Fundamentals II Chpt. 40 Fluid, Electrolyte, and Acid-Base Balance 1-4

Phlebitis

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? Air embolism Phlebitis Sepsis Infiltration

83 mL/hr

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? 103 gtts/hr 100 mL/hr 83 mL/hr 13 mL/hr

O negative

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? B positive O negative A positive AB negative

O negative

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 positive O negative B positive AB negative

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2.

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: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)

Diarrhea

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system? Abdominal distention Vomiting Paralytic ileus Diarrhea

"Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions."

The nurse working at the blood bank is speaking with a potential blood donor client. The client has been living in South America where there was a Zika outbreak. Which statement by the nurse is most appropriate? "While living in South America, you may have been exposed to a lot of different diseases, which makes you ineligible to donate blood." "Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions." "To prevent the spread of microorganisms, anyone who has lived out of the country for over 6 months is unable to donate blood." "As long as you did not receive any blood transfusions while living in South America, you may donate blood."

0.45% NaCl

What commonly used intravenous solution is hypotonic? 0.9% NaCl 10% dextrose in water 0.45% NaCl lactated Ringer's

To assure the IV solution is appropriate for this administration

What is the priority goal for the activity in which the nurse is engaging (scanning an IV bag of solution), related to the administration of a prescribed IV solution? To assure the IV solution is appropriate for this administration To assure effective administration of the prescribed IV solution To provide for effective time management in the administration of the prescribed IV solution To demonstrate effective nursing care in the administration of the prescribed IV solution

aldosterone Aldosterone regulates the extracellular concentration of potassium. It also enhances renal secretion of potassium.

Which hormone regulates the extracellular concentration of potassium within the human body? aldosterone progesterone androgen testosterone

chloride

Which is a common anion? magnesium potassium chloride calcium

Potassium Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. Signs of potassium defecit, or hypokalemia, include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias.

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? Calcium Chloride Phosphorous Potassium

"I've been taking antacids almost every 2 hours over the past several days."

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I've had a fever for the past 3 days that just doesn't seem to go away." "I've had a GI virus for the past 3 days with severe diarrhea." "I've been taking antacids almost every 2 hours over the past several days." "I was breathing so fast because I was so anxious and in so much pain."

hypokalemia.

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: hypocalcemia. hypothyroidism. hypoglycemia. hypokalemia.

blood pressure 100/48 mmHg poor skin turgor heart rate 128/bpm

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply. blood pressure 100/48 mmHg crackles in the lungs distended neck veins poor skin turgor heart rate 128/bpm

1 unit over 2 to 3 hours, no longer than 4 hours

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? 75 mL/hr for the first 15 minutes, then 200 mL/hr 200 mL/hr 1 unit over 2 to 3 hours, no longer than 4 hours As fast as the client can tolerate

Remove the IV.

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? Elevate the arm. Slow the rate of IV fluids. Remove the IV. Apply a warm compress.

hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia.

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? hyperphosphatemia hyperchloremia hypokalemia hypomagnesemia

Metabolic alkalosis Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition.

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 acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic alkalosis

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)? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

Start an IV of normal saline as prescribed.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Encourage fluid intake. Start an IV of normal saline as prescribed. Give the client a glass of orange juice with added sugar. Allow nothing by mouth.

Magnesium Magnesium deficit may lead to muscle weakness, tremors, tetany, seizures, heart block, change in mental status, hyperactive deep tendon reflexes (DTRs), and respiratory paralysis.

A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client? Magnesium Chloride Potassium Phosphorus

respiratory muscle weakness confusion ventricular dysrhythmia

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply. respiratory muscle weakness confusion ventricular dysrhythmia abdominal distention constipation

cardiac irregularities

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? muscle weakness increased intracranial pressure (ICP) cardiac irregularities metabolic acidosis

renin. Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

A decrease in arterial blood pressure will result in the release of: renin. thrombus. insulin. protein.

Avoid salty or excessively sweet fluids.

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. Use regular gum and hard candy. Eat crackers and bread. Use an alcohol-based mouthwash to moisten your mouth.

Discontinue the IV.

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? Attempt to aspirate. Flush with 3-mL normal saline. Discontinue the IV. Slow the rate of infusion by 50%.

Discontinue the IV and relocate it to another site.

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? Discontinue the IV and relocate it to another site. Call the primary care provider to see whether anti-inflammatory drugs should be administered. 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.

Infant

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? Preschool-aged child School-aged child Toddler Infant

Swelling Pallor Coolness

A nurse is inspecting the IV access site of a client receiving intravenous therapy. The nurse suspects that the IV has infiltrated based on which finding at the site? Select all that apply. Swelling Redness Pallor Warmth Coolness

increased hydrostatic pressure The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure.

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? decreased colloid oncotic pressure increased hydrostatic pressure blockage of the lymph nodes increased capillary permeability

decreased urine output orthostatic hypotension slow-filling peripheral veins

A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply. dry mucous membranes poor skin turgor decreased urine output orthostatic hypotension slow-filling peripheral veins

Ensure that the prescribed solution the expected color and consistency.

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 the expected color and consistency. Select a primary tubing of about 37 inches (94 cm) long. Use half-instilled IV solutions before infusing a new one. Avoid replacing IV solutions every 24 hours.

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? hyponatremia hypokalemia hypercalcemia hypermagnesemia

"I should drink 2,500 mL/day of fluid."

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I need to drink no more than 1,000 mL/day" "I should drink 1,500 mL/day of fluid." "I should drink 2,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid."

60 drops/mL

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? 120 drops/mL 30 drops/mL 60 drops/mL 90 drops/mL

50 gtt/min (250 * 20) / 100 = 50

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? 20 gtt/min 30 gtt/min 50 gtt/min 40 gtt/min

Changing the dressing on a client's peripheral IV site

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 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

placing the tourniquet on the upper arm for 2 minutes

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 placing the tourniquet on the upper arm for 2 minutes asking if the client is right or left handed palpating the veins on the nondominant hand

replacement of fluids for those lost from vomiting and diarrhea.

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.

a winged infusion needle.

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: an 18-gauge needle. a winged infusion needle. an intermittent infusion device. a central venous access.

Stop the transfusion immediately.

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? Infuse saline at a rapid rate. Prepare to give an antihistamine. Stop the transfusion immediately. Administer oxygen.

Muscle weakness, fatigue, and dysrhythmias

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? Nausea, vomiting, and constipation Diminished cognitive ability and hypertension Muscle weakness, fatigue, and constipation Muscle weakness, fatigue, and dysrhythmias

Scalp veins should be selected for infants because of their accessibility. Potential sites for neonates and children include: veins of the scalp (neonates under 6 months) because of the accessibility, and dorsal veins of the foot (toddlers). The veins in the leg of an adult should not be used, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation and DVT.

The nurse is determining a site for an IV infusion. What guideline should the nurse consider? Scalp veins should be selected for infants because of their accessibility. Antecubital veins should be used for long-term infusions. Veins in the leg should be used to keep the arms free for the client's use. Veins in surgical areas should be used to increase the potency of medication.

Stop the transfusion and notify the health care provider.

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. Which action should the nurse take? Reassure the client that the feelings are associated with anxiety and will pass. Confirm the shortness of breath by listening to the client's lungs. Stop the transfusion and notify the health care provider. Increase the rate of infusion to restore blood volume more quickly.

The client has anti-A antibodies.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? The client has anti-A antibodies. The client has anti-B antibodies. The client has both anti-A and anti-B antibodies. The client is a universal donor.

ordering type of solution, additive, amount of infusion, and duration

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? preparing solution for administration ordering type of solution, additive, amount of infusion, and duration performing venipuncture regulating the rate of administration

Remove the IV catheter and reinsert another in a different location.

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. Decontaminate the visible portion of the catheter, and then gently reinsert. Apply a new dressing and observe for signs of infection over the next several hours. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.

Metabolic alkalosis

The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis

"The kidneys store and release antidiuretic hormone to increase water retention."

The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction? "The kidneys store and release antidiuretic hormone to increase water retention." "The lungs remove water though exhalation." "The lungs regulate metabolic acid-base disturbances by controlling carbon dioxide." "The heart circulates water and nutrients through the body."

sodium, chloride, and bicarbonate.

The primary extracellular electrolytes are: potassium, phosphate, and sulfate. magnesium, sulfate, and carbon. sodium, chloride, and bicarbonate. phosphorous, calcium, and phosphate.

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

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Watery plasma, or serum, portion of blood." "Fluid in the tissue space between and around cells." "Fluid inside cells." "Fluid outside cells."

phlebitis.

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: an infiltration. a systemic blood infection. phlebitis. rapid fluid administration.

Arterial blood gas

What is the lab test commonly used in the assessment and treatment of acid-base balance? Complete blood count Basic metabolic panel Arterial blood gas Urinalysis

isotonic

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? hypertonic colloid isotonic hypotonic

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

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. Solutes pass through semipermeable membranes to areas of lower concentration. Water shifts from high-solute areas to areas of lower solute concentration. Plasma proteins facilitate the reabsorption of fluids into the capillaries.