# Medical-Surgical Nursing, Fluid/Electrolyte & Acid-Base Balance (ABGs)

> Medical-surgical nursing management of arterial blood gases (ABGs), IV fluid tonicity and volume imbalances, electrolyte emergencies (K+, Na+, Ca2+, Mg2+), perioperative care, chest tubes, TPN, and blood transfusions.

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- **Level:** intermediate
- **Languages:** en → en
- **Total Cards:** 32

## Flashcards (32 Cards)

| # | Front (Term / Prompt) | Back (Definition / Answer) | Example | Multiple-Choice Options |
| :--- | :--- | :--- | :--- | :--- |
| 1 | What are the ABG findings, common clinical etiologies, and nursing priorities in acute Respiratory Acidosis? | ABG: pH < 7.35, PaCO2 > 45 mmHg, HCO3- normal (if uncompensated) or elevated (if chronic/renal compensation). Etiologies: Hypoventilation from central nervous system depression (opioid/sedative overdose), COPD exacerbation, acute asthma, neuromuscular weakness (Guillain-Barré, myasthenia), chest wall trauma (flail chest), or atelectasis. Priorities: Airway clearance, suctioning, bronchodilators, semi-Fowler's position, oxygenation/ventilation support, and naloxone if opioid-induced. |  |  |
| 2 | What symptoms, EKG changes, and treatment are associated with Hypomagnesemia (serum Mg2+ < 1.3 mEq/L or < 1.6 mg/dL)? | Symptoms closely parallel hypocalcemia (and often coexist with refractory hypokalemia and hypocalcemia): hyperactive deep tendon reflexes (3+ to 4+ clonus), muscle tremors, tetany, positive Chvostek and Trousseau signs, dysphagia, and seizures. EKG: prolonged PR and QT intervals, predisposing to Torsades de Pointes. Treatment: Oral magnesium replacement or slow IV Magnesium Sulfate via infusion pump. Nursing priority: Monitor blood pressure, respiratory rate, urine output, and patellar deep tendon reflexes frequently during IV infusion (loss of DTRs is an early clinical sign of magnesium toxicity). |  |  |
| 3 | What nursing safety rules govern Total Parenteral Nutrition (TPN) administration and sudden infusion interruption? | 1. Must be infused via a Dedicated Central Venous Access Line (central line or PICC) using a 0.22-micron in-line filter (1.2-micron for lipid emulsions); 2. Strict aseptic technique during tubing and dressing changes; change TPN solution and tubing every 24 hours; 3. Monitor point-of-care blood glucose every 4 to 6 hours; 4. NEVER stop TPN abruptly. If the current TPN bag empties before the next bag arrives from the pharmacy, immediately hang 10% Dextrose in Water (D10W) at the same infusion rate to prevent severe, rebound profound Hypoglycemia. |  |  |
| 4 | What neuromuscular symptoms and EKG changes characterize Hypokalemia (serum K+ < 3.5 mEq/L)? | Symptoms: Skeletal muscle weakness starting in lower extremities, ascending flaccid paralysis, muscle cramps, hyporeflexia, constipation, and paralytic ileus (smooth muscle weakness). EKG changes: Flattened or inverted T waves, ST-segment depression, and prominent U waves (deflection following the T wave); predisposes to ventricular arrhythmias (PVCs, VT, VF) and increases the risk of Digoxin toxicity. |  |  |
| 5 | How do Isotonic, Hypotonic, and Hypertonic intravenous fluids differ in tonicity and physiological fluid shifting? | Isotonic (0.9% Normal Saline, Lactated Ringer's, and D5W in the bag before infusion): similar osmolality to plasma (~275–295 mOsm/kg); isotonic crystalloids (0.9% NS, LR) expand the extracellular fluid compartment without net intracellular water shift (note: D5W is isotonic in the bag at ~252 mOsm/L but becomes physiologically hypotonic free water once glucose is metabolized). Hypotonic (0.45% Normal Saline): lower osmolality than plasma; shifts water from the intravascular space INTO cells (used for cellular dehydration; strictly contraindicated in increased intracranial pressure, acute stroke/head trauma, or burns). Hypertonic (3% Normal Saline, D5 in 0.9% NS, D10W): higher osmolality than plasma; draws water OUT of cells into the intravascular space (requires central line/pump monitoring for circulatory overload and osmotic demyelination). |  |  |
| 6 | What clinical manifestations and EKG abnormalities define Hyperkalemia (serum K+ > 5.0 mEq/L), and what is the sequence of emergency nursing management? | Manifestations: Paresthesias, muscle twitching progressing to ascending flaccid weakness, abdominal cramping/diarrhea, and life-threatening cardiac conduction delays. EKG progression: Tall peaked T waves -> prolonged PR interval and flattened P waves -> widened QRS complex -> sine-wave pattern and ventricular fibrillation/asystole. Emergency management: 1) Stabilize the myocardium immediately with IV Calcium Gluconate (does not lower serum K+); 2) Shift K+ intracellularly using IV Regular Insulin + Dextrose (D50W), nebulized high-dose Albuterol, and IV Sodium Bicarbonate (if metabolic acidosis is present); 3) Remove K+ from the body via loop diuretics (furosemide), GI potassium binders (patiromer or sodium zirconium cyclosilicate preferred over sodium polystyrene sulfonate), or emergent hemodialysis. |  |  |
| 7 | What safety equipment must always be maintained at the bedside of a patient with a tracheostomy, and what is the correct suctioning technique? | Bedside equipment: Two spare tracheostomy tubes (one identical size, one a size smaller), tracheostomy obturator, sterile tracheostomy care kit, functional suction apparatus, manual resuscitation bag-valve-mask with appropriate mask. Suctioning technique: Pre-oxygenate with 100% O2 for 30-60 seconds; maintain strict surgical asepsis; set suction to 80-120 mmHg; advance catheter without suction until resistance is met or patient coughs; apply intermittent suction while rotating and withdrawing catheter for NO LONGER than 10 to 15 seconds; limit to max 2-3 passes. |  |  |
| 8 | What physical assessment findings and lab parameters indicate Fluid Volume Excess (Hypervolemia)? | Findings: Bounding peripheral pulses, elevated blood pressure, Jugular Venous Distension (JVD) at 45 degrees, S3 ventricular gallop, bilateral basilar pulmonary crackles, dyspnea, orthopnea, rapid weight gain, and dependent peripheral pitting edema. Laboratory results demonstrate hemodilution: decreased Hematocrit, decreased BUN, decreased serum osmolarity, and low urine specific gravity (< 1.010). |  |  |
| 9 | What are the nursing care goals, irrigation rate titration, and troubleshooting for Continuous Bladder Irrigation (CBI) following a TURP? | Goal: Maintain catheter patency and prevent formation of blood clots that obstruct urinary outflow. Titration: Adjust the rate of continuous isotonic saline irrigation to keep the returning urinary drainage light pink to peach in color and clear of large clots. Troubleshooting: If drainage turns bright red or develops thick clots, increase the irrigation rate; if urine outflow stops or the patient reports acute severe suprapubic spasms/distension, check for kinks, turn off irrigation, and gently irrigate manually with 30-50 mL of sterile saline using a catheter-tip syringe to clear clot obstruction. |  |  |
| 10 | What is Autonomic Dysreflexia in spinal cord injury, what are its clinical signs, and what is the immediate nursing priority? | A life-threatening medical emergency occurring in spinal cord injuries at or above T6, triggered by uninhibited sympathetic discharge in response to a noxious stimulus below the lesion (most commonly bladder distension / blocked Foley catheter, or bowel fecal impaction). Signs: Paroxysmal severe hypertension (SBP > 200 mmHg), pounding headache, bradycardia, profuse diaphoresis and flushing ABOVE the level of injury, and pale cold skin with piloerection BELOW the injury. Immediate priority: Sit patient immediately upright into HIGH FOWLER'S position (90 degrees, lowers BP via orthostatic pooling); loosen all tight clothing; check bladder for distension/un-kink Foley catheter; check blood pressure every 2-5 minutes. |  |  |
| 11 | What evidence-based nursing interventions prevent Deep Vein Thrombosis (DVT) in postoperative hospitalized patients? | 1. Early and frequent ambulation starting on post-op day 0 or 1 as soon as stable; 2. Application of Sequential Compression Devices (SCDs) or pneumatic compression boots (keep operating at all times while in bed/chair); 3. Anti-embolism compression stockings (TED hose) sized correctly; 4. Active or passive ankle-pumping and calf-flexion exercises; 5. Prophylactic anticoagulation (Subcutaneous Enoxaparin or low-dose Unfractionated Heparin) as ordered; 6. Adequate systemic hydration; 7. Never place pillows directly behind patient's knees or massage calves. |  |  |
| 12 | What is the distinction between surgical wound Dehiscence and Evisceration, and what is the immediate emergency nursing protocol for Evisceration? | Dehiscence is the separation and disruption of previously joined surgical incision margins. Evisceration is the protrusion of internal visceral organs (usually bowel loops) through the dehisced wound opening. Evisceration protocol: 1) Call for help immediately and stay with the patient; 2) Place patient in Low-Fowler's position with knees flexed (relieves abdominal wall tension); 3) Cover protruding viscera with sterile gauze dressings saturated with warm sterile Normal Saline (never attempt to push organs back in); 4) Take vital signs; 5) Keep patient NPO; 6) Notify surgeon immediately for emergent operating room return. |  |  |
| 13 | What are the ABG findings, precipitating causes, and nursing interventions in Respiratory Alkalosis? | ABG: pH > 7.45, PaCO2 < 35 mmHg, HCO3- normal (acute) or < 22 mEq/L (renal compensation). Causes: Alveolar hyperventilation triggered by hypoxemia, pulmonary embolism, acute anxiety/panic, severe pain, fever, salicylate toxicity, or mechanical overventilation. Interventions: Treat the underlying cause first (rule out life-threatening hypoxemia or pulmonary embolism before attributing tachypnea to anxiety; paper-bag rebreathing is avoided in modern clinical practice due to hypoxemia risk), coach slow pursed-lip or diaphragmatic breathing, manage pain/fever/anxiety, and adjust ventilator rate or tidal volume if mechanically ventilated. |  |  |
| 14 | What are the strict safety administration rules regarding intravenous Potassium Chloride (KCl)? | 1. NEVER administer Potassium Chloride by IV Push, IV Bolus, or Intramuscular route (fatal cardiac arrest will occur immediately); 2. Must always be diluted in IV fluid and infused via an electronic volumetric infusion pump; 3. Maximum peripheral vein infusion rate is 10 mEq/hour (infusions up to 20 mEq/hr require a central venous catheter and continuous cardiac telemetry monitoring); 4. Assess renal function and verify urine output >= 30 mL/hr before initiating infusion ('no pee, no K'); 5. Monitor IV site continuously for burning, phlebitis, and extravasation. |  |  |
| 15 | What emergency nursing actions must be taken if a chest tube is accidentally dislodged from the patient's chest wall versus disconnected from the drainage unit? | If disconnected from the drainage unit: Immediately submerge the distal end of the chest tube 1 to 2 inches into a bottle of sterile water or saline; this establishes a temporary underwater seal and prevents air from entering the pleural cavity. If pulled completely out of the chest wall: Immediately cover the insertion site with a sterile three-sided occlusive dressing (e.g., petrolatum gauze taped on three sides, which acts as a flutter valve allowing air to escape during exhalation while preventing tension pneumothorax during inspiration); notify surgeon immediately. |  |  |
| 16 | What clinical signs define Hypernatremia (serum Na+ > 145 mEq/L), and why must it be corrected slowly? | Signs: Extreme unquenchable thirst, flushed dry skin, dry sticky oral mucous membranes, oliguria, hyperthermia, agitation, hyperreflexia, and lethargy. Must be corrected slowly (reducing serum Na+ by no more than 8-10 mEq/L per 24 hours) with hypotonic fluids (0.45% NS or D5W) because overly rapid reduction shifts water rapidly into brain cells that have adapted with idiogenic osmoles, triggering life-threatening cerebral edema, seizures, and uncal herniation. |  |  |
| 17 | What mandatory safety verification steps must occur before initiating a Packed Red Blood Cell (PRBC) transfusion? | 1. Verify the provider's transfusion order and signed informed consent; 2. Confirm a patent IV catheter (18–20 gauge preferred in adults) primed ONLY with 0.9% Normal Saline (never dextrose or Lactated Ringer's, which cause hemolysis or calcium-citrate clotting); 3. With a second qualified nurse/clinician, perform an independent bedside verification of two unique patient identifiers, blood bank wristband number, ABO/Rh compatibility, unit identification number, expiration date/time, and visual appearance; 4. Record baseline vital signs, start the transfusion within 30 minutes of blood bank release, infuse slowly for the first 15 minutes while remaining with the patient to monitor for acute reactions, and complete the unit within 4 hours. |  |  |
| 18 | What clinical symptoms characterize severe Hyponatremia (serum Na+ < 125 mEq/L), and what nursing precautions are essential? | Symptoms: Cellular swelling and cerebral edema caused by osmotic water shift into brain tissue, presenting with headache, nausea/vomiting, lethargy, confusion, muscle cramps/twitching, seizures, coma, and brainstem herniation. Nursing precautions: Implement Seizure Precautions (padded side rails, bedside suction and oxygen); enforce Fluid Restriction for euvolemic/hypervolemic hyponatremia (e.g., SIADH); perform frequent neurological assessments; and when severe symptomatic hyponatremia requires Hypertonic 3% Normal Saline, infuse via pump with frequent serum Na+ monitoring so correction does NOT exceed 8–10 mEq/L in 24 hours to prevent Osmotic Demyelination Syndrome (ODS / central pontine myelinolysis). |  |  |
| 19 | What are the ABG findings and classic etiologies of Metabolic Alkalosis, and how does the body compensate? | ABG: pH > 7.45, HCO3- > 26 mEq/L, PaCO2 normal or elevated (respiratory compensation). Causes: Loss of upper GI gastric acid via prolonged nasogastric suctioning or severe persistent vomiting; massive loop/thiazide diuretic use (potassium and chloride loss); excessive oral antacid or sodium bicarbonate ingestion. Compensation: Hypoventilation (slower, shallow respirations to retain CO2; limited by the body's mandatory drive to avoid severe hypoxia). |  |  |
| 20 | What are the early signs of an acute hemolytic transfusion reaction, and what is the immediate emergency nursing protocol? | Signs: Fever, chills, flushing, low back/flank pain (due to hemoglobin sludging in renal tubules), dyspnea, tachycardia, hypotension, hemoglobinuria ('red wine' urine), and sense of impending doom. Emergency Protocol: 1) Immediately STOP the transfusion; 2) Disconnect blood tubing entirely from the IV catheter hub; 3) Connect new IV tubing with 0.9% Normal Saline to keep vein open; 4) Assess vitals and notify physician and blood bank immediately; 5) Return remaining blood product and all tubing to blood bank for re-analysis; 6) Collect urine and blood samples to evaluate for free hemoglobin and hemolysis. |  |  |
| 21 | What is the clinical 'Rule of 15' for managing acute hypoglycemia in a conscious hospitalized patient? | If conscious and blood glucose is < 70 mg/dL: 1) Administer 15 grams of fast-acting simple carbohydrate (e.g., 4 ounces [1/2 cup] fruit juice, 4 ounces regular soda, 3-4 commercial glucose tablets, or 1 tube glucose gel); 2) Wait 15 minutes and recheck capillary blood glucose; 3) If blood glucose remains < 70 mg/dL, administer another 15 grams of carbohydrate; 4) Repeat cycle until glucose is > 70 mg/dL; 5) Once normalized, provide a complex carbohydrate and protein snack (e.g., peanut butter crackers or half sandwich) if the next meal is > 1 hour away. (If unconscious or unable to swallow, administer IV 50% Dextrose [D50W] 25-50 mL or IM Glucagon 1 mg). |  |  |
| 22 | How do uncompensated, partially compensated, and fully compensated arterial blood gas states differ? | Uncompensated: pH is abnormal (< 7.35 or > 7.45), the primary parameter (PaCO2 or HCO3-) is abnormal, and the opposing parameter remains within normal limits. Partially Compensated: pH remains abnormal (< 7.35 or > 7.45), and BOTH PaCO2 and HCO3- are abnormal as the opposing system compensates. Fully Compensated: pH has returned to the normal reference range (7.35–7.45), while BOTH PaCO2 and HCO3- remain abnormal (whether the primary disorder was acidosis or alkalosis can be identified by whether pH lies on the acidotic [7.35–7.39] or alkalotic [7.41–7.45] side of 7.40). |  |  |
| 23 | What clinical signs indicate Hypermagnesemia (serum Mg2+ > 2.1 mEq/L or > 2.6 mg/dL), and what is the emergency antidote? | Symptoms reflect progressive neuromuscular and cardiac depression (most commonly in renal failure or high-dose IV magnesium sulfate therapy for preeclampsia). Early (4–5 mEq/L): Cutaneous flushing, warmth, hypotension, and diminished or absent deep tendon reflexes (hyporeflexia/areflexia—the earliest hallmark sign). Moderate-to-severe (> 7–10 mEq/L): Lethargy, bradycardia, heart block, respiratory depression/apnea, and cardiac arrest. Emergency treatment: Immediately STOP the magnesium infusion, support ventilation, and administer IV Calcium Gluconate (10% solution, 10–20 mL IV over 3–5 minutes) as a direct physiological antagonist, plus IV fluids/loop diuretics or hemodialysis if renal function is impaired. |  |  |
| 24 | What clinical manifestations characterize Hypercalcemia (serum Ca2+ > 10.5 mg/dL), and what is the first-line nursing intervention? | Mnemonic 'Stones, Bones, Groans, and Psychiatric Moans': Nephrolithiasis (kidney stones); Bone pain and pathologic fractures; Abdominal groans (constipation, anorexia, nausea, peptic ulcers, pancreatitis); Psychiatric moans (confusion, depression, lethargy, fatigue); decreased DTRs and shortened QT interval. First-line intervention: Aggressive intravenous hydration with 0.9% Normal Saline (200-300 mL/hr) to promote renal calciuresis, followed by Loop Diuretics (Furosemide) once rehydrated. |  |  |
| 25 | How is the Incentive Spirometer correctly used by a postoperative patient to prevent atelectasis and pneumonia? | 1. Position patient in High Fowler's or Semi-Fowler's position; 2. Seal lips tightly around the mouthpiece; 3. Instruct patient to inhale slowly and deeply through the mouth, pulling the piston/ball upward to the target marker; 4. Hold breath for 3 to 5 seconds at the peak of inspiration; 5. Exhale normally through pursed lips; 6. Repeat 10 times every hour while awake; 7. Follow with controlled coughing while splinting any surgical abdominal or thoracic incision with a pillow. |  |  |
| 26 | What physical assessment signs demonstrate neuromuscular irritability in Hypocalcemia (serum Ca2+ < 8.5 mg/dL)? | 1. Positive Chvostek's sign: tapping the facial nerve anterior to the earlobe / over the parotid gland produces involuntary ipsilateral twitching of facial muscles (corner of mouth, nose, eye). 2. Positive Trousseau's sign: inflating a blood pressure cuff on the upper arm >= 20 mmHg above systolic BP for 3 minutes induces carpopedal spasm (involuntary flexion of wrist, MCP joints, and thumb adduction). 3. Paresthesias of fingers, toes, and perioral region; muscle tetany; and EKG showing prolonged QTc. |  |  |
| 27 | What systematic four-step method and ROME mnemonic are used to analyze Arterial Blood Gases (ABGs)? | 1. Check pH: < 7.35 = Acidosis; > 7.45 = Alkalosis (7.40 is absolute neutral midpoint); 2. Check PaCO2: 35-45 mmHg (respiratory component); 3. Check HCO3-: 22-26 mEq/L (metabolic / renal component); 4. Apply ROME rule: Respiratory Opposite (pH and PaCO2 move in opposite directions in primary respiratory disorders); Metabolic Equal (pH and HCO3- move in the same direction in primary metabolic disorders). |  |  |
| 28 | What essential nursing priorities define Post-Anesthesia Care Unit (PACU) phase I admission assessment? | Immediate priorities (ABC principle): 1) Airway patency and respiratory adequacy (respiratory rate, rhythm, SpO2, depth, breath sounds); 2) Circulation and hemodynamic stability (BP, apical pulse, continuous ECG, peripheral perfusion); 3) Surgical site inspection for active hemorrhage or excessive drainage; 4) Neurological status and return of consciousness; 5) Temperature (prevent hypothermia with warm blankets); 6) Pain and nausea management; 7) Patency of all surgical drains, IV lines, and urinary catheters. |  |  |
| 29 | What is the electrolyte composition of Lactated Ringer's (LR) solution, and in what conditions is it contraindicated? | Composition: closely approximates human plasma, containing Sodium (130 mEq/L), Potassium (4 mEq/L), Calcium (3 mEq/L), Chloride (109 mEq/L), and Sodium Lactate (28 mEq/L, metabolized by liver into bicarbonate). It is the fluid of choice for burn resuscitation and surgical trauma. Contraindications: severe liver disease (impaired lactate metabolism leads to lactic acidosis) and severe hyperkalemia or end-stage renal disease (contains potassium). |  |  |
| 30 | What physical assessment findings and lab parameters indicate Fluid Volume Deficit (Hypovolemia)? | Findings: Tachycardia, orthostatic hypotension, weak thready pulses, dry mucous membranes, decreased skin turgor with delayed tenting, flat jugular veins when supine, sunken eyes, thirst, weight loss, and oliguria (< 30 mL/hr). Laboratory results demonstrate hemoconcentration: elevated Hematocrit, elevated BUN with BUN:Cr ratio > 20:1, high serum sodium, and elevated urine specific gravity > 1.030. |  |  |
| 31 | What are the ABG findings, causes, and characteristic compensatory breathing pattern of Metabolic Acidosis? | ABG: pH < 7.35, HCO3- < 22 mEq/L, PaCO2 normal or decreased (respiratory compensation). Causes: High anion gap (DKA, lactic acidosis, renal failure) or normal anion gap (severe diarrhea with base loss, intestinal fistulas). Compensatory pattern: Kussmaul respirations (deep, rapid, labored respirations) by which the respiratory center blows off CO2 to bring arterial pH back toward normal. |  |  |
| 32 | What are the three chambers of a traditional chest tube drainage unit, and what does continuous vigorous bubbling in the water-seal chamber indicate? | Chambers: 1) Drainage Collection Chamber (monitors volume and character of pleural drainage; report > 70–100 mL/hr of bright red blood); 2) Water-Seal Chamber (filled to the 2 cm line with sterile water; acts as a one-way valve allowing air/fluid out of the pleural space but preventing re-entry); 3) Suction Control Chamber (typically -20 cmH2O wet or dry suction; gentle continuous bubbling is normal in a wet-suction control chamber). In the Water-Seal chamber, intermittent tidaling (fluctuation with respiration) is expected and stops when the lung re-expands or tubing is kinked, whereas CONTINUOUS bubbling in the water-seal chamber indicates an AIR LEAK. |  |  |

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