The nurse is caring for a patient who has been vomiting and has diarrhea for 3 days and now has muscle weakness and paresthesias in his hands and feet, along with an irregular pulse rate and rhythm, and shallow respirations with crackles on auscultation of his lungs bilaterally. The nurse suspects that these symptoms are most likely due to which electrolyte imbalance?

Choice A reason:

The nurse should monitor blood glucose levels because dextrose 10% in water (D10W) is a hypertonic solution that contains glucose and can raise the blood sugar level of the patient. The nurse should check the blood glucose level before and after administering D10W to prevent hyperglycemia or hypoglycemia.

Choice B reason:

The nurse should check for signs of phlebitis at the IV site because D10W is acidic and can cause venous irritation. Phlebitis is inflammation of the vein that can result from chemical, mechanical or bacterial causes. Signs of phlebitis include pain, redness, swelling, warmth and tenderness at the IV site.

Choice C reason:

The nurse should assess for fluid overload because D10W is quickly metabolized, leaving behind water that can move into the interstitial space. Fluid overload can cause edema, dyspnea, crackles, distended neck veins, increased blood pressure and decreased urine output. The nurse should monitor the intake and output, vital signs, weight and breath sounds of the patient.

Choice D reason:

The nurse does not need to evaluate serum sodium levels because D10W does not contain sodium or affect the sodium balance of the patient. D10W is used to provide some nutrition with glucose, not to correct electrolyte imbalances.

Choice E reason:

The nurse does not need to observe for signs of hypoglycemia because D10W is unlikely to cause hypoglycemia unless there is a sudden interruption or discontinuation of the infusion. Hypoglycemia is a low blood sugar level that can cause shakiness, diaphoresis, confusion, weakness, hunger and headache. The nurse should monitor the blood glucose level and administer D10W at a steady rate to prevent hypoglycemia.

Choice A reason:

Administer the solution via a central line. This is correct because 3% sodium chloride solution is a hypertonic solution that can cause phlebitis and tissue damage if infused peripherally. A central line can deliver the solution more safely and effectively.

Choice B reason:

Monitor serum sodium levels every 4 hours. This is correct because serum sodium levels can indicate the effectiveness of the therapy and the risk of complications such as hypernatremia or cerebral edema. The normal range of serum sodium is 135 to 145 mEq/L.

Choice C reason:

Titrate the infusion rate according to urine output. This is incorrect because the infusion rate of 3% sodium chloride solution should be titrated according to serum sodium levels, not urine output. Urine output can be affected by other factors such as renal function, fluid intake, and diuretics.

Choice D reason:

Assess for signs of fluid overload. This is correct because 3% sodium chloride solution can cause fluid shifts from the intracellular and interstitial spaces to the intravascular space, leading to fluid overload. Signs of fluid overload include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated central venous pressure (CVP), weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit.

Choice E reason:

Keep an accurate intake and output record. This is correct because intake and output records can help monitor the fluid balance and identify any excesses or deficits. Intake includes oral fluids, intravenous fluids, tube feedings, and blood products. Output includes urine, stool, vomitus, drainage, and insensible losses.