Coursepoint Chapter 40: Fluid, Electrolyte, and Acid-Base Balance
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? A. maintenance of cell size B. removal of waste C. maintenance of blood volume D. transportation of nutrients
A.
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: A. hypoglycemia. B. hypocalcemia. C. hypokalemia. D. hypothyroidism.
C.
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? A. B positive B. AB negative C. A positive D. O negative
D.
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? A. 1,000 mL/day B. 1,500 mL/day C. 3,500 mL/day D. 2,500 mL/day
D.
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's: A. low calcium. B. high sodium. C. high magnesium. D. low potassium.
A.
A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply. A. Facial flushing B. Fever C. Urticaria D. Hematuria E. Low back pain
A. B. D. E.
As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action? A. Not preforming the intervention under sterile conditions B. Not wearing gloves when preforming the intervention C. By pulling the dressing toward the insertion site D. By applying stablizing pressure to the catherter
B.
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? A. bacterial reaction: bacteria present in the blood B. hemolytic transfusion reaction: incompatibility of blood product C. febrile reaction: fever develops during infusion D. allergic reaction: allergy to transfused blood
B.
Edema happens when there is which fluid volume imbalance? A. water excess B. extracellular fluid volume excess C. water deficit D. extracellular fluid volume deficit
B.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? A. a 47-year-old who had a colon resection yesterday and is reporting pain B. a newly admitted 88-year-old with a 2-day history of vomiting and loose stools C. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today D. a 60-year-old who is 3 days post-myocardial infarction and has been stable.
B.
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing: A. pulmonary embolism. B. fluid overload. C. allergic reaction. D. anaphylaxis.
B.
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. A. Determining the amount of IV solution. B. Deciding the location of the IV catheter. C. Prescribing the kind of IV solution. D. Administering the IV solution. E. Deciding the size of the IV catheter.
B. D. E.
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? A. Infiltration B. Air embolism C. Phlebitis D.Sepsis
C.
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? A. Chloride B. Sodium C. Phosphorous D. Potassium
D.
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? A. granulocytes B. cryoprecipitate C. albumin D. platelets
D.
The primary extracellular electrolytes are: A. phosphorous, calcium, and phosphate. B. magnesium, sulfate, and carbon. C. potassium, phosphate, and sulfate. D. sodium, chloride, and bicarbonate.
D.
The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?
25 gtts/min 150/60 (10) = 25
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? A. Discontinue the IV. B. Attempt to aspirate. C. Flush with 3-mL normal saline. D. Slow the rate of infusion by 50%.
A.
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? A. Infant B. School-aged child C. Preschool-aged child D. Toddler
A.
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? A. Notify the primary care provider immediately for possible fluid overload. B. Notify the primary care provider immediately because these are signs of speed shock. C. Check all clamps on the tubing and check tubing for any kinking. D. Place the client in the Trendelenburg position to keep the client's airway open.
A.
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? A. "I should drink 2,500 mL/day of fluid." B. "I should drink 1,500 mL/day of fluid." C. "I need to drink no more than 1,000 mL/day" D. "I should drink more than 3,500 mL/day of fluid."
A.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? A. Increased potassium levels B. Decreased potassium levels C. Decreased oxygen levels D. Increased sodium levels
B.
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? A. 120 drops/mL B. 60 drops/mL C. 90 drops/mL D. 30 drops/mL
B.
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? A. Nausea, vomiting, and constipation B. Diminished cognitive ability and hypertension C. Muscle weakness, fatigue, and dysrhythmias D. Muscle weakness, fatigue, and constipation
C.
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? A. "Fluid outside cells." B. "Fluid inside cells." C. "Fluid in the tissue space between and around cells." D. "Watery plasma, or serum, portion of blood."
C.
A decrease in arterial blood pressure will result in the release of: A. insulin. B. protein. C. thrombus. D. renin.
D.
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis
A.
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: A. hyponatremia. B. hypernatremia. C. hyperkalemia. D. hypokalemia.
A.
The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? A. 83 mL/hr B. 100 mL/hr C. 13 mL/hr D. 103 gtts/hr
A.
Which is a common anion? A. chloride B. calcium C. potassium D. magnesium
A.
A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? A. Check the client's vital signs. B. Stop the transfusion and infuse normal saline using a new administration set. C. Notify the health care provider of the client's response. D. Stop the transfusion and infuse normal saline using the blood tubing.
B.
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? A. 30 gtt/min B. 50 gtt/min C. 20 gtt/min D. 40 gtt/min
B.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: A. blood transfusion therapy. B. total parenteral nutrition. C. cellular hydration. D. volume expander.
B.
The nurse is determining a site for an IV infusion. What guideline should the nurse consider? A. Veins in the leg should be used to keep the arms free for the client's use. B. Scalp veins should be selected for infants because of their accessibility. C. Veins in surgical areas should be used to increase the potency of medication. D. Antecubital veins should be used for long-term infusions.
B.
Which explanations from the student about fluid and electrolyte balance demonstrate that learning has taken place regarding the function of water? A. acts as a buffer for electrolytes and nonelectrolytes B. facilitates cellular metabolism and proper cellular chemical functioning C.. provides a medium for transporting substances throughout the body D. provides a medium for transporting wastes to cells and nutrients from cells E. facilitates digestion and promotes elimination F. helps maintain normal body temperature
B. C. F. E.
Which actions would a nurse perform after selecting a site and palpating accessible veins in order to start an IV infusion? Select all that apply. A. Enter the skin gently with the catheter held by the hub in the non-dominant hand, bevel side down, at a 10- to 30-degree angle. B. Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle. C. Clean the entry site with saline, followed by an alcohol swab according to agency policy. D. Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein. E. Place the dominant hand about 4 in (10 cm) below the entry site to hold the skin taut against the vein. F. When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into the vein until the hub is at the venipuncture site.
B. D. F.
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? A. Slow the rate of IV fluids. B. Elevate the arm. C. Remove the IV. D. Apply a warm compress.
C.
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? A. 3,750 B. 500 C. 3,000 D. 1,000
C.
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? A. Bread products B. Processed meat C. Apricots D. Dairy products
C.
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? A. Use regular gum and hard candy. B. Use an alcohol-based mouthwash to moisten your mouth. C. Avoid salty or excessively sweet fluids. D. Eat crackers and bread.
C.
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: 5.75 mg/dL (1.8 mEq/L)Based on these levels, the nurse would identify which imbalance? A. Hyponatremia B. Hypercalcemia C. Hypokalemia D. Hypermagnesemia
C.
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? A. muscle twitching B. nausea and vomiting C. distended neck veins D. fingerprinting over sternum
C.
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? A. Administer oxygen. B. Prepare to give an antihistamine. C. Stop the transfusion immediately. D. Infuse saline at a rapid rate.
C.
The nurse is caring for a client who has a prescription for a peripheral intravenous (IV) infusion of a liter of 0.9 sodium chloride solution over 10 hours by gravity infusion. The drop factor is 60 gtts/mL. After reviewing the image, what is best action by the nurse to provide the appropriate drops per minute of medication? A. Ensure 50 gtt/min is given over 1 minute B. Adjust clamp below drip chamber so 75 gtts is provided in 15 seconds C. Regulate flow to allow 25 gtts every 15 seconds D. Administer 10 gtt/min over 30 seconds
C.
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? A. "This surgery has a very low chance of hemorrhage, so you will not need blood." B. "Unfortunately, your own blood cannot be reinfused during surgery." C. "Let me refer you to the blood bank so they can provide you with information." D. "We now have artificial blood products, so giving your own blood is not necessary."
C.
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? A. Pulmonary embolus B. Fluid volume excess C. Cardiac dysrhythmias D. Tetany
C.
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? A. Apply antiseptic and a dressing. B. Elevate the client's head. C. Apply a warm compress. D. Position the client on the left side.
C.
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? A. A midline peripheral catheter B. A peripheral venous catheter inserted to the antecubital fossa C. A peripheral venous catheter inserted to the cephalic vein D. An implanted central venous access device (CVAD)
D.
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? A. Continue to use the current intravenous tubing B. Tell the client the infusion will be administered later in the shift C. Notify the health care provider to request a new prescription for an intravenous infusion D. Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing
D.
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? A. asking if the client is right or left handed B. asking the client to pump their fist several times C. palpating the veins on the nondominant hand D. placing the tourniquet on the upper arm for 2 minutes
D.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? A. Leave water on the bedside table. B. Have a loved one tell the client to drink more. C. Ask the client every hour to drink more fluid. D. Offer small amounts of preferred beverage frequently.
D.
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? A. Apply a new dressing and observe for signs of infection over the next several hours. B. Decontaminate the visible portion of the catheter, and then gently reinsert. C. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. D. Remove the IV catheter and reinsert another in a different location.
D.
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? A. hypertonic B. hypotonic C. colloid D. isotonic
D.
