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EMCC ADN EXAM 7
Chapter 52
175
Nursing
Professional
02/25/2012

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Term
An elderly nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding?
Definition
Weak, rapid pulse
Term
A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?
Definition
Review the results of serum electrolytes.
Term
An older client comes to the emergency department experiencing chest pain and shortness of breath. An arterial blood gas is ordered. Which of the following ABG results indicates respiratory acidosis?
Definition
Because of the retention of CO2, the clinical profile of respiratory acidosis includes decreased pH < 7.35, PaCO2 > 42 mmHg, with varying levels of HCO3 related to hypoventilation.
Term
The intake and output (I & O) record of a client with a nasogastric tube that has been attached to suction for 2 days shows greater output than input. Which nursing diagnoses are most applicable? Select all that apply.
Definition
-Deficient Fluid Volume
-Impaired Oral Mucous Membranes
-Decreased Cardiac Output
Term
Which client statement indicates a need for further teaching regarding treatment for hypokalemia?
Definition
Salt substitutes contain potassium.
Term
An elderly man is admitted to the medical unit with a diagnosis of dehydration. Which sign or symptom is most representative of a sodium imbalance?
Definition
Mental confusion

Rationale: Sodium contributes to the function of neural tissue.
Term
The client’s arterial blood gas results are pH 7.32; PaCO2 58; HCO3 32. The nurse knows that the client is experiencing which acid–base imbalance?
Definition
Respiratory acidosis

Because of CO2 retention the PaCO2 is elevated. CO2 is involved in production of acid, which will result in a decreased pH. HCO3 will vary.
Term
A client is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority?
Definition
Neuromuscular

Rationale: The major clinical signs and symptoms of hypocalcemia are due to increased neuromuscular activity and not the renal, cardiac, or GI systems.
Term
The nurse would assess for signs of hypomagnesemia in which of the following clients? Select all that apply.
Definition
-A client with pancreatitis.
-A client with excessive nasogastric drainage.
-A client with chronic alcoholism.
Term
Acid
Definition
a substance that releases hydrogen ions (H+) in solution
Term
Acidosis
Definition
a condition that occurs with increases in blood carbonic acid or with decreases in blood bicarbonate; blood pH below 7.35
Term
Active transport
Definition
movement of substances across cell membranes against the concentration gradient
Term
Agglutinins
Definition
specific antibodies formed in the blood
Term
Agglutinogens
Definition
a substance that acts as an antigen and stimulates the production of agglutinins
Term
Alkalosis
Definition
a condition that occurs with increases in blood bicarbonate or decreases in blood carbonic acid; blood pH above 7.45
Term
Anions
Definition
ions that carry a negative charge; includes chlorine (Cl-), bicarbonate (HCO3-), phosphate (HPO42-), and sulfate (SO4-)
Term
Antibodies
Definition
immunoglobulins, part of the body's plasma proteins, defend primarily against the extracellular phases of bacterial and viral infections
Term
Bases
Definition
(alkalis) have low hydrogen ion concentration and can accept hydrogen ions in solution
Term
Buffers
Definition
prevent excessive changes in pH by removing or releasing hydrogen ions
Term
Cations
Definition
ions that carry a positive charge; includes sodium (Na+), potassium (K+), calcium (Ca2+), and magnesium (Mg2+)
Term
Central venous catheter
Definition
catheter that is usually inserted into the subclavian or jugular vein, with the distal tip of the catheter resting in the superior vena cava just above the right atrium
Term
Colloid osmotic pressure
Definition
a pulling force exerted by colloids that help maintain the water content of blood
Term
Colloids
Definition
substances such as large protein molecules that do not readily dissolve into true solutions
Term
Compensation
Definition
defense mechanism in which a person substitutes an activity for one that he or she would prefer doing or cannot do
Term
Crystalloids
Definition
salts that dissolve readily into true solutions
Term
Central venous catheter
Definition
catheter that is usually inserted into the subclavian or jugular vein, with the distal tip of the catheter resting in the superior vena cava just above the right atrium
Term
Colloid osmotic pressure
Definition
a pulling force exerted by colloids that help maintain the water content of blood
Term
Colloids
Definition
substances such as large protein molecules that do not readily dissolve into true solutions
Term
Compensation
Definition
defense mechanism in which a person substitutes an activity for one that he or she would prefer doing or cannot do
Term
Crystalloids
Definition
salts that dissolve readily into true solutions
Term
Dehydration
Definition
insufficient fluid in the body
Term
Diffusion
Definition
the mixing of molecules or ions of two or more substances as a result of random motion
Term
Drop factor
Definition
the number of drops that equal 1 mL as specified on the package of IV tubing
Term
Electrolytes
Definition
chemical substances that develop an electric charge and are able to conduct an electric current when placed in water; ions
Term
Extracellular fluid (ECF)
Definition
fluid found outside the body cells
Term
Filtration
Definition
process whereby fluid and solutes move together across a membrane from one compartment to another
Term
Filtration pressure
Definition
the pressure in a compartment that results in the movement of fluid and substances dissolved in fluid out of the compartment
Term
Fluid volume deficit
Definition
(hypovolemia) loss of both water and electrolytes in similar proportions from the extracellular fluid
Term
Fluid volume excess (FVE)
Definition
(hypervolemia) retention of both water and sodium in similar proportions to normal extracellular fluid (ECF)
Term
Hematocrit
Definition
the proportion of red blood cells (erythrocytes) to the total blood volume
Term
Hemolytic transfusion reaction
Definition
destruction of red blood cells as a result of transfusion of incompatible blood
Term
Homeostasis
Definition
the tendency of the body to maintain a state of balance or equilibrium while continually changing; a mechanism in which deviations from normal are sensed and counteracted
Term
Hydrostatic pressure
Definition
the pressure a liquid exerts on the sides of the container that holds it; also called filtration force
Term
Hypercalcemia
Definition
an excess of calcium in the blood plasma
Term
Hyperchloremia
Definition
an excess of chloride in the blood plasma
Term
Hyperkalemia
Definition
an excess of potassium in the blood plasma
Term
Hypermagnesemia
Definition
an excess of magnesium in the blood plasma
Term
Hypernatremia
Definition
an excess of sodium in the blood plasma
Term
Hyperphosphatemia
Definition
an excess of phosphate in the blood plasma
Term
Hypertonic
Definition
solutions that have a higher osmolality than body fluids
Term
Hypervolemia
Definition
increased blood volume
Term
Hypocalcemia
Definition
deficiency of calcium in the blood plasma
Term
Hypochloremia
Definition
deficiency of chloride in the blood plasma
Term
Hypokalemia
Definition
deficiency of potassium in the blood plasma
Term
Hypomagnesemia
Definition
deficiency of magnesium in the blood plasma
Term
Hyponatremia
Definition
deficiency of sodium in the blood plasma
Term
Hypophosphatemia
Definition
deficiency of phosphate in the blood plasma
Term
Hypotonic
Definition
solutions that have a lower osmolality than body fluids
Term
Hypovolemia
Definition
an abnormal reduction in blood volume
Term
Infiltration
Definition
occurs when the tip of the IV is outside the vein and the fluid is entering the tissues instead; manifested by local swelling, coolness, pallor, and discomfort at the IV site
Term
Insensible fluid loss
Definition
fluid loss that is not perceptible to the individual
Term
Interstitial fluid
Definition
fluid that surrounds the cells, includes lymph
Term
Intracellular fluid (ICF)
Definition
fluid found within the body cells, also called cellular fluid
Term
Intravascular fluid
Definition
plasma
Term
Ions
Definition
atoms or group of atoms that carry a positive or negative electric charge; electrolytes
Term
Isotonic
Definition
solutions that have the same osmolality as body fluids
Term
Metabolic acidosis
Definition
a condition characterized by a deficiency of bicarbonate ions in the body in relation to the amount of carbonic acid in the body; the pH falls to less than 7.35
Term
Metabolic alkalosis
Definition
a condition characterized by an excess of bicarbonate ions in the body in relation to the amount of carbonic acid in the body; the pH rises to greater than 7.45
Term
Milliequivalent
Definition
one-thousandth of an equivalent, which is the chemical combining power of a substance
Term
Obligatory losses
Definition
essential fluid losses required to maintain body functioning
Term
Oncotic pressure
Definition
Colloid osmotic pressure
Term
Osmolality
Definition
the concentration of solutes in body fluids
Term
Osmosis
Definition
passage of a solvent through a semipermeable membrane from an area of lesser solute concentration to one of greater solute concentration
Term
Osmotic pressure
Definition
pressure exerted by the number of nondiffusible particles in a solution; the amount of pressure needed to stop the flow of water across a membrane
Term
Overhydration
Definition
occurs when water is gained in excess of electrolytes, resulting in low serum osmolality and low serum sodium levels, also known as hypo-osmolar imbalance or water intoxication
Term
Peripherally inserted central catheter (PICC)
Definition
a long venous catheter inserted in an arm vein and extending into the distal third of the superior vena cava
Term
pH
Definition
a measure of the relative alkalinity or acidity of a solution; a measure of the concentration of hydrogen ions
Term
Pitting edema
Definition
edema in which firm finger pressure on the skin produces an indentation (pit) that remains for several seconds
Term
Plasma
Definition
the fluid portion of the blood in which the blood cells are suspended
Term
Renin-angiotensin-aldosterone system
Definition
system initiated by specialized receptors in the juxtaglomerular cells of the kidney nephrons that respond to changes in renal perfusion
Term
Respiratory acidosis
Definition
(hypercapnia) a state of excess carbon dioxide in the body
Term
Respiratory alkalosis
Definition
a state of excessive loss of carbon dioxide from the body
Term
Selectively permeable
Definition
cell membranes that allow substances to move across them with varying degrees of ease
Term
Solutes
Definition
substances dissolved in a liquid
Term
Solvent
Definition
the liquid in which a solute is dissolved
Term
Specific gravity
Definition
the weight or degree of concentration of a substance compared with that of an equal volume of another, such as distilled water, taken as a standard
Term
Third space syndrome
Definition
fluid shifts from the vascular space into an area where it is not readily accessible as extracellular fluid
Term
Transcellular fluid
Definition
compartment of extracellular fluids; includes cerebrospinal, pericardial, pancreatic, pleural, intraocular, biliary, peritoneal, and synovial fluids
Term
Volume expanders
Definition
used to increase the blood volume following severe loss of blood, or loss of plasma
Term
a nurse is collecting data from an older adult client who states he has had vomiting and diarrhea for the last 48 hours. Which of the following findings should indicate to the nurse that the client is hypovolemic? Select all that apply
Definition
-Tachypnea
-furrowed tongue
-sunken eyeballs
-tachycardia
-hypotension
Term
A nurse is providing teaching about a healthy lifestyle for a group of young adults who are training for a marathon. Which of the following should the nurse include in the teaching session?
Definition
Fluid intake should be increased with:
-excessive vigorous exercise
-exercise in high altitudes
-exercise in dry climates
-caffeine should be avoided
Term
A nurse is caring for a client who was admitted to the hospital for peritonitis and has signs of dehydration. Which of the following laboratory findings would be expected for this client? Select all that apply
Definition
-Increased Hct
-Increased serum sodium
-Increased urine osmolarity
Term
A nurse on a medical-surgical unit has been assigned to care for four clients. Which of the following clients is at risk for fluid volume excess (hypervolemia)?
Definition
A client who has heart failure
Term
A nurse on a medical-surgical unit has been assigned to care for four clients. Which of the following clients is at risk for fluid volume excess (hypovolemia)?
Definition
-client receiving a high-ceiling loop diuretic
-a client who lost 500ml of blood during surgery
-a client who is 4 hr postoperative and is receiving nasogastric suction
Term
A nurse is reviewing the labratory findings for a group of clients. Which of the following findings should be reported to the provider?
Definition
serum calcium 8.5 mg/dL

this is below the expected reference range
Term
A nurse on a medical surgical unit is caring for a client who is hypernatremic. Which of the following should be included in the plan of care?
Definition
Infuse hypotonic IV fluids

plan of care for hypernatremic clients:
-hypotonic or isotonic fluids
-encourage water intake
-restrict sodium intake
-loop diuretic will increase excretion of sodium
Term
Causes of hypovolemia
Definition
Abnormal loss from skin, GI tract or kidneys. Decreased fluid intake, Massive bleeding.

Examples: Excessive diuretic or laxative use, V/N/D, NGT drainage, hemmorage, frank or occult.
Term
Increased risk for hypovolemia
Definition
bowel, inflammed tissue, burns, crush injuries, pelvis or hip fracturs, pleural effusions, intestinal obstructions, hypoalbuminemia
Term
Dehydration causes
Definition
decreased water intake, decreased thrist sensation, prolonged fever, enteral feedings (tube) without sufficient water intake.
Term
Goals for hypervolemia
Definition
maintain fluid balance, prevent respiratory (pulmonary edema) and cardiovascular complications (CHF) and eliminate cause of overload.
Term
Hypovolemic shock

(what to do)
Definition
EMERGENCY! multiple fluid challenges given to restore circulating volume. IV therapy, blood transfusions, drugs to support blood pressure, o2 therapy and treat cause.
Term
People at most risk for dehydration
Definition
infants, confused or comatose patients, elderly, brian injuries or inadequate production of ADH
Term
Overhydration can lead too...
Definition
cerebral edema, impaired neurological function and death
Term
Dehydration
Definition
Water lost from body without signif. loss of electrolytes causing increased serum osmolality and increased serum sodium levels. (Hypernatremia)
Term
Interventions for dehydration
Definition
assess vs, weight, tissue turgor, neck and hand vein filling, mucus membranes bowel sounds and breath sounds, monitor daily weight, I &O, labs, monitor LOC, orientation and seizure precautions, assist with mobility, positioning (orthostasis), safety and skin care, mouth care
Term
Fluids to adminster for dehydration
Definition
isotonic NS or LR or hypotonic fluids
Term
Interventions for hypervolemia
Definition
assess s/sx of overload, monitor daily weight, vs, I&O, assess and doc. edema, assess breath sounds, pulse oximeter, and heart sounds, position in high folers, monitor labs and chest xray, restrict fluid and NA, diuretics as ordered, and do client teaching.
Term
Assessment for dehydration
Definition
irritability, confusion, dizziness, weakness, extreme thirst, fever, dry skin and mucus membrane, sucken eyeballs, poor turgor, decrease urine output, increased heart rate with falling blood pressure
Term
Goals of hypovolemia
Definition
Restore fluid volume, replace electrolytes as needed, and eliminate cause of fluid volume deficit.
Term
Assessment of hypervolemia
Definition
Weight gain, difficutly breathing, legs swollen, fingers and feet swollen (pitting or nonpitting), mental confusion, tachycardia, full bounding pulses, increased BP
Term
Adult water weight %
Definition
40-60%
Term
Overhydration causes
Definition
fluids and electrolytes lost at equal balance but only water is replaced, malignant tumors, aids, head injury, drug adminstration, psychogenic polydipsia.
Term
Causes of hypervolemia
Definition
Excessive intake of salt, rapid adminstration of sodium-containing infusions, excessive irrigation of body cavities or organs, agressive fluid replacements, blood or plasma infusions, use of hypertonic fluids, disease proccesses causing altered regulatory mechanisms.
Term
People at increased risk for hypovolemia
Definition
Children and elderly
Term
Assessment for hypovolemia
Definition
Increased respirations and heart rate, subnormal temps, orthostasis, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, dark malodorous urine, increased specific gravity, increased HCT, alter LOC and confusion
Term
Interventions for hypovolemia
Definition
Assess vital signs, weight, tissue turgor, neck and hand vein filling, mucus membranes, bowel sounds and breath sounds, mointor labs, I &O, daily weight, adminster fluids PO & IV (isotonic NS or LR)
Term
average urine output of adults
Definition
1400-1500 ML
Term
Normal range of sodium levels
Definition
135-145 mEq/L
Term
Normal range of potassium levels
Definition
ICF 125-140 mEq/L
Serum 3.5-4.0 mEq/L
Term
Normal range of Calcium levels
Definition
8.5-10.5 mEq/L
Term
Normal range of magnesium levels
Definition
1.5-2.5 mEq/L
Term
Normal range of chloride levels
Definition
95-108 mEq/L
Term
Normal range of phosphate levels
Definition
2.5-4.5 mEq/L
Term
Normal range of bicarbonate levels
Definition
maintained through metabolic processes
Term
Functions of Sodium
Definition
-regulate ECF volume and distribution
-maintain blood volume
-transmit nerve impulses and contracting muscles
Term
Functions of Potassium
Definition
-maintainign ICF osmolality
-transmitting nerve and other electrical impulses
-regulating cardia impule transmission and muscle contraction
-skeletal and smooth muscle function
-regulating acid base balance
Term
Functions of Calcium
Definition
-forming bones and teeth
-transmiting nerve impulses
-regulating muscle contractions
-blood clotting
-maintaining cardiac pacemaker
Term
Functions of Magnesium
Definition
-intracellular metabolism
-operating sodium-potassium pump
-relaxing muscle contractions
-transmitting nerve impulses
-regulating cardiac function
Term
Functions of Chloride
Definition
-HCl production
-regulating ECF balance and vascualr volume
-regulating acid-base balance
-buffer in oxygen-carbon exchange
Term
Functions of Phosphate
Definition
-forming bones and teeth
-metabolizing carbohydrate, protein, fats
-cellular metabolism, procucing ATP and DNA
-muscle, nerve and RBC function
-regulating acid-base balance
-regulating calcium levels
Term
Functions of Bicarbonate
Definition
martian body buffer involved in acid-base regulation
Term
Normal pH of body fluids
Definition
between 7.35-7.45
Term
hyponatremia risk factor
Definition
-loss of sodium (sweating, diuretics, gastrointestional fluid loss)
-Gain of water (hypotonic tube feedings, excessive water drinking, Excessive Dextrose in water via IV)
-syndrome of inappropriate ADH (head injury, AIDS, brain tumor)
Term
hyponatremia clinical manifestations
Definition
-lethargy/confusing/apprehension
-muscle twitching
-abdominal cramps
-anorexia, nausea, vomiting
- headache
-seizures, coma
-sodium below 135
Term
hyponatremia nursing interventions
Definition
-assess clinical manifestations
-monitor fluid in/out
-monitor lab data
-encourage high sodium food when permitted
-limit water intake as indicated
Term
hypernatremia risk factor
Definition
-loss of water (insensible water loss, diarrhea, water deprivation)
-Gain of sodium (saline solutions, hypertonic tube feeding w/o adequate water, excessive table salt use)
-conditions- Diabetes, heat stroke
Term
hypernatremia clinical manifestations
Definition
thirst
dry sticky mucosa
tongue dry and red
weakness
SEVERE:
-fatigue/restlessness
-decreasing level of consciousness
-disorientation
-convulsions


serum sodium above 145
Term
hypernatremia nursing interventions
Definition
-monitor fluid in/out
-monitor behavior changes
-monitor lab findings
-encourage fluid as ordered
-monitor diet as ordered
Term
hypokalemia risk factor
Definition
-loss of potassium (vomiting and gastic suction, diarrhea, heavy sweating, diuretics, poor potassium intake, hyperaldosteronism
Term
hypokalemia clinical manifestations
Definition
-muscle weakness, leg cramps
-fatigue, lethargy
-anorexia, nausea, vomiting
-decreased bowel sounds
-cardiac disrythmias
-weak irregular pulses
-below 3.5 serum potassium
Term
hypokalemia nursing interventions
Definition
-monitor heart rate and rhythm
-administer oral potassium as indicated
-teach about potassium rich foods
-teach how to prevent loss of potassium (i.e. dont abuse diuretics and laxatives
Term
hyperkalemia risk factor
Definition
decreased potassium excretion
high potassium intake (too much potassium salt substitutes)
Term
hyperkalemia clinical manifestations
Definition
-diarrhea
-irratibility. apathy, confusion
-cardiac dysrhythmias or arrest
-muscle weakness, no reflexes
-decreased heart rate
-irregular pulse
-numbness in extremities

potassium above 5.0
Term
hyperkalemia nursing interventions
Definition
-monitor cardiac status
=diuretics as ordered
-hold potassium supplements
-teach to avoid high potaqssium foods
Term
What are important considerations for giving potassium?
Definition
-ALWAYS DILUTE
-NEVER GIVE BY IV PUSH
-check by two nurses prior to administering
-usually 20 potassium to 40 solution
Term
hypocalcemia risk factor
Definition
surgical removal of parathyroid glands
-inadequate vitamin D intake
Term
hypocalcemia clinical manifestations
Definition
-numbness, tingling of extemities and around mouth
-muscles tremors and cramps (can progress to tetany)
-cardiac dysrhythmias
-positive Trousseaus & Chvosteks signs
-confusion anxiety
Term
hypocalcemia nursing interventions
Definition
-protect confused client
-administer calcium
Term
hypercalcemia risk factor
Definition
-prolonged immobilization
-certain conditions (hyperparathyroidism, malignancy of the pone, pagets disease)
Term
hypercalcemia clinical manifestations
Definition
- "too much calcium = too calm" - you'll see muscle weakness & fatigue.
remember groans (constipation), moans (fatigue, lethargy), bones (bone pain), stones (kidney stones) and psychiatric overtones (depression & confusion) to help remember signs & symptoms.
Term
hypercalcemia nursing interventions
Definition
increase movement and exercise
limit intake of high calcium
Term
hypomagnesium risk factor
Definition
excessive loss from gastrointestional tract
longterm use of certain drugs (diuretics, some antibiotics)
chronic alcoholism
burns
Term
hypomagnesium clinical manifestations
Definition
muscle cramps,
tremors,
cardiac dysrhythmias,
hyperactive reflexes,
tetany.
Term
hypomagnesium nursing interventions
Definition
encourage magnesum rich foods
care of patient that might sieze
-increased risk of toxicity
Term
hypermagnesium risk factor
Definition
abnormal retention of magnesium:
renal failure
treatment with magnesium salts
adrenal insufficency
Term
hypermagnesium clinical manifestations
Definition
weakness,
hyporeflexia
cardiac dysrhythmias
respiratory depression
Term
hypermagnesium nursing interventions
Definition
notify primary care is patellar reflexes are absent
advise that OTC drug must be ran by provider
Term
chvostek's sign
Definition
contraction of facial muscles when tapping facial nerve in front of ear
Term
trousseaus sign
Definition
when you hold BP cuff at 20 mmHg higher than systolic for 3-5 minutes, sign is positive if there is a carpal spasm
Term
respiratory acidosis
Definition
If the pH is acidic (below 7.35) and the CO2 is high
Term
respiratory alkalosis
Definition
If the ph is alkalotic (above 7.45)and the CO2 is low
Term
metabolic alkalosis.
Definition
If the ph is alkalotic (above 7.45) and the bicarb level is high,
Term
metabolic acidosis.
Definition
If the ph is acidic (below 7.35) and the bicarb level is low
Term
cause of metabolic acidosis
Definition
-increase of nonvolatile acids in blood(diabtes, starvation, renal impairment)
-decreased bicarbonate (diarrhea)
-excessive infusion of chloride containing IV fluids
-excessive ingestion or acids
-cardiac arrest
Term
cause of metabolic alkalosis
Definition
-vomiting
-too many antacids
-potassium-losing diuretics
Term
cause of respiratory acidosis
Definition
-impaired alveolar exchange (pneumonia)
-chronic lung disease (asthma)
-overdose of drugs that decrease respiratory rate
-airway obstruction
Term
cause of respiratory alkalosis
Definition
-hyperventilation
-fever
-brainstem injury
-increased basal metabolic rate
Term
clinical manifestations of metabolic acidosis
Definition
-deep rapid respiration (Kussmauls repirations)
-lethargy, confusion
-headache
-weakness
-nausea ad vomiting
Term
clinical manifestations of metabolic alkalosis
Definition
-decreased respiratory rate and depth
-dizziness
-numbness and tingling of extremities
-tetany
Term
clinical manifestations of respiratory acidosis
Definition
-increased pulse and respiration
-headache, dizziness
confusion, decreased consciousness
-convulsions
-warm flushed skin

SEVERE:
weakness
headache
Term
clinical manifestations of respiratory acidosis
Definition
-shortness of breath, tight chest
-lightheaded
-difficulty concentrating
-blurred vision
Term
nursing interventions for metabolic acidosis
Definition
-monitor ABG values (arterial blood gas), intake and output, and LOC (level of consciousness)
-administer IV sodium bicarbonate carefully if ordered
-treat underlying problem as ordered
Term
nursing interventions for metabolic alkalosis
Definition
-monitor intake and output closely
-monitor vitals, esp. resp. & LOC (level of consciousness)
administer IV fluids carefully
-treat underlying problem as ordered
-
Term
nursing interventions for respiratory acidosis
Definition
-frequently assess respiratory status and lung sounds
-monitor airway and ventilation
-monitor fluid I/O
-pulmonary therapy measures (inhalation therapy bronchodialters etc)
Term
nursing interventions for respiratory acidosis
Definition
-monitor vitals and ABG values (arterial blood gas)
-assist client to breathe more slowly
-help client breathe in paper bag or apply rebreather mask
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