ADN2 Exam3 Fluid, Electrolyte, and Acid base Balance
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my won blood to be used in case i need during surgery." What is the appropriate nursing response? - "Let me refer you to the blood bank so they can provide you with information" - "We now have artificial blood products, so giving your own bblood is not necessary." - "This surgery has a very low chance of hemorrhage, so you will not need blood." - "Unfortunately, your own blood cannot be reinfused durign surgery."
"LET ME REFR YOU TO THE BLOOD BANK SO THEY CAN PROVIDE YOU WITH INFORMATION." Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be reinfused.
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? - Palpating the veins on the nondominant hand - Asking if the client is right or left handed - Asking the client to pump their fist several times - Placing the tourniquet on the upper arm for 2 minutes
"Placing the tourniquet on the upper arm for 2 minutes" The tourniquet should not be applied longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client.
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? - 1 unit over 2 to 3 hours, no longer than 4 hours - As fast as the client can tolerate - 75 mL/hr for the first 15 minutes, then 200 mL/hr - 200 mL/hr
1 unit over 2 to 3 hours, no longer than 4 hours Packed red blood cells are addministered 1 unit over 2 to 3 hours for no longer than 4 hours
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24 hour period. In evaluating this client's urine output for the same 24 hour period, the nurse realizes that it should total approximately how many mL? - 3,000 - 3,750 - 500 - 1,000
3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.
A health care provider orders an infsuion of 250 mL in 100 minutes. The set is 20 gtt/ml what is the flow rate? - 40gtt/min - 20 gtt/min - 30 gtt/min - 50 gtt/min
50 gtt/min The flow rate (gtt/min) equals the volume (mL) times drop factor (gtt/mL) divided by the time in minutes. 250x20= 5000. 5000/100 = 50
A home care nurse is visiting a client with acute kidney injury who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? - Use regular gum and hard candy - Use an alcohol-based mouthwash to moisten your mouth - Avoid salty or excessively sweet fluids - Eat crackers and breads
AVOID SALTY OR EXCESSIVELY SWEET FLUIDS To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids.
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is MOST likely to meet the client's needs? - A peripheral venous catheter inserted to the cephalic vein - Midline peripheral catheter - A peripheral venous catheter inserted to the antecubital fossa - An implanted Central Venous access device (CVAD)
An implanted CENTRAL VENOUS ACCESS DEVICE (CVAD) Implanted CVADs are ideal for long-term uses such as chemotherapy.
The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching? - Skeletal function - Cardiac function - Auditory function - Optic function
CARDIAC FUNCTION Potassium is essential for normal cardiac function.
A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes Hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? - Metabolic acidosis - Muscle weakness - Cardiac irregularities - Increased intracranial pressure (ICP)
CARDIAC IRREGULARITIES Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac arrythmias.
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client? - Every 36 hours - Every 72 hours - Every 24 hours - Every 12 hours
EVERY 72 HOURS IV tubings are generally changed every 72 hours or as per the facility's policy.
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Ensure that the prescribed solution the expected color and consistency. Before preparing the solution, the nurse should inspect the container and determine that the solution's color and consistency matches that expected based on the prescription, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: - Hypothyroidsim - Hypocalcemia - Hypoglyemia - Hypokalemia
HYPOKALEMIA The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? - Metabolic alkalosis - Metabolic acidosis - Respiratory acidosis - Respiratory alkalosis
METABOLIC ALKALOSIS Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss in stomach acid may result in this condition.
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? - Muscle cramping and tetany - Nausea, vomiting, and constipation - Diminished cognitive ability and hypertension - Muscle weakness, fatigue, and constipation
MUSCLE CRAMPING and TETANY Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures
A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum pottasium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert? - Muscle weakness, fatigue, and arrythmias - Dimnished cognitive ability and hypertension - Nausea, vomiting, and constipation - Muscle weakness, fatigue, and constipation
MUSCLE WEAKNESS, FATIGUE, AND ARRYTHMIAS Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and arrythmias. ~ Hypercalcemia includes nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech ~Diminished cognitive ability and hypertension may result from hyperchloremia ~ constipation is a sign of hypercalcemia
As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action? - By pulling the dressing toward the insertion site - By applying stabilizing pressure to the catheter - Not wearing gloves when performing the intervention - Not performing the intervention under sterile conditions.
NOT WEARING GLOVES WHEN PERFORM THE INTERVENTION The changing of peripheral venous access site dressing requires the use of clean gloves to minimize the transmission of microorganisms during the procedure and to prevent the nurse from coming in contact with blood
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? - Have a loved one tell the client to drink more - Leave water on the bedside table - Ask the client every hour to drink more fluid - Offer small amounts of preferred beverages frequently
OFFER SMALL AMOUNTS OF PREFERRED BEVERAGE FREQUENTLY Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.
Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently plapates the area. These signs and symptoms are indicative of: - Rapid fluid Administration - An Infiltration - Phlebitis - A systemic blood infection
PHLEBITIS Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includs manifestation such as chills, fever, tachycardia, and hypotension
A nurse is administering Intravenous (IV) therapy to a clinet. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse MOST suspect? -Infiltration -Air embolism -Phlebitis -Sepsis
PHLEBITIS Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site.
A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the health care provider to order?
Packed Cells Packed cells are especially useful in the treatment of chronic anemia.
A client has been receiving intravenous (IV) Fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? - Remove the IV - Slow the rate of IV fluids - Elevate the arm - Apply a warm compress
REMOVE THE IV The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein.
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?
Remove the IV The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.
A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?
SACRAL AREA The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. The edema cannot be assessed in the face, hands, and abdomen as these are not dependent areas.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal Saline as prescribed To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump? - The pump stops pushing fluid in the client's vein when the needle is displaced. - The pump will continue to infuse fluid even when the needle is displaced - The pump will sound an audible and visual alarm warning the nurse of the situation - The pum compresses the tubing to infuse the solution at a precise, preset rate
THE PUMP WILL CONTINUE TO INFUSE FLUID EVEN WHEN THE NEEDLE IS DISPLACED The nurse should be aware that an infsion pump continues to infuse fluid even when the needle is displaced. The pump continues to infuse fluid into the tissue until the machine's maximum preset pressure reaches its limit.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.
A decrease in arterial blood pressure will result in the release of:
renin
