Chapter 16 - Fluid and Chemical Balance
A hospital client has been experiencing nausea and has a standing order for the administration of an intravenous antisemitic. The nurse knows that the antisemitic must be diluted in 50 mL of IV fluid before being administered and should be given over a period of 20 minutes. The nurse will administer the drug using secondary tubing that has a drop factor of 10 gtts/mL. At what rate should the nurse program the infusion pump?
150 mL
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?
2,500 mL/day
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing interventions?
I received a blood transfusion in the United Kingdom
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.
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 displace.
Accurate fluid volume assessment has been ordered for a client who has been acutely ill since the time of admission to the hospital. The nurse can best monitor this client's fluid balance by:
accurately measuring and recording the client's intake and output.
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 the complication?
apply a warm compress
A nurse is caring for a client who is to be provided nutrition intravenously for a short duration following a tracheostomy. Which intravenous solution needs to be administered to this client?
crystalloid solution
After surgery, a client is on IV for the next 4 days. How often should the nurse change the IV tubing for this client?
every 72 hours. IV tubings are changed every 72 hours or as the facility policy.
A client has been admitted to the health agency with symptoms of malnutrition. The nurse needs to administer a solution of nutrients to meet the caloric and nutritional needs of the client. The nutrient solution is packaged in a glass container and needs to be administered with tubing that has a drop factor of 60 drops/mL. What type of tubing should the nurse use in this case?
filtered tubing
A 56-year old male client has been diagnosed with liver cirrhosis and recent laboratory testing reveals significant hypoalbuminemia. The nurse should anticipate that an assessment of the client may reveal:
fluid accumulation in the client's abdominal space
The student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response.
fluid in the tissue space between and around cells
A client who is administered to the health care facility has been diagnosed with cerebral edema. Which intravenous solutions needs to be administered to this client?
hypertonic solution
The nurse is caring for a client who baseline weight is 125 lbs. The client weighs 115 today. How does the nurse document the client's status.
moderately dehydrated.
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 interventions should the nurse perform for this client?
stop the transfusion immediately
A client has been ordered a blood test. When taking a venous blood sample, which interventions should the nurse perform?
tap the skin over the vein several times
A post-surgical client has been ordered an infusion of normal saline at 125 mL/hour until such time as the client begins drinking adequately. The infusion of this intravenous fluid will cause:
increased fluid volume with no significant redistribution of body fluids.
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?
ordering type of solution, additive, amount of infusion, and duration.
