Chapter 16 Foundations PrepU
Which statement by the client indicates understanding of adequate hydration?
"I should drink 2,500 mL/day of fluid."
What common IV solution is hypotonic?
0.45% NaCl
A nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body fluid is lost via the gastrointestinal tract?
100 mL
How much daily average intake should adults have for adequate hydration?
2500 mL/day
A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?
50 gtt/min
Granulocytes
A type of white blood cell that can help fight infections. A group of leukocytes containing granules in their cytoplasm; neutrophils, eosinophils, basophils.
A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?
Compare the total intake and output of fluids for the 24 hours
What does cross-matching do?
Determines compatibility between blood specimens
The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema?
Elevate the legs
What is interstitial fluid?
Fluid in the tissue space between and around cells
Which client has more extracellular fluid?
Newborn Explanation: Newborns have more extracellular fluid than intracellular fluid.
What type of blood is compatible for a client with type A negative?
O- and A-
A client has been prescribed a blood test. When taking a venous blood sample, which intervention should the nurse perform?
Tap the skin over the vein several times.
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?
The average adult daily fluid source is: 1,300 mL from ingested water, 1,000 mL from ingested food, and 300 mL from metabolic oxidation, totaling 2,600 mL fluid.
A woman had a left mastectomy with axillary node dissection due to cancer. How would this affect placement of an intravenous line?
The left arm should not be used.
A nurse is preparing to start an intravenous infusion for a client. Which preprocedural assessment is essential before inserting the cannula?
The nurse should assess the preferred site: at least 2 inches (5 cm) above the crease of the wrist.
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?
Tighten the roller clamp to stop the infusion.
Which client would be a candidate for total parenteral nutrition?
a client with colitis and bloody diarrhea
Which veins can you use to start an IV on an adult?
cephalic vein metacarpal vein basilic vein vein on the dorsal aspect of the hand
Which is a common anion?
chloride common negatively charged ion.
What symptoms are associated with Hyponatremia
confusion muscle weakness edema
What is the physiologic process that drives the thirst factor?
decreased blood volume intracellular dehydration
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:
fluid volume excess.
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?
hypertonic Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink.
Which location might the nurse use to assess the condition of an insertion site for a central venous access device?
over the jugular vein
A nurse is initiating a peripheral venous access IV infusion prescribed for a client preoperatively. In what position would the nurse place the client to perform this skill?
low-fowler
A client has a prescription to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem?
Oral hygiene
The nurse is caring for a client who was in a motor vehicle accident and requires treatment for internal bleeding from the trauma. Which solution does the nurse anticipate infusing?
colloidal
The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?
Stop the transfusion
TPT (total parenteral nutrition) is for clients such as those with:
Trauma, burns, liver/renal failure, inflammatory bowel disease.
Why do the lipids given parenteral nutrition look like milk?
"The white milky solution contains lipids, or fat, to provide extra calories."
A client asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond?
"There is no way you can contract a disease by giving blood."
What is the average adult fluid intake and loss in each 24 hours?
1,500 to 3,500 mL
When addressing the client's insensible fluid loss via respiration, which amount does the nurse anticipate as the usual average?
300 mL/day
A nurse is preparing to administer intravenous fluids to a client using microdrip tubing. What volume will the tubing administer?
60 drops/ml Microdrip tubing, regardless of the manufacturer, delivers a standard volume of 60 drops/ml.
Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium?
Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L). True: Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).
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 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.
IV client's arm is swollen and cool to the touch, what should the nurse do?
Remove the peripheral intravenous catheter
What symptoms are associated with Hypocalcemia
Seizures Tetany Latent tetany: numbness, tingling, cramps in extremities Bronchospasm Laryngeal spasm Anxiety, irritability, depression EKG changes
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?
Sodium is regulated by the renin-angiotensin-aldosterone system.
The nurse is assessing an adult client with general weakness. The nurse will begin preparing for the insertion of a peripheral intravenous line if which assessment finding(s) are present? Select all that apply.
The client reports using laxative substances daily. The client has been vomiting for several days. The client has a serum potassium level of 2.0 mEq/l (2.0 mmol/l). (hypokalemia) The client has severe iron-deficiency anemia.
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.
What is intravascular fluid?
Watery plasma, or serum, portion of blood.
Can a surgical client give their own blood weeks prior to surgery in case of a need for transfusion?
Yes, the nurse should refer the patient to the blood bank.
The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which will the nurse document on the I&O record? Select all that apply.
client drinking milk client's urination vomiting infusion of IV solution
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?
daily weights
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
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 72 hours IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first.
What should the nurse be concerned about with a client with heart failure, edema, orthopnea, and confusion?
excess extracellular volume related to heart failure, manifested as edema and orthopnea
Which statement is an appropriate nursing concern for an 80-year-old client diagnosed with heart failure, with symptoms of edema, orthopnea, and confusion?
excess extracellular volume related to heart failure, manifested as edema and orthopnea
In which fluid compartment is most of the body's fluid is located?
intracellular Intracellular is the fluid within cells, constituting about 70% of the total body water.
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?
isotonic
The primary extracellular electrolytes are:
sodium, chloride, bicarbonate
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as
total parenteral nutrition.
A client has been admitted to the hospital with a diagnosis of acute kidney injury, a health problem that necessitates vigilant monitoring of the client's fluid balance. What is the most accurate way that the care team can achieve this assessment goal?
weighing the client once per day
The nurse is caring for a client who is being discharged with total parenteral nutrition (TPN) to be delivered via a peripherally inserted central catheter (PICC). When teaching the client about care and management of the PICC line at home, what point(s) will the nurse include? Select all that apply.
"Contact your health care provider if you see yellow or greenish drainage at the PICC site." "If you have a cold or flu-like symptoms, wear a mask when you are preparing to give yourself TPN." "Ensure that you have washed your hands thoroughly before handling the PICC line."
A nursing instructor is discussing administration of total parenteral nutrition (TPN) with a nursing student. Which statement by the student would require further teaching?
"I will be sure to change the TPN tubing every other day." TPN tubing should be changed daily to reduce the potential for infection.
The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate?
42 gtt/min When infusing by gravity, divide the total volume in mL (1,000 mL) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtt/mL. The correct answer is 42 gtt/min.
The nurse is caring for a client with severe edema who has crackles in the lungs. Which nursing intervention is the priority for this client?
Administer furosemide as ordered. Control of edema, and thus restoration of fluid balance, can be accomplished by treating the disorder contributing to the increased fluid volume, restricting or limiting oral fluids, reducing salt consumption, discontinuing IV fluid infusions or reducing the infusing volume, and/or administering drugs that promote urine elimination. The priority is to administer the furosemide, as this will decrease the fluid volume and decrease the crackles in the lungs.
The tourniquet should be released
As soon as blood flow is established, before needle removal from the arm, within 1 minute of its application
A nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?
Infants have more total body fluid and ECF than adults.
IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. What's the complication?
Infiltration Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site, and significant decrease in the flow rate. The signs of sepsis include red and tender insertion site, fever, malaise, and other vital sign changes. The symptoms of thrombus are local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.
The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1,000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply.
Offer the client fluids in small containers Provide moisturizer for the lips and mouth Remove the water pitcher from the client's bedside (do not give hard candy, it can increase the client's thirst)
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?
Restart infusion in another vein and apply a warm compress.
Client receiving multiple antibiotics, When choosing a site for intravenous insertion, which guideline will the nurse follow?
Use distal parts of larger veins where accessible.
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration.
How can the nurse best monitor the client's fluid balance?
accurately measuring and recording the client's intake and output
The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply.
cup of ice cream infusion of IV solution serving of jello 100ml from melted ice chips
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?
hemolytic transfusion reaction: incompatibility of blood product
A client with cerebral edema should have what IV solution?
hypertonic solution because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment.
What is the most potentially harmful risk posed for the client when accessing the vein?
infection
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third-spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia.
A client has a health care provider's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?
replace fluid and electrolytes
What symptoms are associated with Hypokalemia
Muscle weakness Aches Fatigue CARDIAC ARRHYTHMIAS abdominal distention nausea/vomiting
A client's peripheral intravenous site, the nurse notices the area is red and warm. What is this?
Phlebitis
IV site is red with a red streak along the vein that is painful to the client. Priority nursing aciton?
Remove the IV
The nurse is administering albumin to a client to promote movement of fluid into the capillaries. The "pulling force" of fluid by use of a protein such as albumin is known as:
colloid oncotic pressure. Plasma proteins, particularly albumin, concentrated in the intravascular space or plasma facilitate the reabsorption of fluid into the capillaries by the action of colloid oncotic pressure.
The nurse is caring for a client who ran an outdoor marathon during peak heat in the summer. The client's baseline weight is reported as 125 lb (56.7 kg); however, on admission today, the client weighs 115 lb (52.2 kg). Based on the percentage of weight lost, the nurse will document the client's fluid volume status using which describing term?
moderately dehydrated Mild dehydration is present when there is a 3% to 5% loss of body weight; moderate dehydration is associated with a 6% to 10% loss of body weight; and severe dehydration, a life-threatening emergency, occurs with a loss of more than 9% to 15% of body weight. This client has lost 8% of body weight (10 lb/4.5 kg) and is therefore moderately dehydrated.
