Ch 41 Fluid & Electrolytes
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."
"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 nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? Discontinue the IV and relocate it to another site. Call the primary care provider to see whether anti-inflammatory drugs should be administered. Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.
Discontinue the IV and relocate it to another site. Explanation: The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.
A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate? Offer the client sugar-free candy to help combat thirst. Give the client a fluid containing additional sodium to enhance the feeling of fullness. Have the client use an alcohol-based mouthwash every 2 hours to reduce the thirst sensation. Apply a petroleum-based gel to the client's lips to prevent cracking.
Offer the client sugar-free candy to help combat thirst. Explanation: To minimize thirst for clients on fluid restriction, offer sugar-free candy and gum to help minimize thirst. Salty or very sweet fluids should be avoided. Rinsing the mouth with water and then having the client spit it out before swallowing may be helpful. Alcohol-based mouthwashes should be avoided because they have a drying effect. A water-based gel, not petroleum based, can be applied to the client's lips to moisten and prevent drying and cracking.
The primary extracellular electrolytes include which of the following? Potassium, phosphate, and sulfate Magnesium, sulfate, and carbon Sodium, chloride, and bicarbonate Phosphorous, calcium, and phosphate
Sodium, chloride, and bicarbonate Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? asking the client to pump their fist several times placing the tourniquet on the upper arm for 2 minutes asking if the client is right or left handed palpating the veins on the nondominant hand
placing the tourniquet on the upper arm for 2 minutes Explanation: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.
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? 3,750 3,000 1,000 500
3,000 Explanation: 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 a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? 42 gtt/min 83 gtt/min 167 gtt/min 5,000 gtt/min
83 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min
While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority? Apply a tourniquet to the client's upper arm. Apply pressure to the site with sterile gauze until hemostasis is achieved. Have the client perform the Valsalva maneuver. Measure the catheter and compare it with the length listed in the chart.
Apply a tourniquet to the client's upper arm. Explanation: In the event that a portion of the catheter breaks off during removal of a PICC, the nurse should immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of the piece of catheter into the right atrium. The other actions should be performed during a routine PICC removal. Use of the Valsalva maneuver by the client during expiration reduces the risk for air embolism. Measurement and inspection of the PICC following removal ensures that the entire catheter was removed. Application of adequate pressure with sterile gauze following PICC removal prevents hematoma formation.
The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client? B positive O negative A positive AB negative
O negative Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. B positive, A positive, and AB negative are not considered compatible in this scenario.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Ask the client every hour to drink more fluid. Offer small amounts of preferred beverage frequently. Have a loved one tell the client to drink more. Leave water on the bedside table.
Offer small amounts of preferred beverage frequently.
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and fatigue and the nurse's assessment reveals an irregular heart rate. The nurse should assess the client's levels of which electrolyte? Calcium Chloride Phosphorous Potassium
Potassium Explanation: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. Signs of potassium defecit, or hypokalemia, include muscle weakness, fatigue and arrythmias.
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.
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's blood pressure has dropped from 146/92 mmHg to 107/68 mmHg over the course of several minutes. Increased levels of which of the following will be released into the client's bloodstream? Protein Erythropoietin Renin Insulin
Renin Explanation: Decreased arterial blood pressure can stimulate renin release as part of a compensatory response. Low BP does not prompt the release of insulin, erythropoietin or protein.