient's wishes and are
to be followed. Surgery does not provide an exception to a patient's advance directives or living will.
Name 5 Expected Outcomes for Deficient Knowledge Nursing Diagnosis:
Patient will...
-Explain the purpose and expected results of the planned surgery.
-Ask questions when a term or procedure is not known
-Adhere to the NPO requirements
-State an understanding of preoperative preparations (e.g., skin preparation, bowel preparation).
-Demonstrate correct use of exercises and techniques to be used after surgery for the prevention of
complications (e.g., splinting the incision, coughing/deep breathing, performing leg exercises, ambulating as
early as permitted).
NPO Guidelines:
-Patient is instructed to not have anything to eat or drink by mouth 6-8hrs prior to procedure.
-NPO decreases aspiration risk.
-Patients should be given written and oral instructions to stress adherence
-Surgery can be cancelled if NPO 6-8hrs prior to surgery is not followed.

What types of assessments are done in collaboration? Things to Consider When Administering Regularly Scheduled Medications:

-History & data collection -Medical physicians & anesthesia providers should be consulted for instructions about regularly taken
-Age; discharge planning prescription medications prior to surgery.
-Drugs and substance use -Drugs for cardiac disease, respiratory disease, seizures, and HTN are commonly allowed with a sip of water
-Medical history, including cardiac pulmonary histories before surgery.
-Previous surgical procedures & anesthesia; blood donations. -Diabetic patient who takes insulin may be given a reduced or modified dose of intermediate- or long-acting
insulin based on the blood glucose level or may be given regular (fast-acting) insulin in divided doses on the
Preoperative Phase-What Assessment the Nurse Finds: day of surgery. As an alternative, an IV infusion of 5% dextrose in water may be given with the insulin to
prevent low blood sugar during surgery.
past & present: meds, diet, allergies (latex), personal habits, occupation, finances, family support, knowledge
of surgery, attitude. Bowel or Intestinal Preps:
Preoperative Phase-Assessment: -Are performed to prevent injury to the colon and to reduce the number of intestinal bacteria.
-Enema or laxative may be ordered by the physician.
-Nursing hx (^). -Perform skin preparation to decrease the risk of impairment of skin integrity.
-Physical Exam
-Diagnostic Tests: CBC, electrolytes, creatinine, urinalysis, x-ray exams, EKG, blood type, PTT, PT, platelet Skin Preparation Considerations:
count; Blood donations; pregnancy test; clotting studies.
-Radiographic; CXR; EKG -Skin prep before surgery is the first step in the prevention of surgical wound infection.
-Bloodless Surgery/Discharge -Provide a warm, comfortable, and private environment during the procedure since it can be uncomfortable to
the patient.
Preoperative Teaching r/t Informed Consent: -If pt is at home, he/she may shower with antiseptic solution 2 days before surgery; if in hospital, showering
and cleaning are repeated the night before or in the morning before transfer to surgical suite.
Surgeon is responsible for obtaining the signed consent before sedation and/or surgery. The nurse's role is to
clarify facts presented by the physician and dispel myths that the patient or family may have about surgery. Skin Preparation Considerations Con't:
To Obtain an Informed Consent:
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-The CDC recommends that if shaving is necessary, the hair should be removed using disposable sterile 3. Take a deep breath though nose, using shoulder muscles to expand lower rib cage outward during
supplies and aseptic principles immediately before the start of the surgical procedure. inhalation.
-Shaving is now considered an inappropriate hair removal method; only clippers or depilatories are to be used 4. Exhale, concentrating first on moving chest, then on moving lower ribs inward, while gently squeezing the
for hair removal. rib cage and forcing air out of the base of lungs.

Preparing the Patient for Tubes: Splinting of the Surgical Incision:

Tubes: Pt may need an indwelling urinary catheter (Foley) before, during, or after surgery. A NG tube may be 1. Unless coughing is contraindicated, place a pillow, towel, or folded blanket over surgical incision and hold
inserted before abdominal surgery to decompress or empty the stomach and the upper bowel. the item firmly in place.
2. Take 3 slow, deep breaths to stimulate your cough reflex.
Preparing the Patient for Drains: 3. Inhale through nose, and then exhale through mouth.
4. On 3rd deep breath, cough to clear secretions from lungs while firmly holding the pillow, towel, or folded
Drains: are often placed during surgery to help remove fluid from the surgical site. Some drains are under the blanket against incision.
dressing; others are visible and require emptying.
Purpose of External Pneumatic Compression Devices:
Preparing the Patient for Vascular Access:
-To promote venous return and prevent DVT.
Vascular Access: is placed for patients receiving a general anesthetic and most patients receiving other -Examples: Kendall SCD machine, sleeves and TED stockings; Venodyne pneumatic compression system;
types of anesthetics. Access is needed to give drugs and fluids before, during, and after surgery. Flowtron DVT calf garments.
-Patients who are dehydrated or are at risk for dehydration may receive fluids before surgery.
How to relieve anxiety pre and intra-operatively:
Preoperative-Implementation:
Decrease anxiety by providing a climate of privacy, comfort, and confidentiality.
-Informed consent Interventions Include:
-Nutrition/fluids-IV; NPO after MN -Preoperative teaching
-Elimination-enemas, foley. -Encouraging communication
-Hygiene- skin scrub; remove nail polish, hair pins, hospital gown. -Promoting rest
-VS; Height/weight -Using distraction
-Special orders (insert tubes, medications) -Teaching family members
-Promote comfort-anti-anxiety meds
-Skin preparation What to do on the Day of Surgery:
Pre-operative Teaching: -Complete pre-op checklist sheet in medical record, VS, skin prep removal of prosthetics, hair pins, dentures,
bowel and bladder prep, TEDS, IV, NG Tube, ID band, and pre-op medications. Make sure lab informed &
-Leg and deep breathing exercises radiology reports on chart. Be sure abn. labs reported to MD.
-ROM exercises -ALLERGIES
-Moving patient
-Coughing and splinting Preparation of Patient's room for return after OR:
Preoperative Monitoring: IV pole, open bed, suction, Oxygen, emergency kits, and clamps.
-Patient and diagnostic tests Preoperative Patient Prep:
-TED socks, elastic wraps, pneumatic compression devices, and early ambulation.
-Patient wears an identification band.
Deep (Diaphragmatic) Breathing: -Dentures, prosthetic devices, hearing aids, contact lenses, fingernail polish, and artificial nails must be
removed.
1. Sit upright on the edge of the bed or in a chair, being sure that your feet are placed firmly on the floor or
stool. (After surgery, deep breathing is done with the patient in Fowler's position or in semi-Fowler's position). Medications Hazardous to Surgery:
2. Take a gentle breath through mouth then breath out gently and completely.
3. Take a deep breath through nose and mouth, and hold this breath to the count of 5; exhale though nose Certain Antibiotics: combined with curariform muscle relaxant cause respiratory paralysis and apnea.
and mouth Anti-Depressants: MAO inhibitors-second line choice for tx of depression. Cause hypotension effects of
anesthesia, St. Johns Wart. Parnate, Nardil.
Expansion Breathing: Phenothiazines: (Thorazine-antipsychotic. Also for severe NV, seizures) increase hypotension action of
anesthesia.
1. Find a comfortable upright position, with knees slightly bent
2. Place hands on each side of lower rib cage, just above waist Medications Hazardous to Surgery Con't:
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Diuretics: electrolytes imbalance and resp depression. Advantages: Most controllable method; induction and reversal accomplished with pulmonary ventilation; few
Steroids: inhibits wound healing SE.
Anticoagulants: warfarin and heparin- affect bleeding, unexpected bleeding; herbals-ASA, ginko, NSAIDS, Disadvantages: must be used in combination with other agents for painful or prolonged procedures; limited
Ticlid, Plavix. muscle relaxant effects; postop nausea and shiver common; explosive.
Common Agents: Suprance, Ethrane, Fluothane!, Nitrous oxide (N2O)!
Intra Operative Care:
General Anesthesia, IV:
Primary concerns of the nurse is the safety & advocacy for the patient during surgery as the patient is unable
to protect or advocate for himself. It is the responsibility of all of the surgical team members to protect the Advantages: Rapid and pleasant induction; low incidence of postop N/V; requires little equipment.
patient. Disadvantages: Must be metabolized and excreted from the body for complete reversal; contraindicated in
presence of hepatic or renal disease; increased cardiac and respiratory depression; retained by fat cells.
Intraoperative Care, Holding area: Common Agents: Pentothal!, Ketalar, Diprivan; Hypnotics like versed, ativan, valium are adjuncts to general.
-Enter prior to OR; nurse continues to prepare patient (insert Foley or start IV). General Anesthesia, Balanced:
-Nurse assist in transfer to and from OR, maintain proper body alignment.
Advantages: Minimal disturbance to physiologic function; minimal SE; can be used with older and high-risk
In the OR, ID site of Procedure: patients
Disadvantages: Drug interactions can occur; pharmacologic effects on the body may be unpredictable.
When the procedure involves a specific site, validating the side on which a procedure is to be performed (e.g., *Common Agents: COMBINATION OF: Nitrous oxide, for amnesia; morphine for analgesia; pavulon
for amputation, cataract removal, hernia repair) is the responsibility of each health care professional before (Pancuronium), for muscle relaxation.
and at the time of surgery. Facilities usually have the patient and/or nurse initial the correct surgical site.
Name the 4 Adjunctive Anesthetic Agents:
NTK Before the Surgery:
-Opioid analgesic: alfenta, demerol, morphine.
-Code status -Anticholinergic: atropine, scopolamine
-Any allergies -Benzodiazepine: valium, versed
-The position pt is supposed to be in -Sedative-hypnotics: atarax, vistaril, seconal, nembutal.
-Medical hx
-What meds have been taken Use of Opioid Analgesic for an Adjunct Agent:
-Last PO intake.
-Anesthesia induction
6 Positions for Surgery: -Alfenta
-Demerol and Morphine: pain prevention and pain relief.
-Supine
-Trendelenburg: supine with feet slightly lowered. Use of Anticholinergic for an Adjunct Agent:
-Jacknife: like leaning over a table with arms out to the side
-Lithotomy: supine with feet in stirrups. -To dry up excessive secretions
-Lateral -Atropine, scopolamine
-Prone
Use of Benzodiazepine for an Adjunct Agent:
Insufflation:
-Amnesia and anxiety
A minimally invasive procedure where gas or air is injected into a body cavity before surgery to separate -Valium and Versed
organs and improve visualization.
Use of Sedative-Hypnotics for an Adjunct Agent:
What are the 4 types of Anesthesia?
-Amnesia and sedation
General (inhalation, IV, balanced): depresses the CNS, resulting in analgesia amnesia, and -Atarax, Vistaril, Seconal, Nembutal
unconsciousness, with loss of muscle tone and reflexes. Used for surgery of head, neck, upper torso, and
abdomen. Advantages of Regional or Local Anesthesia:
Regional or local:
Cryothermia: Advantages: gag and cough reflexes stay intact (decreases risk for aspiration); allows participation
Hypnosis/Hypoanesthesia: and cooperation by the pt; less disruption of physical & emotional body functions; decreased chance of
sensitivity to agent; decreased intraoperative stress.
General Anesthesia, Inhalation:
Disadvantages of Regional or Local Anesthesia:
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Disadvantages: not practical for extensive procedures b/c of the amount that would be required to -Circulation
maintain anesthesia; difficult to administer to an uncooperative or upset pt; no way to control agent after -Therapeutic response to anesthesia
administration; absorbs rapidly into the blood and causes cardiac depression (hypotension) or overdose; -Risk for Injury: proper positioning
increased nervous system stimulation (overdose). -Maintain surgical asepsis
-Risk for infection.
3 Common Agents for Regional or Local Anesthesia: -Surgical site: closure of surgical wounds with stitches, staples, or tapes. Risk for infection.
-Xylocaine Name 7 Intraoperative Complications:
-Lidocaine
-Novocain -Hypoventilation
Topical: Dermoplast (benzocaine) -Oral Trauma- endotracheal intubation
-Hypotension
4 Types of Regional (which is a form of Local): -Cardiac dysrhythmias
-Hypothermia
Epidural: Injection into the epidural space (dura mater). For anorectal, vaginal, perineal, hip, & lower -Peripheral nerve damage
extremity surgeries. -Malignant hyperthermia
Field: A series of injections around the operative field. For chest procedures, hernia repair, dental surgery, &
some plastic surgeries. Malignant Hyperthermia:
Spinal: Injection into the cerebrospinal fluid in the subarachnoid space. For lower abdominal, pelvic, hip, and
knee surgery. Due to abnormal and excessive intracellular collection of Ca+ resulting in hypermetabolism and increased
Nerve: Injection into or around one nerve or group of nerves in the involved area. For limp surgery or to muscle contraction.
relieve chronic pain.
Manifestations of Malignant Hyperthermia:
Cryothermia Anesthesia:
-Tachycardia, dysrhythmias, muscle rigidity (especially of the jaw and upper chest), hypotension, tachypnea,
Advantages: Reflexes remain intact, decreases chance of adverse reactions, decreased intraoperative skin mottling, cyanosis, and myoglobinuria (presence of muscle proteins in the urine).
stress. -The most sensitive indication is an unexpected rise in the end-tidal carbon dioxide level with a decrease in
Disadvantages: Not used in long or extensive procedure, no way to control depth of anesthesia, may not be oxygen saturation.
appropriate for anxious patient.
Name 7 S/S of MH:
Hypnosis/Hypoanesthesia:
-High fever ^ to 111.2F (late sign), tachycardia (early sign)
*Advantages: reflexes remain intact. -Dysrhythmias
Disadvantages:* requires patient cooperation, requires special training. -Muscle rigidity (esp. jaw & upper chest), heart failure
-Pseudotetany
Induces a passive, trance-like state. -Myoglobinuria (muscle protein in urine)
-^ CA+ & K+
Conscious Sedation: -Skin mottling/cyanosis
Conscious sedation is the IV delivery of sedative, hypnotic, and opioid drugs to reduce the level of Name 4 ways to Treat MH:
consciousness but allow the patient to maintain a patent airway and to respond to verbal commands.
-Discontinue inhalent anesthetic
What are the 2 common agents used in conscious sedation? -Give Dantrium (Dantrolene) (for risk or previous HX: may give before, during, and after surgery to prevent)
-Intubate & oxygen 100%
Versed, Ativan -Cooling: cooling blanket, iced IV saline or iced saline lavage of stomach, bladder, rectum.
-More pg 275 Chart 17-1
Flumzazenil/Romazicon: reversal agent for benzodiazepines (Versed, Ativan)
Name 3 Complications During Intraoperative Care:

-Overdose of anesthesia
-Unrecognized hypoventilation
Name 7 Intraoperative Nursing Concerns: -Intubation complications

Who is responsible for accompanying pt and providing report to PACU nurses? And what must they
-Patent airway (ABCs)
provide?
-Breathing/Oxygenation
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-Anesthesiologist and circulating nurse -The passage of flatus or stool.
-Must provide a "Hand-Off Report" which allows for 2-way verbal communications, information must be clear -The presence of active bowel sounds usually indicates return of peristalsis; however, the absence of bowel
& standardized (SBAR), and provides for clarification of information about patient. sounds does not confirm a lack of peristalsis.

Purpose of the PACU: Name 4 causes of ineffective wound healing:

-Provides ongoing evaluation & stabilization of patients. -Infection

-To anticipate, prevent, treat any complications of surgery. -Distention from edema or paralytic ileus
-Stress at the surgical site
How often should you look at the surgical incision in PACU? -Health problems (e.g., diabetes)
Q15min What 4 patients are more at risk for fluid and electrolyte imbalance?
What 6 things are monitored in the PACU? -Older or debilitated
-Diabetic
Airway: breathing appropriately? Labored? Why? -Crohn's disease
Mental Status: what is it? Is it appropriate? -Heart failure
Surgical incision: bleeding? Look at it q15min.
VS: Temp/Pulse/BP Wound Dehiscence:
IV Fluids: solution type, amount in bag, rate
Other Tubes/Drains: Foley, NG, trach, chest -A partial or complete separation of the outer wound layers, sometimes described as "splitting open of the
wound"
What do you immediately assess when pt comes into PACU? -Occurs most often between the 5th and 10th days after surgery
Immediately assess for patent airway and adequate gas exchange. Although some patients may be awake Wound Evisceration:
and able to speak, talking is not a good indicator of adequate gas exchange.
-The total separation of all wound layers and protrusion of internal organs through the open wound.
What is the order of return to consciousness after general anesthesia? -Occurs most often between the 5th and 10th days after surgery
1. Muscular irritability What 5 patients does wound separation occur most in?
2. Restlessness and delirium
3. Recognition of pain -Obese
4. Ability to reason and control behavior -Diabetic
-Immune deficiency
What is the order of return of motor and sensory functioning after local or regional anesthesia? -Malnutrition
-Ones using steroids
1. Sense of touch
2. Sense of pain Patients are also at risk for developing pressure ulcers from:
3. Sense of warmth
4. Sense of cold -Positioning during surgery, prolonged contact with damp surgical linens, and contact with unpadded surfaces.
5. Ability to move -Examine the patient's skin for areas of redness or open areas.

What type of assessments are very important after epidural or spinal anesthesia? What are 4 types of Drains?

Motor and sensory assessment
When do you test for the return of sympathetic nervous system tone?
-Begin after the patient's sensation has returned to at least the spinal dermatome level of T10.
-You test by gradually elevating the patient's head and monitoring for hypotension.
Gravity Drains: Penrose and T-tube; drain directly through a tube from the surgical area.
Closed-Suction Drainage System: Jackson-Pratt and Hemovac; drain into a collecting vessel.
What is monitored with the Penrose Drain?
Monitor the dressing for drainage.

What is assessed for the Jackson Pratt & Hemovac drain?

Assess suction: compress to re-charge.

What is the best indicator of intestinal activity? 8 Guidelines for Post-Surgical Dressings:

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-Surgeon changes 1st dressing secretions in a postoperative client can lead to which condition?
-Changed to MD order specifications or protocol 1. Pneumonia
-Use aseptic technique until sutures/staples removed 2. Hypoxemia
-Usually changed Qshift w/ sterile saline. May be left open to air 3. Fluid imbalance
-Staples usually removed after 6-8days & steri-strips used; removed by MD or nurse 4. Pulmonary embolism
-Note site appearance, temp, drainage
-Montgomery Straps 1.
-Wound Infections: TX & depridement Postoperative respiratory problems are atelectasis, pneumonia and pulmonary emboli. Pneumonia is the
inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by
Montgomery Straps the retention of pulmonary secretions.

Are recommended to secure dressings on wounds that require frequent dressing changes. These straps allow
the nurse to perform wound care without the need to remove adhesive strips thus decreasing risk of skin
irritation and injury.
They are prepares strips of nonallergenic tape with ties inserted through holes at one end. Onset of straps is
placed on either side of a wound and the straps are tied like shoelaces.
• Replace the ties and straps whenever they are soiled or every 2-3 days
The nurse is developing a plan of care for a client scheduled for surgery. The nurse should include
which activity in the nursing care plan for the client on the day of surgery?
1. Avoid oral hygiene and rinsing with mouthwash
2. Verify that the client has not eaten for the last 24 hours
3. Have the client void immediately before going into surgery
4. Report immediately any slight increase in BP or pulse

Name 10 Complications in Postop: 3.

The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Oral
-Hypotension hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and
-Dysrhythmia fluids for 6 to 8 hours before surgery instead of 24 hours. A slight increase in BP and pulse is common during
-Venous Thrombosis the preoperative period due to anxiety.
-Pulmonary Embolism
-Hiccoughs A client with a perforated gastric ulcer is scheduled for surgery. The client cannot sign the operative
-Abdominal distention (paralytic ileus) consent form because of sedation from opioid analgesics that have been administered. The nurse
-Immobility with skin integrity should take which most appropriate action in the care of this client?
-Urinary retention, UTI 1. Obtain a court order for the surgery.
-Wound infection, dehiscence, hemorrhage, evisceration 2. Have the charge nurse sign the informed consent immediately
3. Send the client to surgery without the consent form being signed
What are the 5 common opioid agents used for post-op pain relief? 4. Obtain a telephone consent from a family member, following agency policy
-Morphine, Dilaudid, Demerol, Percodan, tylox/Percocet 4.
-Assess within 5-10min for hypotension, decreased respiratory. Every effort should be made to obtain permission from a responsible family member to perform surgery if the
-Give on schedule instead of on demand. client is unable to sign the consent form. A telephone consent must be witnessed by two persons who hear
-Narcan reversal agent for opioids; Flumazenil/Romazicon reversal agent for benzodiazepines (versed, the family member's oral consent. The two witnesses then sign the consent with the name of the family
Ativan) member, noting that an oral consent was obtained. Consent is not informed if it is obtained from a client who
is confused, unconscious, mentally incompetent, or under the influence of sedatives. In an emergency the
General Anesthesia Post-op Nutrition: client may not be able to sign and family members may not be available. In this situation, a health care
provider is permitted legally to perform surgery without consent, but tin this case it is not an emergency.
Progress from liquids to regular; NPO till bowel sounds!
Agency policies regarding informed consent should always be followed.
The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to
A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the
the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour?
nurse is most likely to stimulate further discussion between the client and the nurse?
1. Urine output of 20ml/hour
1. "If it's any help, everyone is nervous before surgery."
2. Temperature of 37.6 C
2. "I will be happy to explain the entire surgical procedure with you."
3. Blood pressure of 114/70
3. "Can you share with me what you've been told about your surgery?"
4. Serous drainage on the surgical dressing
4. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate".
1.
3.
Urine output should be maintained at a minimum of 30mL/hour for an adult. An output of less than that for
Explanations should begin with the information that the client knows. By providing the client with individualized
each of 2 consecutive hours should be reported to the health care provider.
explanations of care and procedures, the nurse can assist the client in handling anxiety and fear for a smooth
A postoperative client asks the nurse why it is so important to deep-breathe and cough after surgery. preoperative experience. Clients who are calm and emotionally prepared for surgery withstand anesthesia
When formulating a response, the nurse incorporates the understanding that retained pulmonary better and experience fewer postoperative complications.
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The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. effect. The treatment for evisceration is usually immediate wound closure under local or general anesthesia.
The nurse should include which piece of information in discussions with the client? The nurse also documents the findings and actions taken.
1. Inhale as rapidly as possible
2. Keep a loose seal between the lips and the mouthpiece A client who has undergone preadmission testing, has had blood drawn for serum lab studies,
3. After maximum inspiration, hold the breath for 15 seconds and exhale. including a complete blood count, coagulation studies and electrolytes and creatine levels. Which lab
4. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to
be postponed?
4 1. Sodium, 141mEq/L
For optimal lung expansion with the incentive spirometer, the client should assume the semi-Fowlers or high 2. Hemoglobin, 8.0 g/dL
fowlers position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with 3. Platelets, 210,000/mm3
a constant flow through the unit. The breath should be held for 5 seconds before exhaling slowly. 4. Serum creatine, 0.8 mg/dL

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The
client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the
client needs additional teaching if the client makes which statement?
1. "Aspirin can cause bleeding after surgery."
2. "Aspirin can cause my ability to clot blood to be abnormal."
3. "I need to continue to take the aspirin until the day of surgery."
4. "I need to check with my HCP about the need to stop the aspirin before the scheduled surgery."
3.
Anticoagulants altered normal clotting factors and increase the risk of bleeding after surgery. Aspirin has
properties that can alter the clotting mechanism and should be discontinued at least 48 hours before surgery.
However, the client should always check with his or her health care provider regarding when to stop taking the
aspirin when a surgical procedure is scheduled.
The nurse assess a client's surgical incision for signs of infection. Which finding by the nurse would
be interpreted as a normal finding at the surgical site?
1. Red, hard skin
2. Serous drainage
3. Purulent drainage
4. Warm tender skin
2 4. Conjugated estrogen (Premarin)
Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection.
Wound infection usually appears 3 to 6 days after surgery.
A client who has had abdominal surgery complains of feeling as though "something gave way" in the
incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding
through the incision. Which nursing interventions should the nurse take? Select all that apply
1. Contact the surgeon
2. Instruct the client to remain quiet
3. Prepare the client for wound closure
4. Document the findings and actions taken
5. Place a sterile saline dressing and icepacks over the wound
6. Place the client in a prone position without a pillow under the head.
The complete blood count includes the hemoglobin analysis. All these values are within normal range except
for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon
The nurse receives a telephone call from the postanesthesia care unit stating that a client is being
transferred to the surgical unit. The nurse plans to take which action first on arrival of the client?
1. Assess the patency of the airway
2. Check tubes or drains for patency
3. Check the dressing to assess for bleeding
4. Assess the vital signs to compare with preoperative measurements
1.
The first action of the nurse is to assess the patency of the airway snd respiratory function. If the airway is not
patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs
followed by checking of the dressing and tubes or drains.
The nurse is reviewing a prescription sheet for preoperative client that states that he client must be
NPO after midnight. The nurse would telephone the physician to clarify that which medication should
be given to the client and not withheld?
1. Prednisone
2. Ferrous sulfate
3. Cyclobenzaprine (Flexeril)
1.
Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the
ability of the body to withstand stress. When stress is severe corticosteroids are essential to life. Before and
during surgery, dosages may be increased temporarily. These last few medications may be withheld before
surgery without undue effects on the client.

1, 2, 3 ,4
Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal
organs through an incision. If wound dehiscence or evisceration occurs, the nurse should call for help, stay
with the client, and ask another nurse to contact the surgeon and obtain needed supplies to care for the client.
The nurse places the client in a low fowlers position and the client is kept quite and instructed not to cough.
Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive

©SGT XENIIA MARIE RAZALO LAWAN PAFR

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