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

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

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

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 assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

1+

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 assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?

3.5 cm H2O

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

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)

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

Arterial blood gas

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias

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

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

Decreased potassium levels

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.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?

Ensure that the prescribed solution is clear and transparent.

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

Metabolic alkalosis

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 idemonstrating inappropriate technique by implementing which action?

Not wearing gloves when preforming the intervention

A nurse is educating a group of adults on dietary requirements. What food should the nurse recommend as a significant source of phosphorous?

Nuts

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

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.

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.

Which client would be a candidate for total parenteral nutrition?

a client with colitis and bloody diarrhea

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

Which is a common anion?

chloride

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

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

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 age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia.

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.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of:

phlebitis.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes

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

renin.

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 primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.

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. -Deciding the size of the IV catheter. -Administering the IV solution.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

Banana

A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot?

Infant

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

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 nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant?

weight gain of 0.75 kg in a day