Fundamentals of Nursing: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance
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
Major control over the extracellular concentration of potassium within the human body is exerted by insulin and a) Progesterone b) Testosterone c) Albumin d) Aldosterone
Aldosterone Explanation: Two hormones exert major control over the extracellular concentration of potassium: insulin and aldosterone. Aldosterone enhances renal secretion of potassium.
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a) Muscle weakness b) Cardiac irregularities c) Metabolic acidosis d) Increased intracranial pressure (ICP)
Cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias
What is the rate of administration for packed red blood cells? a) 1 unit over 2 to 3 hours, no longer than 4 hours b) IV push over 3 minutes c) As fast as the patient can tolerate d) 200 mL/hr
Correct response: 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. Answer A describes platelets, answer C represents cryoprecipitate, and answer D describes fresh-frozen plasma.
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?
Correct response: 25 Explanation: 150 (mL) x 60 (minutes) / 10 (drop factor) = 25 drops per minute
Which of the following fluids should be administered slowly to prevent circulatory overload? a) 5% NaCl b) 0.9% NaCl c) 0.45% NaCl d) Dextrose 5%
Correct response: 5% NaCl Explanation: When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% (NaCl) and 5% saline (NaCl).
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) 40 gtt/min b) 50 gtt/min c) 30 gtt/min d) 20 gtt/min
Correct response: 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.
The oncoming nurse is assigned to the following patients. Which patient should the nurse assess first? a) A newly admitted 88-year-old with a two-day history of vomiting and loose stools b) A 20-year-old, 2 days post-operative open appendectomy who refuses to ambulate today c) A 47-year-old who had a colon resection yesterday and is complaining of pain d) A 60-year-old who is 3 days post-myocardial infarction and has been stable
Correct response: A newly admitted 88-year-old with a two-day history of vomiting and loose stools Explanation: Young children, elderly people, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI patient presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med)
Which client will have more adipose tissue and less fluid? a) A man b) A child c) A woman d) An infant
Correct response: A woman Explanation: Women have a lower fluid content because they have more adipose tissue then men.
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 peripheral venous catheter inserted to the cephalic vein b) A midline peripheral catheter c) An implanted central venous access device (CVAD) d) A peripheral venous catheter inserted to the antecubital fossa
Correct response: An implanted central venous access device (CVAD) Explanation: Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy.
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 of the following interventions should the nurse perform for this complication? a) Elevate the client's head. b) Position the client on the left side. c) Apply a warm compress. d) Apply antiseptic and a dressing.
Correct response: Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
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 of the following interventions should the nurse perform for this complication? a) Elevate the client's head. b) Apply a warm compress. c) Apply antiseptic and a dressing. d) Position the client on the left side.
Correct response: Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
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) Dairy products b) Apricots c) Processed meat d) Bread products
Correct response: Apricots Explanation: Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.
What is the lab test commonly used in the assessment and treatment of acid-base balance? a) Urinalysis b) Arterial blood gas c) Complete blood count d) Chemistry I
Correct response: Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood focusing on the red and white blood cells. The urinalysis assesses the components of the urine
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?" Which of the following would the nurse include as a suggestion for this client? a) Use regular gum and hard candy. b) Avoid salty or excessively sweet fluids. c) Eat crackers and bread. d) Use an alcohol-based mouthwash to moisten your mouth.
Correct response: 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, also 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.
Potassium is needed for neural, muscle, and a) Auditory function b) Optic function c) Skeletal function d) Cardiac function
Correct response: Cardiac function Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a) Metabolic acidosis b) Increased intracranial pressure (ICP) c) Cardiac irregularities d) Muscle weakness
Correct response: Cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias.
Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client 's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client? a) Water excess b) Impaired skin integrity c) Risk for injury d) ECF deficient fluid volume
Correct response: ECF deficient fluid volume Explanation: The most appropriate nursing diagnosis is ECF deficient fluid volume deficit because the client has the defining characteristics of the diagnosis. Impaired skin integrity is associated with edema and diarrhea. Risk for injury can occur if electrolyte or fluid imbalances cause postural hypotension, loss of consciousness, or impaired cognition. Water excess is characterized by symptoms like weight gain, headache, and delirium.
A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV? a) Use half-instilled IV solutions before infusing a new one. b) Select a primary tubing of about 37 inches (94 cm) long. c) Avoid replacing IV solution every 24 hours. d) Ensure that the prescribed solution is clear and transparent.
Correct response: Ensure that the prescribed solution is clear and transparent. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.
Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? a) Fluid volume deficit related to congestive heart failure, as evidenced by shortness of breath b) Congestive heart failure related to edema c) Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea d) Fluid volume excess related to loss of sodium and potassium
Correct response: Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea. Explanation: Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is which of the following? a) Fluid volume deficit b) Myocardial Infarction c) Fluid volume excess d) Atelectasis
Correct response: Fluid volume excess Explanation: A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess.
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 IV complication does this describe? a) Speed shock b) Infiltration c) Thrombus d) Sepsis
Correct response: Infiltration 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 significant decrease in the flow rate. The signs of sepsis include red and tender insertion site, fever, malaise, and other vital sign changes. The symptoms of thrombus are local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.
A severely malnourished client has been admitted to a health care facility. The nurse is preparing to administer total parenteral nutrition (TPN) to the client. How should the nurse administer the TPN solution? a) It is administered in a peripheral vein with its tip terminating in the jugular vein. b) It is administered in a vein distant from the heart through peripheral veins. c) It is administered in a peripheral vein with its tip terminating in the superior vena cava. d) It is administered in a peripheral vein in a lower limb.
Correct response: It is administered in a peripheral vein with its tip terminating in the superior vena cava. Explanation: TPN solution should be administered through a catheter inserted into the subclavian or jugular vein; the tip terminates in the superior vena cava. Sometimes a peripherally inserted central catheter is used; this long catheter is inserted in a peripheral arm vein but its tip terminates in the superior vena cava as well. Total parenteral nutrition is a hypertonic solution of nutrients designed to meet almost all caloric and nutritional needs. It is preferred for clients who are severely malnourished or may not be able to consume food or liquids for a long period. A TPN solution is not infused in a peripheral vein with its tip terminating in the jugular vein.
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider? a) It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. b) As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 10 mL of fluid remains in the original container. c) The nurse should use new tubing when attaching additional IV solutions. d) Generally, the nurse should change the administration sets of simple IV solutions every 24 hours.
Correct response: It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. Explanation: The nurse's ongoing verification of the IV solution and the infusion rate with the physician's order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Every 72 hours is recommended for changing the administration sets of simple IV solutions
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?
Correct response: It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. Explanation: The nurse's ongoing verification of the IV solution and the infusion rate with the physician's order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Every 72 hours is recommended for changing the administration sets of simple IV solutions.
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation? a) Check all clamps on the tubing and check tubing for any kinking. b) Notify the primary care provider immediately because these are signs of speed shock. c) Notify the primary care provider immediately for possible fluid overload. d) No intervention is necessary as this is a normal finding with IV infusion.
Correct response: 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. The client may be exhibiting signs of fluid overload. Be prepared to tell the health care provider what the past intake and output totals were, as well as the vital signs and pulse oximetry findings of the client.
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 indicative of what? a) A systemic blood infection b) Phlebitis c) Rapid fluid administration d) An infiltration
Correct response: Phlebitis Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, 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.
A decrease in arterial blood pressure will result in the release of a) Thrombus b) Insulin c) Renin d) Protein
Correct response: Renin Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release
A woman age 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 what? a) An access route to replace fluids in combination with blood products b) Replacement of fluids for those lost from vomiting and diarrhea c) Intravenous fluids to be administered on an outpatient basis d) An access route to administer medications intravenously
Correct response: 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 for the presence of edema in a client who is confined to bed after fracturing her femur. The nurse would pay particular attention to which area? a) Sacral area b) Hands c) Legs d) Abdomen
Correct response: Sacral area Explanation: The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. When the client is sitting or standing, the edema can be assessed in the legs. The edema cannot be assessed in the hands and abdomen, as these are not dependent areas.
The passageways of the kidney permit the urine to flow to the bladder and a) Surround the Bowman's capsule, which is where the formation of urine begins b) Selectively reabsorb or secrete substance to maintain fluids and electrolytes c) Control external sphincter of the urethra and permit the control of urination d) Act as a valve that covers the junction between the ureters and the bladder
Correct response: Selectively reabsorb or secrete substance to maintain fluids and electrolytes Explanation: The capillaries of the glomerulus are porous, and, as the blood passes through the glomerular capillaries, some constituents of the blood are filtered out
Which of the following statements accurately describes the role of antidiuretic hormone in the regulation of body fluids? When antidiuretic hormone is present, a) The frequency of voiding increases b) Urine output is increased and diluted c) The renal tubules become permeable to water d) The renal tubules become impermeable to water
Correct response: The renal tubules become permeable to water Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water.
A client who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor? a) Increased blood volume and intracellular dehydration b) Decreased blood volume and intracellular dehydration c) Decreased blood volume and extracellular overhydration d) Increased 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.
Mr Powell, a dehydrated 35 year old has intravenous fluid running at 250 cc/h. for rapid rehydration. He is complaining of burning at the site. You see no redness, swelling, heat, or coolness upon inspection. You suspect a) Infiltration b) That the fluid is infusing too rapidly for comfort c) That something is wrong with the IV fluid d) Phlebitis
Explanation: The fluid is infusing too rapidly. You should slow the infusion to 200 cc/h.
When 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 what? a) Hypothyroidism b) Hypoglycemia c) Hypokalemia d) Hypocalcemia
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.
The primary extracellular electrolytes are: a) Sodium, chloride, and bicarbonate b) Phosphorous, calcium, and phosphate c) Magnesium, sulfate, and carbon d) Potassium, phosphate, and sulfate
Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.
Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? a) Fluid volume deficit related to congestive heart failure, as evidenced by shortness of breath b) Fluid volume excess related to loss of sodium and potassium c) Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea d) Congestive heart failure related to edema
Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea Explanation: Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid.
A 50-year-old client with hypertension is being treated with a diuretic. The client complains of muscle weakness and falls easily. The nurse should assess which electrolyte? a) Potassium b) Chloride c) Phosphorous d) Sodium
Potassium Explanation: 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. (less) Reference: Taylor et al. Fundamentals of Nursing, 7th ed. Philadelphia:
A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation? a) Set up a sonogram for the client to determine the end point of the line. b) Reapply the dressing and notify the physician for further instructions. c) Sedate the client, remove the PICC line, and then notify the physician. d) Swab the line with sterile saline and gently reinsert the line.
Reapply the dressing and notify the physician for further instructions. Explanation: When a PICC line is not all the way out, the nurse should notify the physician. The physician will most likely order a chest x-ray to determine where the end of the PICC line is. A dressing should be reapplied before the chest x-ray, to prevent further dislodgement.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as a) Cellular hydration b) Total parenteral nutrition c) Blood transfusion therapy d) Volume expander
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.
