Chapter 40: Fluid, Electrolyte, and Acid-Base

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells." 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).

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?

83 gtt/min 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

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." Infiltration is the escape of IV fluid into the tissue, and phlebitis is the inflammation of a vein. All other options are incorrect.

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply.

- Deciding the location of the IV catheter. - Administering the IV solution. - Deciding the size of the IV catheter. The nurse is responsible for deciding the location and size of the IV catheter, as well as for administering the solution. The primary care provider is responsible for prescribing the kind and amount of solution.

A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply.

- pulse rate 90 bpm - blood pressure 104/68 mmHg An increase in pulse rate of more than 20 beats per minute is a more sensitive indicator of ECF volume deficit than is a decrease in blood pressure. A drop of more than 15 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure with an increase in pulse rate frequently means the client is experiencing ECF volume depletion.

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 Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

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) 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.

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?

Apricots Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)?

Changing the dressing on a client's peripheral IV site Changing a peripheral IV dressing poses a lower risk to the client's safety than the other listed nursing actions and this would be the safest task to delegate. It would be inappropriate to delegate a blood transfusion, deaccess an implanted port, or remove a PICC to an LPN.

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).

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 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 phosphorus. Increased intracranial 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.

Which is a common anion?

chloride Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

decreased potassium levels Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

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 Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?

flush the IV with 3 mL of normal saline If fluid is slow to infuse, the nurse should reposition the client's arm and/or flush the IV. Changing to IV infusion will not resolve the problem and heparin is not used for clearing peripheral IVs. Deep vein thrombosis is unrelated to slow IV fluid infusion.

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 decrease in arterial blood pressure will result in the release of:

renin Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:

replacement of fluids for those lost from vomiting and diarrhea. The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

The primary extracellular electrolytes are:

sodium, chloride, bicarbonate

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 nurse needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility.

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." 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.

The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction?

"The kidneys store and release antidiuretic hormone to increase water retention." The pituitary glands store and release antidiuretic hormone rather than the kidneys. The other statements are correct regarding fluid and electrolyte balance.

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 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 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 Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?

Not wearing gloves when performing the intervention The changing of a 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 into contact with blood. The intervention does not require sterile precautions. The manner in which the nurse is applying stabilizing pressure to the catheter and pulling the adhered dressing toward the insertion site demonstrates appropriate technique.

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative 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. Rh-negative persons should never receive Rh-positive blood.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

arterial blood gas 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 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 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.

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

Electrolytes The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.

A client with stage III breast cancer has been prescribed 10 weeks of chemotherapy. Which intravenous (IV) access does the nurse anticipate will be needed?

Groshong catheter tunneled into the subclavian vein A Groshong catheter is a tunneled catheter that is frequently used for extended therapy. The tunneling helps to secure the catheter, as well as reduce the potential for infection. The other catheter choices are not appropriate at this time.

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 Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include 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.

The nurse is preparing to insert an intravenous catheter into an adult client. Place the following steps in the correct order. Use all options.

- Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the site. - Cleanse the site with chlorhexidine. - Place nondominant hand 1 to 2 in (2.5 to 5 cm) below the site and pull the skin taut. - Insert the needle gently. - Release the tourniquet. - Stabilize the catheter or needle Interrupting the blood flow to the heart by applying a tourniquet causes the vein to distend. Distended veins are easy to see, palpate, and enter. Cleansing is necessary because organisms on the skin can be introduced into the tissues or the bloodstream with the needle. Chlorhexidine is the preferred antiseptic solution. Pressure on the vein and surrounding tissues using the nondominant hand helps prevent vein movement as the needle or catheter is being inserted. Inserting the needle or catheter gently minimizes trauma and deters passage of the needle through the vein. The tourniquet should be released after the needle is inserted, to restore normal blood flow, as it is no longer needed. Continue to stabilize the catheter or needle while flushing it with saline, to prevent trauma.

A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply.

- clients with inflammatory bowel disease - clients with major trauma or burns - clients with liver and renal failure The nurse knows that clients with major trauma or burns, clients with liver and renal failure, and clients with inflammatory bowel disease are likely candidates for TPN. Clients who have not eaten for a day or clients recovering from cataract surgery are not likely candidates for TPN. Clients who have not eaten for 5 days and are not likely to eat during the next week are considered for TPN.

A physician 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 The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

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 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 a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor. Aspiration is never performed from a peripheral IV. Flushing or slowing the infusion will not alleviate this problem.

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 Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

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?

O negative 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.

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 The tubing is contaminated and, if the nurse continues to use the current tubing, the bag's contents will become contaminated during infusion. This action will result in harming the client and can increase the risk of an systemic infection, resulting form poor medical and surgical aseptic techniques.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate?

Remove the IV catheter and reinsert another in a different location. An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?

The client has anti-A antibodies. Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction. Clients with type O blood are universal donors.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

Total parenteral nutrition Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.

What is the initial purpose of the action in which the nurse is engaging, during the preparation for the administration of a prescribed IV solution?

allowing for effective access to the solution Inserting the spike punctures the seal in the IV container and allows access to the contents. Inverting the container allows easy access to the entry site. Touching the opened entry site on the IV container and/or the spike on the administration set results in contamination and the container/administration set would have to be discarded. The action demonstrated is not associated with the need for additional staff.

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?

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. 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.

When considering client safety, what is the primary purpose of the action demonstrated by the nurse involved in preparing for the administration of a prescribed IV solution?

preventing embolus The nurse is engaged in a technique that removes air from the tubing. If not removed from the tubing, large amounts of air can act as an embolus. While the process demonstrated does allow for the other actions, they are not associated with the primary purpose: removing air from the tubing.