EAQ Chapter 29

Which percentage of sodium chloride is considered half-normal?

0.45% sodium chloride - A percentage of 0.45% sodium chloride in the solution is considered half-normal. A percentage of 3% sodium chloride is considered hypertonic saline. A percentage of 0.9% sodium chloride is considered normal. A percentage of 0.25% sodium chloride is considered quarter-normal.

Which concentration of saline may cause hemolysis of red blood cells?

0.25% of sodium chloride - A 0.25% sodium chloride solution is hypotonic and may cause hemolysis of red blood cells. A 5% sodium chloride solution is hypertonic and is contraindicated in patients with hypernatremia or hyperchloremia. A 0.9% sodium chloride solution is considered normal saline. 0.45% sodium chloride solution is also hypotonic but does not cause hemolysis of red blood cells.

A patient requires treatment with a hypotonic intravenous fluid. Which intravenous fluid will be ordered by the health care provider?

0.25% NaCl

Which solution may have other electrolytes added without causing the fluid to be hypertonic?

0.25% NaCl - 0.25% sodium chloride is hypotonic. Rapid administration of hypertonic saline that is 3 or 6% NaCl is avoided to prevent osmotic demyelination syndrome. A solution of 0.9% NaCl is already isotonic; adding electrolytes will cause it to be hypertonic.

A primary health care provider orders potassium supplements for a patient who is lethargic and dehydrated. After assessing the laboratory reports, the nurse finds the patient's potassium levels are 4 mEq/L. Which adverse effect would the nurse monitor for in this patient?

Complaints of chest discomfort - Normal potassium levels range from 3.5 to 5.0 mEq/L. Therefore a potassium level of 4 mEq/L indicates normal potassium concentration. When administered extra potassium supplements, the patient may develop symptoms of hyperkalemia; therefore the nurse would monitor the patient for chest discomfort caused by irregular cardiac activity due to hyperkalemia. Hypokalemia may cause nausea, but hyperkalemia does not manifest as nausea. A decrease in hemoglobin causes anemia and is evidenced by hemoglobin levels. A decrease in WBC is observed with infections but is not caused by administering potassium.

A patient has been ordered to receive a unit of packed red blood cells. Which action will the nurse perform first?

Confirm the identity of the patient. - Although all of the actions listed are important, the highest-priority action is confirmation of the identity of the patient. Failure to do this is a major safety violation. Because blood types can vary individually, patient identification is the highest physiologic safety priority. A large bore IV is needed versus small bore for blood administration. If the patient is not correctly identified and blood type verified first, there is no need to obtain the blood from the blood bank. The consent is important for legal purposes, but physiologic safety is the priority.

A patient is hospitalized due to euvolemic hyponatremia. Which drug is useful for treating the patient?

Conivaptan - Conivaptan is a nonpeptide dual arginine vasopressin (AVP) V1A and V2 receptor antagonist that is used to treat euvolemic hyponatremia. Hetastarch, Dextran 70, and acetazolamide are not indicated for the treatment of euvolemic hyponatremia. Hetastarch and Dextran 70 are used in colloid replacement therapy. Acetazolamide is a diuretic that is used to correct metabolic acid-base imbalance.

A patient is prescribed oral sodium polystyrene sulfonate. On assessing the patient's medical history, the nurse finds that the patient has gastric ulcers. Which information will the nurse provide the patient in order to prevent adverse effects of the therapy?

Contact the primary health care provider. - The patient is advised to contact the primary health care provider because oral sodium polystyrene sulfonate may cause gastrointestinal irritation. The patient has pre-existing gastric ulcers, and the drug can increase their severity. It is evident that the patient is hyperkalemic. Hence it is not advisable to eat foods rich in potassium. The hyperkalemia may worsen if the medication is discontinued. Taking the medication with food does not reduce the gastrointestinal irritation.

Which intravenous fluid is appropriate for a patient who has lost 30% of his or her blood slowly as a result of internal hemorrhage?

Dextran 70 - When there is a slow blood loss of 20% to 50%, nonprotein plasma expanders such as dextran 70 are administered. Whole blood is administered in extreme cases when there is a blood loss of over 50%. A solution of 3% saline is administered when there is a slow blood loss of 20% or less. PRBCs are used in patients with a blood loss of over 50%, in patients with anemia, or in patients with substantial hemoglobin deficit.

The nurse is caring for a patient with clotting factor deficiency. Which product is necessary for this patient?

Fresh frozen plasma (FFP) - FFP is used to increase the clotting factor in patients who show demonstrated deficiency in clotting factor. Hetastarch is used as a nonprotein plasma expander to increase the blood volume in patients with decreased blood levels. PPF is used to manage acute bleeding. PRBCs are used to increase the oxygen-carrying capacity in patients with anemia, in patients with hemoglobin deficit, and in patients with blood loss up to 25%

A patient reports severe thirst and fever. The nurse finds that the patient's blood pressure is 140/95 mm Hg. Which assessment will the nurse perform prior to administering 5% dextrose intravenously?

Intake and output - Severe thirst, high body temperature, and high blood pressure are the symptoms of hypernatremia. The treatment includes dietary restrictions, the use of diuretics, or intravenous administration of dextrose. But before prescribing 5% dextrose, the nurse would review the patient's intake and output. A decreased urine output is observed in patients with hypernatremia. Abdominal pain is associated with hyponatremia. Chest pain and shortness of breath can occur due to hypervolemia. Acid-base imbalance is observed in patients when crystalloids or colloids are administered.

A patient with diarrhea has reduced urine output. Which treatment will the nurse expect the health care provider to prescribe?

Lactated Ringer's solution - Reduced urine output is called oliguria. It is a symptom associated with diarrhea. Crystalloids can be used to manage specific fluid and electrolyte balance and to increase urinary output. Therefore the nurse would expect the primary health care provider to prescribe lactated Ringer's solution, which is a crystalloid. Dextran, acetazolamide, and sodium bicarbonate are not crystalloids and do not increase urinary output. Dextran is a solution of glucose that is used to maintain colloid oncotic pressure. Acetazolamide and sodium bicarbonate are the diuretics that are used to maintain acid-base balance in the body.

Which blood product is administered to anemic patients?

Packed red blood cells - Packed red blood cells are useful in anemic patients to increase oxygen-carrying capacity. Cryoprecipitate is useful for arresting acute bleeding and for facilitating quick clotting. Fresh frozen plasma is useful for patients with low levels of clotting factors. It doesn't increase the oxygen-carrying capacity of the blood. Plasma protein fraction provides clotting factors and is used in cases of acute bleeding to arrest the bleeding. It doesn't help increase oxygen-carrying capacity.

Which assessment finding in an adult patient requires immediate nursing action?

Urinary output of 250 mL in 24 hours - The patient requires immediate nursing assistance because the urinary output should be at least 30 mL/hr or 400 mL/24 hours. The patient's average urinary output at the moment is 10 mL per hour. Taking the PaO2 level is to check the arterial blood gas. Serum sodium and serum potassium are assessed for judging kidney-related diseases, and both levels are within normal range. The PaO2 level is also within normal range.

The nurse is assessing a patient who has symptoms of anorexia, lethargy, and confusion and finds the patient's potassium level to be 3 mEq/L. Which question will the nurse ask the patient before initiating the treatment?

"Do you have a history of ulcers?" - Hypokalemia is caused by the loss of potassium and becomes evident by symptoms such as anorexia, lethargy, and confusion. The nurse would find out about a history of ulcer or gastrointestinal bleeding in the patient before initiating oral potassium supplements because this drug may worsen abdominal ulcers. Jaundice is caused by bile duct obstruction, which is unrelated to potassium intake. Brain injury or trauma is also irrelevant when prescribing potassium supplements. Morning sickness is a feeling of nausea soon after waking up in the morning. Potassium intake is unrelated to morning sickness.

Which level represents normal sodium concentration outside the cells?

139 mEq/L - The normal sodium concentration of the extracellular fluid is 135 to 145 mEq/L. Therefore a sodium level of 139 mEq/L is normal. A sodium concentration of 129 mEq/L is considered low. Patients with 149 mEq/L have a higher than normal sodium concentration. A sodium concentration of 159 mEq/L is also considered hypernatremia, or a high sodium concentration.

A patient who has just undergone surgery exhibits tachycardia and a hemoglobin level of 7 g/100 mL. Which fluid therapy will the nurse expect to administer?

250 mL of packed red blood -The nurse would administer the red blood cells (RBCs) to increase the patient's oxygen-carrying capacity. The patient has anemia, so this therapy should help alleviate tachycardia because, in this case, tachycardia is a result of sympathetic nervous system (SNS) activation in response to hypoxemia. As the tissues receive more oxygenated blood from the infusion of additional hemoglobin, the SNS stimulation should subside and improved tissue oxygenation should help improve healing. The patient needs hemoglobin, so albumin and plasma are improper therapy because they do not provide hemoglobin. Whole blood can help replenish hemoglobin, but because whole blood contains more fluid than RBCs, it increases the risk of fluid volume overload and is not indicated

How much volume of 0.9% sodium chloride is required to raise the plasma volume by 1 L?

5 L to 6 L - To raise the plasma volume by 1 L, 5 L to 6 L of 0.9% sodium chloride are required. One liter of 5% colloid solution is required to raise the plasma volume by 1 L. To raise the plasma volume by 1 L, 0.5 L of 25% colloid solution is required. To raise the volume of the plasma by 1 L, 1.5 L to 2 L of 3% saline solution must be used.

The nurse is assessing a patient who has been diagnosed with jaundice. The patient has a total protein level of 4.5 g/dL. Which treatment will the nurse expect the primary health care provider to prescribe?

5% albumin - On assessment, the nurse finds that the patient has hypoproteinemia along with jaundice. Therefore the treatment should include a colloid that restores the protein level and also does not affect the patient's liver. Albumin is metabolized by the reticuloendothelial system and excreted by the liver. Therefore administration of 5% albumin would be the most suitable treatment. Dextran 70 is also a colloid, but it is metabolized in the liver, so it is not as effective as 5% albumin. Conivaptan is a vaptan used to treat hyponatremia but not hypoproteinemia. Lactated Ringers solution is a crystalloid solution and is not used for colloidal replacement therapy.

A patient has experienced a slow blood loss of about 20%. Which solution is administered to treat the patient?

5% dextrose in water - Administration of crystalloids is suggested to manage a slow blood loss of about 20%. Therefore 5% dextrose in water should be administered to the patient because it is a crystalloid solution. Hetastarch, Dextran 70, and FFP are not used to treat slow blood loss of 20%. Hetastarch and Dextran 70 are nonprotein plasma expanders, which are administered in cases of slow bleeding causing a loss of 20% to 50% of blood volume. FFP is used to manage bleeding resulting in 20% rapid loss or a slow loss of over 50% of the total blood volume.

A patient is prescribed a sodium polystyrene sulfonate enema. The nurse is reviewing the patient's laboratory reports. Which potassium level does the nurse expect?

5.9 mEq/L - Sodium polystyrene sulfonate is given to patients with hyperkalemia. The normal range of serum potassium level is 3.5 to 5 mEq/L; therefore the nurse would find the serum potassium level of the patient to be 5.9 mEq/L. A serum potassium level of 3.5 mEq/L is considered in the normal range, so the enema would not be required. A serum potassium level of 4.2 mEq/L is considered a normal level of potassium in the blood. A serum potassium level of 2.3 mEq/L is considered a low potassium level. If sodium polystyrene sulfonate were administered to a patient with hypokalemia, the potassium level would decrease further.

Which aspect of a patient's history is a contraindication for administering sodium polystyrene sulfonate?

Addison's disease - Sodium polystyrene sulfonate is a potassium exchange resin that is used in the treatment of hyperkalemia. Potassium replacement products are contraindicated in patients with Addison's disease. Phenytoin interacts with dextrose and results in precipitation. Hypernatremia is not related to the administration of sodium polystyrene sulfonate. Sodium replacement products are contraindicated in patients with hypernatremia. Phenytoin, and quinupristin and dalfopristin, do not interact with potassium elimination products. Quinupristin and dalfopristin is an antibiotic that interacts with sodium but not potassium.

Which nursing intervention is appropriate when administering intravenous potassium replacement to a patient?

Administer the medication in a diluted form. - Intravenous dosage forms of potassium must always be given in a diluted form. There is no use or place for undiluted potassium because undiluted potassium is associated with cardiac arrest. Potassium should not be administered as a bolus or pushed. Heat will not aid the infusion. Unless the patient is prone to constant hypokalemia, teaching the signs and symptoms is not a priority when administering the medication.

Which protein is responsible for 70% of the colloidal osmotic pressure?

Albumin - Albumin is responsible for 70% of the colloidal osmotic pressure. Globulin is a plasma protein, which makes a lesser contribution to the colloidal osmotic pressure. Fibrinogen is not the chief contributing protein for the colloidal osmotic pressure because it causes a much lower amount of pressure on the blood vessel wall. Fibronectin is an extracellular matrix protein that is not responsible for causing colloidal osmotic pressure.

The nurse is administering hypertonic saline solution to treat a patient with severe hyponatremia. Which nursing action is the priority?

Assess level of consciousness - The nurse would be alert to signs of hypernatremia when administering hypertonic saline solutions. Flushed skin, increased thirst, elevated temperature, and decreased urinary output are signs and symptoms of hypernatremia. However, these signs are not as high a priority as decreased level of consciousness and confusion, which are signs of severe hypernatremia.

Which is the appropriate nursing intervention by the nurse for a patient with a potassium level of 3.2 mEq/L?

Attach leads for cardiac monitoring. - The patient is at high risk for cardiac dysrhythmias caused by a low potassium level. Oxygen and intravenous fluids are not a priority; sodium polystyrene sulfonate is used for hyperkalemia, not hypokalemia.

The nurse is caring for a patient who has lost 20% of blood rapidly. Which is the fluid of choice to control the blood loss?

Cryoprecipitate and plasma protein fraction (PPF) - When there is a 20% rapid blood loss, cryoprecipitate and PPF are given. If there is 20% slow blood loss, crystalloids are administered. Dextran 40 and other nonprotein plasma expanders are given when there is a slow blood loss of 20% to 50%. Normal saline is a crystalloid and is administered when there is a slow blood loss of 20%. FFP is given when there is a deficiency of clotting factor levels.

Which is the fluid of choice in a patient who has lost 15% of blood volume slowly?

Crystalloids - When a patient has lost about 15% of the blood slowly, crystalloids are the fluid of choice. Dextran is a nonprotein plasma expander and is given to patients who have lost about 20% to 50% of blood slowly. Whole blood is given to patients who have lost over 50% of blood slowly or 20% of blood rapidly. PPF is given to control acute bleeding in patients.

A patient receiving a unit of red blood cells suddenly develops shortness of breath, chills, and fever. Which intervention by the nurse is correct?

Discontinue the infusion and notify the Rapid Response Team. - These are signs and symptoms of a blood transfusion reaction that could escalate to anaphylaxis; therefore the blood transfusion should be stopped immediately (not continued or slowed), and emergency action should be taken. This is not an expected reaction. The nursing intervention should be immediate, and the infusion should be stopped completely. After the infusion is stopped, the nurse would notify the health care provider.

For which symptoms does the nurse assess in a patient with hypernatremia? Select all that apply.

Edema, hypertension and reddish, flushed skin. - Hypernatremia is the condition of increased sodium, above 145 mEq/L. The nurse has to assess for symptoms like edema, hypertension, and reddish, flushed skin. Paralytic ileus and cardiac dysrhythmias are not symptoms of hypernatremia. They are symptoms associated with late hypokalemia.

The nurse is administering whole blood to a patient who experienced severe blood loss and who also has an underlying coagulation disorder. Which formulation will the nurse expect to administer to this patient?

Fresh frozen plasma - Fresh frozen plasma is not used often, except in patients who have severe blood loss or underlying coagulation disorders. Heparin is an anticoagulant that could worsen this patient's condition of severe blood loss. Blood products are given with lactated Ringer's solution, but this is not effective in controlling bleeding. Hetastarch is given when the patient shows a slow loss of blood. It is not effective in controlling the bleeding.

Which laboratory report will the nurse review before administering albumin to a patient?

Hemoglobin - Albumin is contraindicated in patients with severe anemia, so the nurse would check the patient's hemoglobin levels before administering albumin. Variation in the patient's glucose levels or thyroxin levels causes diabetes and thyroid dysfunction, respectively, and these are not contraindications for administering albumin. Vitamin K levels play an important role in the clotting mechanism, but do not affect the administration of albumin.

Sodium polystyrene sulfonate is used to treat which condition?

Hyperkalemia

A patient is experiencing nausea, cardiac dysrhythmias, and shortness of breath. Which electrolyte alteration does the nurse suspect in the patient?

Hypokalemia - The early symptoms of hypokalemia include anorexia, hypotension, lethargy, mental confusion, nausea, and muscle weakness. Late symptoms include neuropathies, paralytic ileus, and cardiac dysrhythmias, in which case the patient may feel palpitations or shortness of breath. Hyponatremia is a condition resulting from sodium loss. It is indicated by lethargy, hypotension, stomach cramps, vomiting, diarrhea, and seizures. Hypercalcemia is indicated by early signs like constipation, headache, increased thirst, dry mouth, and a metallic taste in the mouth. Acute dehydration is indicated by a decrease in urinary output

An older adult with heart failure is admitted to the hospital. The patient appears lethargic and is unable to recognize family members. The patient has a serum sodium level of 110 mEq/L and a serum potassium level of 3 mEq/L. The nurse will tell the patient's family members that the patient's condition is caused by which of the following?

Low potassium levels -Lethargy and mental confusion are symptoms of early hypokalemia. Because the patient's potassium level is 3 mEq/L, the result is lethargy and mental confusion, making the patient unable to recognize family members. Irregular heart rate is not associated with weakness and confusion. It may result in hypotension or hypertension. Low sodium levels are also associated with lethargy, but mental confusion would not be present. Not all older adult patients have mental confusion. Therefore the mental confusion shown by the patient is not necessarily because of age.

Which food will the nurse recommend for a patient who has hypokalemia?

Mashed potatoes - Hypokalemia indicates a low potassium level. Mashed potatoes will help resolve hypokalemia in the patient. Mashed potatoes are higher in potassium than the amount of broccoli that would be present in cream of broccoli soup. Lean turkey and beef bouillon, protein-rich foods, are recommended for patients with a protein deficiency.

A patient is prescribed an isotonic intravenous fluid. Which intravenous fluid is likely to be ordered by the health care provider?

Normal Saline

The nurse is preparing to administer a transfusion of a blood product. What is the appropriate intravenous fluid to hang as a maintenance infusion?

Normal saline - Of the intravenous solutions listed, the only one that is compatible with blood products is saline.

A patient who was injured in a motor vehicle accident has hypovolemic shock due to excess blood loss. The laboratory reports show that the patient has anemia. Which treatment will the nurse expect the provider to order?

Packed red blood cells - The patient has hypovolemic shock due to excess blood loss and is anemic. Therefore administration of red blood cells would help to restore the blood volume as well as increase oxygen-carrying capacity. Albumin is also contraindicated in patients with hypovolemic shock because it increases the blood volume but cannot restore oxygen-carrying capacity. Normal saline is contraindicated in patients with hypovolemic shock because it is not effective in restoring oxygen-carrying capacity. A plasma protein fraction is indicated for patients with acute loss of blood due to gastric bleeding.

Which fluid is given to increase the oxygen-carrying capacity in patients?

Packed red blood cells (PRBCs) - To increase the oxygen-carrying capacity in patients, PRBCs are given. Albumin is given to increase the blood volume through colloid oncotic pressure. FFP is given to increase the clotting factor levels in patients with a demonstrated deficiency. PPF is given to manage acute bleeding.

Which patient condition is a contraindication for the administration of dextran?

Renal insufficiency - In patients with renal insufficiency, dextran administration is contraindicated because the dextran tends to increase fluid volume, which may not be excreted by the impaired kidneys. Dextran doesn't affect hemoglobin levels; hence, it is not contraindicated in anemic patients. The function of the liver is not affected by dextran administration. The use of dextran does not affect bone function or structure; hence, it is not contraindicated in osteoporosis.

A patient with hypokalemia is ordered to receive an intravenous (IV) dose of potassium chloride (KCl) 15 mEq in 250 mL of 0.9% saline to infuse over 1 hour. What action will the nurse take prior to starting the infusion?

Review the electrocardiogram (ECG) - Potassium infusions are used to treat patients with severe hypokalemia. The most concentrated solutions used are 60 mEq/L, with a rate not more than 40 mEq/hour. Hence cardiac monitoring is indicated when concentrated potassium chloride is administered intravenously. An ice pack is placed over the IV site to relieve the burning after or during the therapy. There is no need to replace the IV cannula unless there are signs of phlebitis or infiltration. The nurse needs to assess the current serum potassium concentration, not the 24-hour intake and output.

Which drug is used to treat hyperkalemia?

Sodium polystyrene sulfonate - Sodium polystyrene sulfonate is also known as potassium exchange resin and is used to treat hyperkalemia. Potassium is contraindicated in patients with hyperkalemia. Conivaptan is a nonpeptide dual arginine vasopressin (AVP) V1A and V2 receptor antagonist. It is administered in patients with low serum sodium levels at normal water volume. Sodium chloride is used as a replacement electrolyte for the treatment or prevention of sodium loss.

The nurse is assessing a patient whose protein level is 4 g/dL. Which symptom may be present in this patient as a result of this protein level?

Swelling in the legs - A protein concentration of 4 g/dL signifies a lowered protein concentration in the body that increases fluid concentrations in the tissue, causing edema. Swelling in the lower extremities or legs indicates an edematous condition. Hepatomegaly, or increased liver size, is seen in hepatic infections, which cause elevation in hepatic enzymes but may not directly affect the protein concentration. Severe diarrhea will reduce the sodium and water concentrations in the body but not the protein concentration. Hypovolemic shock is due to loss of blood and is a fatal condition that is treated by administering blood products.

Which product is preferred in patients with extreme blood loss of over 25%?

Whole blood - Whole blood is more beneficial in patients who undergo extreme blood loss of over 25% because whole blood also contains plasma, which is the chief fluid volume of the blood. FFP is given to patients who show demonstrated deficiency of clotting factor. PPF is used to manage acute bleeding. PRBCs are used to increase the oxygen-carrying capacity in patients.