NRS 2024 PREPU Ch 41 Fluid, Electrolyte, and Acid-Base Balance

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 Metabolic alkalosis Respiratory alkalosis Respiratory acidosis

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. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high.

The nurse is reviewing the arterial blood gas results of a client on nasogastric suctioning. 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? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Metabolic alkalosis

Metabolic alkalosis -Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. Nasogastric suction frequently causes metabolic alkalosis. Acidosis would be accompanied by a lower pH and there is no evidence of a respiratory etiology.

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? Sepsis Phlebitis Infiltration Air embolism

Phlebitis -Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.

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-B antibodies. The client has both anti-A and anti-B antibodies. The client has anti-A antibodies. The client is a universal donor.

The client has anti-A antibodies. -Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction. Clients with type O blood are universal donors.

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? circulatory overload hypervolemia hypovolemia edema

hypovolemia -The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.

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)

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 other blood gas findings do not correlate with metabolic alkalosis.

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

"Fluid in the tissue space between and around cells." -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 nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I should drink more than 3,500 mL/day of fluid." "I should drink 1,500 mL/day of fluid." "I need to drink no more than 1,000 mL/day" "I should drink 2,500 mL/day of fluid."

"I should drink 2,500 mL/day of fluid." -In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.

A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted? 20- to 25-degree angle 40- to 45-degree angle 30- to 35-degree angle 10- to 15-degree angle

10- to 15-degree angle

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr 60 gtt/min 600 gtt/min 100 gtt/min 160 gtt/min

100 gtt/min -100gtt/min is the correct rate. 1000 mL divided by 10 hours = 100 mL per hour x 60 gtt/minute, divided by 60 minutes/hour.

The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate? 25 gtt/min 20 gtt/min 42 gtt/min 125 gtt/min

42 gtt/min -When infusing by gravity, divide the total volume in mL (1,000 mL) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtt/mL. The correct answer is 42 gtt/min.

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving? A hypotonic solution A hypertonic solution An isotonic solution Packed red blood cells

A hypotonic solution -Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. Hypertonic solutions draw water out of body cells while isotonic solutions have little effect on the distribution of body fluids. Blood transfusions do not cause the entry of water into body cells.

The nurse is caring for a client whose breast cancer necessitated a total mastectomy and lymph node dissection. The nurse will prioritize what assessment related to potential fluid and electrolyte imbalance? Assessment for edema Assessment for signs of hypokalemia Assessment for extracellular fluid deficit Assessment for hypercalcemia

Assessment for edema -Procedures that involve disruption of the lymphatic system create a risk for edema because the system is unable to absorb normal amounts of extracellular fluid. The client is less likely to face disruptions to potassium and calcium levels. ECF excess is more likely than a deficit.

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate? Fully open the roller clamp on the infusion set and infuse the remaining PRBCs as rapidly as possible. Insert a larger gauge IV catheter and transfer the infusion to the new insertion site. Discontinue the infusion and record the volume left in the blood bag.

Discontinue the infusion and record the volume left in the blood bag. -Transfusions must be completed within 4 hours due to the potential for bacterial growth in a blood product at room temperature.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? Select a primary tubing of about 37 inches (94 cm) long. Avoid replacing IV solutions every 24 hours. Use half-instilled IV solutions before infusing a new one. Ensure that the prescribed solution the expected color and consistency.

Ensure that the prescribed solution the expected color and consistency. -Before preparing the solution, the nurse should inspect the container and determine that the solution's color and consistency matches that expected based on the prescription, 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 accounts for about 30% of the total body water? Extracellular fluid Intracellular fluid Transcellular fluid Intravascular fluid

Extracellular fluid

Cells that are surrounded by this type of fluid in the intravascular space will swell and possibly burst. Hypotonic solution Hypertonic solution Isotonic solution Osmolar solution

Hypotonic solution

An adult client has developed gastric esophageal reflux disease and is treating it with frequent doses of antacids. The nurse will assess for what acid-base disorder? Respiratory alkalosis Metabolic acidosis Respiratory acidosis Metabolic alkalosis

Metabolic alkalosis -Ingestion of large amounts of antacids cause metabolic alkalosis due to the increase in stomach pH. This alkalosis is unrelated to respiratory function.

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? AB negative B positive A positive O negative

O negative -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. B positive, A positive, and AB negative are not considered compatible in this scenario.

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

Remove the IV. -The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next? Decrease the rate of the intravenous fluids. Remove the peripheral intravenous catheter. Elevate the swollen extremity on a pillow. Place a warm compress over the swollen site.

Remove the peripheral intravenous catheter. -The assessment findings of a swollen IV site with surrounding tissue swelling and cool to touch indicate infiltration. The correct action for an infiltrated IV is to remove the IV. Decreasing the rate of fluids requires the health care provider's prescription and is not indicated for infiltration. Placing a warm compress is not indicated for infiltration. Elevating the swollen extremity is for peripheral edema, not infiltration.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Elevate the client's head. Restart infusion in another vein and apply a warm compress. Apply antiseptic and a dressing. Position the client on the left side.

Restart infusion in another vein and apply a warm compress. -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.

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

To assure the IV solution is appropriate for this administration -The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is appropriate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.

Lactated Ringer's intravenous solution contains multiple electrolytes in about the same concentrations as found in plasma. TRUE OR FALSE

True

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 extracellular overhydration decreased blood volume and intracellular dehydration increased blood volume and extracellular overhydration

decreased blood volume and intracellular dehydration -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.

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? hypotonic, followed by isotonic isotonic hypertonic hypotonic

hypertonic -A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.

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 hypomagnesemia hypokalemia

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. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? maintenance of cell size removal of waste maintenance of blood volume transportation of nutrients

maintenance of cell size -The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells? normal saline solution albumin granulocytes plasma

plasma -The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells. Albumin pulls third-spaced fluid by increasing colloidal osmotic pressure but does not restore clotting factors. The infusion of granulocytes improves the ability of the body to overcome infection. Normal saline is an isotonic solution that replaces fluid loss but does not replace clotting factors.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: blood transfusion therapy. volume expander. cellular hydration. total parenteral nutrition.

total parenteral nutrition. -Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.

Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply. 0.45% NaCl (½-strength normal saline) 5% dextrose in 0.9% NaCl 0.9% NaCl (normal saline) 10% dextrose in water (D10W) Lactated Ringer's solution 5% dextrose in water (D5W)

-5% dextrose in 0.9% NaCl -0.9% NaCl (normal saline) -Lactated Ringer's solution

The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom(s) does the nurse document that correlates with the admitting diagnosis? Select all that apply. Blood clotting Seizure activity Slurred speech Report of excessive urination Report of muscle cramps Report of numbness and tingling of the mouth

-Blood clotting -Seizure activity -Report of muscle cramps -Report of numbness and tingling of the mouth

The student nurse asks the instructor how buffer systems work in the body to maintain the pH of the blood. The instructor explains the buffer systems to the students. Which buffer systems will be discussed by the instructor? Select all that apply. Protein buffer system Carbonic acid-sodium bicarbonate buffer system Phosphate buffer system Potassium buffer system Respiratory buffer system

-Protein buffer system -Carbonic acid-sodium bicarbonate buffer system -Phosphate buffer system

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

0.45% NaCl -Half-strength saline (0.45% NaCl) is hypotonic. Normal saline (0.9% NaCl) and lactated Ringer's are isotonic. 10% dextrose in water (D10W) is hypertonic.

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

1 unit over 2 to 3 hours, no longer than 4 hours -Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? 3,500 mL/day 1,000 mL/day 1,500 mL/day 2,500 mL/day

2,500 mL/day -In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. 1,000 mL/day and 1,500 mL/day are too low, and 3,500 mL/day is too high.

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 3,750 3,000 500

3,000 -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.

Which of the following pH findings would indicate the presence of acidosis? 7.5 7.4 7.3 7.8

7.3

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 midline peripheral catheter An implanted central venous access device (CVAD) A peripheral venous catheter inserted to the cephalic vein A peripheral venous catheter inserted to the antecubital fossa

An implanted central venous access device (CVAD) -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. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Instruct client to remain flat for 30 minutes. Ask client to perform Valsalva maneuver. Apply petroleum-based ointment and sterile occlusive dressing. Apply pressure to insertion site for at least 3 minutes.

Apply pressure to insertion site for at least 3 minutes. -The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.

A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status? HCO3: 25 mEq/L (25 mmol/L) SaO2: 89% pH: 6.45 PaCO2: 48 mm Hg (6.38 kPa)

HCO3: 25 mEq/L (25 mmol/L) -Normal values include: HCO3: 22 to 26 mEq/L; pH: 7.35 to 7.45; PaCO2: 35; and SaO2: oxygen saturation greater than 95%.

The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect? Hypophosphatemia Hypermagnesemia Hypokalemia Hypocalcemia

Hypocalcemia -The parathyroid gland regulates calcium levels, and partial removal can cause hypocalcemia. Hypocalcemia is manifested by numbness and tingling as well as tetany. The signs and symptoms do not relate to altered magnesium or potassium levels. Calcium and phosphorus have an inverse relationship, so with low calcium, the nurse will expect a high, not a low, phosphorus level.

The Which of the following electrolyte imbalances occurs when the sodium in the extracellular fluid is below 135 mEq/L? Hypocalcemia Hypomagnesemia Hypokalemia Hyponatremia

Hyponatremia

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and fatigue and the nurse's assessment reveals an irregular heart rate. The nurse should assess the client's levels of which electrolyte? Phosphorous Calcium Potassium Chloride

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, fatigue and arrythmias.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? Sodium is regulated by the renin-angiotensin-aldosterone system. Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). Sodium is not regulated by natriuretic peptides. If sodium is low, it means that there is not enough water.

Sodium is regulated by the renin-angiotensin-aldosterone system. -Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.

Arterial blood gases are laboratory tests commonly used to determine the adequacy of oxygenation and ventilation, as well as in the assessment and treatment of acid-base imbalance. TRUE OR FALSE

True

Major electrolytes found inside cells include potassium, phosphorus, and magnesium. TRUE OR FALSE

True

Surgical hypoparathyroidism, vitamin D deficiency, and malabsorption are also causes of hypocalcemia. TRUE OR FALSE

True

Which of the following blood types is considered the universal donor? Type A+ Type B- Type AB Type O

Type O

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

a winged infusion needle. -Winged infusion needles are short, beveled needles with plastic flaps or wings. They may be used for short-term therapy or when therapy is given to a child or infant.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? an infant age 4 months a man age 50 years a woman age 45 years an adolescent age 17 years

an infant age 4 months -An infant has considerably more total body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits. An adolescent at 17 years is considered to have an adultlike body system similar to the 45-and 50-year-old.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they 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 milk yogurt

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

cardiac irregularities -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 arrythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

Which is a common anion? potassium calcium chloride magnesium

chloride -Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? nausea and vomiting distended neck veins fingerprinting over sternum muscle twitching

distended neck veins -Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

Edema happens when there is which fluid volume imbalance? extracellular fluid volume deficit extracellular fluid volume excess water deficit water excess

extracellular fluid volume excess -When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance? increased respiratory rate hypoventilation renal retention of H ions increased excretion of bicarbonate ions by the kidneys

increased respiratory rate -Hyperventilation results in increased CO exhalation and a consequent increase in pH, with the goal of attaining the ideal of 7.35 to 7.45. Retention of hydrogen ions, increased excretion of bicarbonate ions, and hypoventilation are all processes that contribute to decreased pH and an exacerbation of acidosis.

A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert? muscle weakness, fatigue, and constipation nausea, vomiting, and constipation muscle weakness, fatigue, and arrythmias diminished cognitive ability and hypertension

muscle weakness, fatigue, and arrythmias -Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and arrythmias. 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 student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? asking if the client is right or left handed asking the client to pump their fist several times 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 -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 nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. Deciding the size of the IV catheter. Prescribing the kind of IV solution. Determining the amount of IV solution. Administering the IV solution. Deciding the location of the IV catheter.

-Deciding the size of the IV catheter. -Administering the IV solution. -Deciding the location of the IV catheter.

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? 5,000 gtt/min 42 gtt/min 83 gtt/min 167 gtt/min

83 gtt/min -The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min

Acidosis occurs when there is a lack of H ions or a gain of base (bicarbonate) and the pH exceeds 7.45. TRUE OR FALSE

False

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance? Hyperphosphatemia Hypokalemia Hyponatremia Hypermagnesemia

Hyperphosphatemia -Calcium and phosphorus have a reciprocal relationship—if the calcium level is low, the phosphorus level would be high. A magnesium deficiency, not excess, may be accompanied by hypocalcemia. Sodium and potassium deficiencies are not typically associated with low calcium levels.

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 been taking antacids almost every 2 hours over the past several days." "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." -Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.

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

-respiratory muscle weakness -ventricular arrythmia -confusion

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? Transparent semipermeable membrane dressing Occlusive dressing Sealed IV dressing Gauze dressing

Gauze dressing -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 nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? Check the client's vital signs. Stop the transfusion and infuse normal saline using the blood tubing. Stop the transfusion and infuse normal saline using a new administration set. Notify the health care provider of the client's response.

Stop the transfusion and infuse normal saline using a new administration set. -A client who reports difficulty breathing during a blood transfusion may be having a transfusion reaction. The first action is to stop the transfusion and infuse normal saline using a new administration set. Changing the administration set prevents the client from receiving more of the blood that is causing the reaction. After stopping the transfusion and infusing normal saline using a new administration set, the nurse should check the client's vital signs and notify the health care provider of the reaction.

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

Stop the transfusion immediately. -The nurse needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility.

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? potassium and sodium potassium and chloride chloride and magnesium calcium and phosphorus

calcium and phosphorus -The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance.

A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action? to avoid restriction of mobility to reduce the potential for blood clots to prevent pain and discomfort to prevent compromising circulation

to prevent compromising circulation -The nurse looks for a large vein when using a needle with a large gauge to prevent compromising circulation. To reduce the potential for blood clots and restrict a client's mobility, the nurse does not use foot or leg veins. The nurse avoids using veins on the inner surface of the wrist to prevent pain and discomfort.

The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching? Cardiac function Neurologic function Skeletal integrity Visual acuity

Cardiac function -Potassium is essential for normal cardiac function. Optic, auditory, and skeletal function are not significantly dependent on potassium.

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? AB negative O negative B positive A positive

O negative -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 assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? 2+ 4+ 3+ 1+

1+ -The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

A health care provider 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? 90 drops/mL 120 drops/mL 30 drops/mL 60 drops/mL

60 drops/mL -Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

A home care nurse is visiting a client with acute kidney injury 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. Eat crackers and bread. Use regular gum and hard candy. Use an alcohol-based mouthwash to moisten your mouth. SUBMIT ANSWER

Avoid salty or excessively sweet fluids. -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 client's blood pressure has dropped from 146/92 mmHg to 107/68 mmHg over the course of several minutes. Increased levels of which of the following will be released into the client's bloodstream? Erythropoietin Renin Protein Insulin

Renin -Decreased arterial blood pressure can stimulate renin release as part of a compensatory response. Low BP does not prompt the release of insulin, erythropoietin or protein.