Chapter 40: Fluid, Electrolyte, and Acid-Base Balance

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 teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

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

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply.

1. Ask provider to order a low-salt diet. 2. Administer furosemide as ordered. 3. Reduce infusing fluid volume as ordered. 4. Treat the underlying condition that contributes to increased fluid volume.

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply.

1. The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. 2. A symptom of fluid overload is distended neck veins. 3. Fluid overload is more likely in very young children. 4. The infusion rate must be carefully monitored during the administration of blood.

A nurse is preparing the site for insertion of a peripheral venous catheter using chlorhexidine. Which actions would be appropriate for the nurse to do? Select all that apply.

1. rub in a side to side motion 2. use a back and forth motion

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr

100 gtt/min

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

A nurse is calculating the output of a client with renal failure and takes into account all modes of fluid loss. When addressing the client's insensible fluid loss via respiration, which amount would the nurse anticipate as the usual average?

300 mL/day

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 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 Jell-O 250 mL of IV normal saline 1 cup of apple juice

610

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

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 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.

A nurse is inspecting the IV site of a client and notices that the site is swollen, red, warm to the touch and painful. Which action by the nurse is appropriate?

Discontinue the IV and relocate it to another spot.

A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status?

HCO3: 25 mEq/L (25 mmol/L)

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?

Infants

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

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

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.

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

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?

Potassium

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

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.

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 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.

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 statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

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

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 hormone regulates the extracellular concentration of potassium within the human body?

aldosterone

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

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

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

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 likely to find?

hypokalemia

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance?

hypokalemia

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 nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

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

total parenteral nutrition.