Fluids and Electrolytes Chapter 40
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? 1,000 500 3,750 3,000
3,000 Explanation: 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.
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? 100 mL/hr 83 mL/hr 103 gtts/hr 13 mL/hr
83 mL/hr Explanation: When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (8). This is 83 mL/hr. Other options are incorrect.
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)? Initiating a client's transfusion of packed red blood cells Deaccessing a client's implanted port Removing a client's PICC in anticipation of the client's discharge Changing the dressing on a client's peripheral IV site
Changing the dressing on a client's peripheral IV site Explanation: 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 nurse is changing a client's peripherally-inserted central catheter (PICC) dressing. What is the nurse's best action?
PICC's should be covered with a transparent dressing that allows for easy inspection. Opaque gauze or mepore dressings are not transparent and cannot be used.
Potassium is needed for neural, muscle, and: auditory function. cardiac function. optic function. skeletal function.
cardiac function. Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.
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. hypothyroidism. hypoglycemia. hypocalcemia.
hypokalemia. Explanation: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? Sealed IV dressing Transparent semipermeable membrane dressing Gauze dressing Occlusive dressing
Gauze
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? "We now have artificial blood products, so giving your own blood is not necessary." "Let me refer you to the blood bank so they can provide you with information." "This surgery has a very low chance of hemorrhage, so you will not need blood." "Unfortunately, your own blood cannot be reinfused during surgery."
Let me refer you to the blood bank so they can provide you with information." Explanation: 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.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Have a loved one tell the client to drink more. Offer small amounts of preferred beverage frequently. Ask the client every hour to drink more fluid. Leave water on the bedside table.
Offer small amounts of preferred beverage frequently. Explanation: Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.
A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order? White blood cells Platelets Packed cells Whole blood D5W 1000 mL
Packed cells Explanation: Packed cells are especially useful in the treatment of chronic anemia.
A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. Which nursing interventions would the nurse perform? Select all that apply. Monitor vital signs and pulse oximetry. Apply warm compresses as ordered by the primary care provider. Restart the IV at another site. Rub or massage the affected area. Stop the infusion immediately. Place client on left side in Trendelenburg position.
Stop the infusion immediately. Apply warm compresses as ordered by the primary care provider. Restart the IV at another site. Explanation: If a thrombus (blood clot) forms at the site of the IV, the infusion should be stopped immediately in order to prevent the thrombus from becoming dislodged. Application of a warm, moist compress will help to dissolve the thrombus, and the IV should be restarted in another site. The area should not be rubbed or massaged because this could cause the thrombus to become an embolus. Monitoring vital signs and pulse oximetry would not be necessary, nor would placing the client in the Trendelenburg position.
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? "I received a blood transfusion in the United Kingdom." "My blood type is B positive." "I have never given blood before." "My spouse would also like to donate blood."
"I received a blood transfusion in the United Kingdom." Explanation: Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.
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? 200 mL/hr 75 mL/hr for the first 15 minutes, then 200 mL/hr 1 unit over 2 to 3 hours, no longer than 4 hours As fast as the client can tolerate
1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.
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 Explanation: The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? 40 gtt/min 30 gtt/min 20 gtt/min 50 gtt/min
50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? Constipation related to immobility Risk for Infection related to inadequate personal hygiene Pain related to surgical incision Acute Confusion related to cerebral edema
Acute Confusion related to cerebral edema Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.
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? Dairy products Bread products Apricots Processed meat
Apricots Explanation: Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.
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? Use an alcohol-based mouthwash to moisten your mouth. Avoid salty or excessively sweet fluids. Use regular gum and hard candy. Eat crackers and bread.
Avoid salty or excessively sweet fluids. Explanation: 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 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 Turkey Yogurt Milk
Banana Explanation: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.
A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? Call the primary care provider to see whether anti-inflammatory drugs should be administered. Discontinue the IV and relocate it to another site. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.
Discontinue the IV and relocate it to another site. Explanation: The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.
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. Explanation: 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.
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Fluid in the tissue space between and around cells." "Fluid inside cells." "Watery plasma, or serum, portion of blood." "Fluid outside cells."
Fluid in the tissue space between and around cells." Explanation: 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 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? Change from infusion with an electronic pump to infusion by gravity. Flush the IV with 2 mL of 100 U/mL heparin. Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. Flush the IV with 3 mL of normal saline.
Flush the IV with 3 mL of normal saline. Explanation: 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.
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 Nausea, vomiting, and constipation Diminished cognitive ability and hypertension Muscle weakness, fatigue, and constipation
Muscle weakness, fatigue, and dysrhythmias Explanation: 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.
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? Notify the primary care provider immediately for possible fluid overload. Place the client in the Trendelenburg position to keep the client's airway open. Notify the primary care provider immediately because these are signs of speed shock. Check all clamps on the tubing and check tubing for any kinking.
Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify the primary care provider immediately because the client may be exhibiting signs of fluid overload. The Trendelenburg position is not used to rectify this complication, but to help raise the blood pressure of a client with hypotension.
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 B positive AB negative A positive
O negative Explanation: 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.
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? Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. Decontaminate the visible portion of the catheter, and then gently reinsert. Remove the IV catheter and reinsert another in a different location. Apply a new dressing and observe for signs of infection over the next several hours.
Remove the IV catheter and reinsert another in a different location. Explanation: 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.
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? increased blood volume and intracellular dehydration decreased blood volume and intracellular dehydration increased blood volume and extracellular overhydration decreased blood volume and extracellular overhydration
decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.
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: colloid solution. electrolytes. interstitial fluid. nonelectrolytes.
electrolytes. Explanation: 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.
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. hypokalemia. hyperkalemia. hypernatremia.
hyponatremia. Explanation: 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.
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: rapid fluid administration. an infiltration. a systemic blood infection. phlebitis.
phlebitis. Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.
The primary extracellular electrolytes are: potassium, phosphate, and sulfate. magnesium, sulfate, and carbon. phosphorous, calcium, and phosphate. sodium, chloride, and bicarbonate.
sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client?
Gauze dressing Explanation: A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. Transparent semipermeable membranes are a type of sealed IV dressing. Occlusive dressings would not be appropriate.
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets Explanation: 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 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 occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." Explanation: Infiltration is the escape of IV fluid into the tissue, and phlebitis is the inflammation of a vein. All other options are incorrect.
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 A positive B positive AB negative
O negative Explanation: 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.
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice? regulating the rate of administration ordering type of solution, additive, amount of infusion, and duration preparing solution for administration performing venipuncture
ordering type of solution, additive, amount of infusion, and duration Explanation: The nurse prepares the solution for administration, performs a venipuncture, regulates the rate of administration, monitors the infusion, and discontinues the administration when fluid balance is restored. The health care provider, not the nurse, specifies the type of solution, additional additives, the volume (in mL), and the duration of the infusion.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: cellular hydration. blood transfusion therapy. volume expander. total parenteral nutrition.
total parenteral nutrition. Explanation: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? "My spouse would also like to donate blood." "I have never given blood before." "I received a blood transfusion in the United Kingdom." "My blood type is B positive."
"I received a blood transfusion in the United Kingdom." Explanation: Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? asking the client to pump their fist several times asking if the client is right or left handed placing the tourniquet on the upper arm for 2 minutes palpating the veins on the nondominant hand
placing the tourniquet on the upper arm for 2 minutes Explanation: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.
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: an access route to administer medications intravenously. replacement of fluids for those lost from vomiting and diarrhea. an access route to replace fluids in combination with blood products. intravenous fluids to be administered on an outpatient basis.
replacement of fluids for those lost from vomiting and diarrhea. Explanation: 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.
A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant? bounding pulse weight gain of 0.75 kg in a day slightly distended neck veins increased blood pressure
weight gain of 0.75 kg in a day Explanation: Although increased blood pressure, bounding pulse, and distended neck veins are signs of ECF volume excess, rapid weight gain (more than 0.5 kg per day) is the most significant symptom indicating ECF volume excess. A weight gain of 1 kg reflects retention of 1 L of ECF. Additionally, because the veins are very distensible, large volumes of fluid can be retained without any increase in blood pressure or changes in pulse or neck veins.