Ch. 40 F & E, Acid‐Base Balance
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? Transparent semipermeable membrane dressing Occlusive dressing Sealed IV dressing Gauze dressing
Correct response: Gauze dressing Explanation: A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. Transparent semipermeable membranes are a type of sealed IV dressing. Occlusive dressings would not be appropriate.
Edema happens when there is which fluid volume imbalance?
Extracellular fluid volume excess
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.
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 is clear and transparent.
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
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?
Notify the primary care provider immediately for possible fluid overload
A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?
Stop the transfusion and infuse normal saline using a new administration set.
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:
a winged infusion needle.
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
an infant age 4 months
Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:
hyponatremia.
A nurse is educating a group of adults on dietary requirements. What food should the nurse recommend as a significant source of phosphorous?
nuts
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
total parenteral nutrition.
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?
60 drops/mL
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?
Cardiac dysrthmias
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?
3.5 cm H2O
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
Offer small amounts of preferred beverage frequently.
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:
hypokalemia.
Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea Congestive Heart Failure related to edema Fluid Volume Excess related to loss of sodium and potassium Fluid Volume Deficit related to congestive heart failure, as evidenced by shortness of breath
Correct response: Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea Explanation: Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid.
Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium? Insulin promotes the transfer of potassium from the extracellular fluid into skeletal muscle and liver cells. Aldosterone enhances renal excretion of potassium. A person loses approximately 30 mEq (30 mmol) of potassium. Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L).
Correct response: Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L). Explanation: Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phosphorus
A decrease in arterial blood pressure will result in the release of
renin
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Acute Confusion related to cerebral edema
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:
fluid overload
Which is a common anion? magnesium potassium chloride calcium
Correct response: chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.
What is the lab test commonly used in the assessment and treatment of acid-base balance? Complete blood count Basic metabolic panel Arterial blood gas Urinalysis
Correct response: Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level.
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?
"I should drink 2,500 mL/day of fluid."
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?
"Let me refer you to the blood bank so they can provide you with information."
The nurse is preparing to insert an intravenous catheter into an adult client. this is the correct order.
1) Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the site. 2) Cleanse the site with chlorhexidine. 3) Place nondominant hand 1 to 2 in (2.5 to 5 cm) below the site and pull the skin taut. 4) Insert the needle gently. Release the tourniquet. 5) Stabilize the catheter or needle.
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 this client's needs?
An implanted central venous access device (CVAD)
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I need to drink no more than 1,000 mL/day" "I should drink 1,500 mL/day of fluid." "I should drink 2,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid."
Correct response: "I should drink 2,500 mL/day of fluid." Explanation: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.
A decrease in arterial blood pressure will result in the release of: protein. thrombus. renin. insulin.
Correct response: renin. Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.
The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply.
Rate of the IV solution Location of the IV catheter access Client's reaction to the procedure Type of IV solution Gauge and length of the IV catheter
During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?
Stop the transfusion immediately.
The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by the students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply.
"The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." The adrenal glands regulate blood volume by secreting aldosterone." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst."
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Fluid inside cells." "Fluid outside cells." "Fluid in the tissue space between and around cells." "Watery plasma, or serum, portion of blood."
Correct response: "Fluid in the tissue space between and around cells." Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).
The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients? An increased sense of thirst Increase in nephrons in the kidneys Increased renal blood flow Cardiac volume intolerance
Correct response: Cardiac volume intolerance Explanation: The older adult client is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. Older adults typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? hypertonic colloid isotonic hypotonic
Correct response: isotonic Explanation: Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.
The primary extracellular electrolytes are: potassium, phosphate, and sulfate. magnesium, sulfate, and carbon. sodium, chloride, and bicarbonate. phosphorous, calcium, and phosphate.
Correct response: sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: cellular hydration. volume expander. total parenteral nutrition. blood transfusion therapy.
Correct response: total parenteral nutrition. Explanation: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.
Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?
Muscle weakness, fatigue, and dysrhythmias
The nurse has inserted a peripheral intravenous catheter. When applying a transparent dressing, what is the nurse's best action?
The transparent dressing should be placed in such a manner as to allow full coverage and visibility of the insertion site, without excessively covering the tubing.
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?
cardiac irregularities
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
Which client will have more adipose tissue and less fluid? A woman A man An infant A child
Correct response: A woman Explanation: Women have a lower fluid content because they have more adipose tissue then men.
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?
Hypovolimia
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? As fast as the client can tolerate 1 unit over 2 to 3 hours, no longer than 4 hours 75 mL/hr for the first 15 minutes, then 200 mL/hr 200 mL/hr
Correct response: 1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.
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? Slow the rate of IV fluids. Remove the IV. Apply a warm compress. Elevate the arm.
Correct response: Remove the IV. Explanation: 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 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: hypocalcemia. hypothyroidism. hypoglycemia. hypokalemia.
Correct response: hypokalemia. Explanation: 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 nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take?
Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins
The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by the students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply. "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The kidneys react to hypovolemia by stimulating fluid retention." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." The adrenal glands regulate blood volume by secreting aldosterone." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst."
Correct response: "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." The adrenal glands regulate blood volume by secreting aldosterone." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." Explanation: The heart and blood vessels (not the kidneys) react to hypovolemia by stimulating fluid retention. The other statements made by the students are correct.
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? Hypernatremia Hyperchloremia Hypokalemia Hypomagnesemia
Correct response: Hypokalemia Explanation: Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.
The nurse is caring for a client diagnosed with an acute myocardial infarction requiring strict monitoring of intake and output. Calculate the intake for the shift. Record your answer using a whole number rounded to the nearest 10 mL. 550 mL of urine ¼ cup of grapes 200 mL of liquid stool 4 oz of Jello 250 mL of IV normal saline 1 cup of apple juice
Correct response: 610 Explanation: The nurse would include all items that are liquid or turn to liquid at room temperature in the calculation. Jello, IV normal saline, and apple juice are calculated as intake. Urine and stool are calculated as output. Grapes will not be included as intake. Convert all units to mL, rounded to the nearest 10 mL: 4 oz of Jello = 120 mL 1 cup of apple juice = 240 mL 120 mL + 250 mL IV fluid +240 mL = 610 mL
A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action?
Discontinue the IV.
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? 3.5 cm H2O 5 cm H2O 9.5 cm H2O 12 cm H2O
Correct response: 3.5 cm H2O Explanation: The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? Constipation related to immobility Pain related to surgical incision Acute Confusion related to cerebral edema Risk for Infection related to inadequate personal hygiene
Correct response: Acute Confusion related to cerebral edema Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.
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 this client's needs? An implanted central venous access device (CVAD) A peripheral venous catheter inserted to the antecubital fossa A peripheral venous catheter inserted to the cephalic vein A midline peripheral catheter
Correct response: An implanted central venous access device (CVAD) Explanation: Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Elevate the client's head. Apply a warm compress. Position the client on the left side. Apply antiseptic and a dressing.
Correct response: Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
A home care nurse is visiting a client with renal failure 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? Avoid salty or excessively sweet fluids. Use regular gum and hard candy. Eat crackers and bread. Use an alcohol-based mouthwash to moisten your mouth.
Correct response: Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.
The nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal pH. Place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2. 1H2CO3 level in the blood decreases 2pH becomes more alkaline 3Blood level of CO2 decreases 4Decreased respirations 5Carbon dioxide retention 6Carboinc acid formed
Correct response: H2CO3 level in the blood decreases pH becomes more alkaline Blood level of CO2 decreases Decreased respirations Carbon dioxide retention Carbonic acid formed Explanation: When respirations are increased, the H2CO3 level begins to decrease, causing the pH to become more alkaline. When the blood level of CO2 decreases, respirations slow, resulting in CO2 retention and the formation of carbonic acid, signaling stabilization of the pH balance.
The nurse is administering intravenous (IV) therapy to a client. 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? Sepsis Phlebitis Infiltration Air embolism
Correct response: Phlebitis Explanation: 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. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.
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 will continue to infuse fluid even when the needle is displaced. The pump stops pushing the fluid in the client's vein when the needle is displaced. The pump compresses the tubing to infuse the solution at a precise, preset rate. The pump will sound an audible and visual alarm warning the nurse of the situation.
Correct response: The pump will continue to infuse fluid even when the needle is displaced. Explanation: The nurse should be aware that an infusion 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 infusion pump adjusts the pressure according to the resistance it meets. The pump does not compress the tubing to infuse the solution at a precise, preset rate, which is done by a volumetric controller. An electronic infusion device would sound an audible alarm if the infusion container is empty, air is detected in the tubing, or resistance is met in delivering the fluid. The infusion pump does not stop pushing the fluid in the client's vein when the needle becomes displaced.
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? cardiac irregularities muscle weakness increased intracranial pressure (ICP) metabolic acidosis
Correct response: cardiac irregularities Explanation: 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 dysrhythmias. Muscle weakness is associated with low magnesium or high phosophorus. Increased intracraniel pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.
