NUR FUND + PREP U Chapter 39 Fluid, Electrolyte, and Acid-Base Balance

The student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response?

"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).

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate?

"Granulocytes are a type of white blood cell that can help fight infection." Explanation: Granulocytes are a type of white blood cell that are used to fight infection.

A client who is receiving total parenteral nutrition and lipids asks the nurse why the solution looks like milk. What is the most appropriate nursing response?

"The white milky solution contains lipids or fat to provide extra calories."

What is the rate of administration for packed red blood cells?

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

Mr. Jones is admitted to your 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 will you be alert?

4. Muscle weakness, fatigue, and dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias.

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O?

55-year old with congestive heart failure on furosemide Explanation: Agencies often specify the types of clients that are placed automatically on I&O.

The nurse is calculating an infusion rate for the following order: Infuse 1000 ml of 0.9% Na Cl over 12 hours using an electronic infusion device. What is the infusion rate?

83 ml/hour Explanation: When calculating the infusion rate with an electronic device, divide the total volume to be infused (1000 ml) by the total amount of time in hours (8).

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 B AB O Explanation: Persons with type AB blood are often called universal recipients, a fact that is rooted in their lack of agglutinins for either A or B antigens.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

A newly admitted 88-year-old with a 2-day history of vomiting and loose stools Explanation: Young children, older adults, and people who are ill are especially at risk for hypovolemia.

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?

An implanted central venous access device (CVAD) Explanation: Implanted CVADs are ideal for long-term uses such as chemotherapy.

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.

Answer: 50 gtts/min Rationale: When administering 500mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula: gtt/min = (500x60)/600 500 x 60 = 30,000/600 = 50 gtts/min

A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply.

Answer: a. "Try to drink at least six to eight glasses of water each day." c. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." f. "Weigh yourself daily and report any changes in your weight." Rationale: Generally, fluid intake and output average 2,600 mL per day.

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply.

Answer: a. 5% dextrose in water (D5W) d. 0.33% NaCl (1/3-strength normal saline) e. 0.45% NaCl (1/2-strength normal saline)

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access devise is most likely to meet this client's needs?

Answer: a. An implanted central venous access device (CVAD) Rationale: Implanted CVADs are ideal for long-term uses such as chemotherapy.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

Answer: a. An infant age 4 months Rationale: An infant has considerably more total-body fluid and extracellular fluid (ECF) than does an adult.

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?

Answer: a. Avoid salty of excessively sweet fluids. Rationale: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids.

When providing care for a client who has a peripheral intravenous catheter in situ, the nurse should do what?

Answer: a. Change the site every 3-4 days. Rationale: Peripheral IV site should be rotated every 72-96 hours, depending on the institutional protocol. IV insertion sites are not cleansed daily.

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. Which of the following would the nurse expect to find when assessing the client's gastrointestinal system?

Answer: a. Diarrhea Rationale: The client with hyperkalemia would experience diarrhea. Abdominal distention, vomiting, and paralytic ileum would reflect hypokalemia.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and present with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms?

Answer: a. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. Rationale: The nurse is observing the signs and symptoms of speed-shock: the body's reaction to a substance that is injected into the circulatory system too rapidly.

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 which of the following?

Answer: a. Electrolytes Rationale: 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.

A nurse is caring for a patient who has fluid imbalance related to the development of ascites. Which imbalances would the nurse monitor for in this patient? Select all that apply.

Answer: a. Extracellular fluid volume deficit b. Protein deficit d. Sodium deficit e. Plasma-to-interstitial fluid shift

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of what?

Answer: a. Fluid volume excess Rationale: Edema is a characteristic sign of fluid volume excess (hypervolemia). Metabolic acidosis and hyponatremia are not directly associated with the development of peripheral edema.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. What is this electrolyte imbalance known as?

Answer: a. Hyponatremia Rationale: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water.

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?

Answer: a. Increased respiratory rate Rationale: Hyperventilation results in increased CO exhalation and a consequent increase in pH, with the goal of attaining the ideal of 7.35-7.45.

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?

Answer: a. Notify the primary care provider immediately for possible fluid overload. Rationale: If the client's lungs sounds were previously clear, but now some crackles in the bases are auscultated, notify the primary care provider immediately.

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 what?

Answer: a. Phlebitis Rationale: Phlebitis is a local infection at the sit 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.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms?

Answer: a. Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. Rationale: The client is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document.

Answer: b. 2 Rationale: Grade 2 phlebitis presents with pain at access site with erythema (reddening) and/or edema.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?

Answer: b. Administer oral K supplements as ordered. Rationale: Nursing interventions for a patient with hypokalemia (low potassium) include encouraging foods high in potassium and administering oral K as ordered.

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?

Answer: b. Apricots Rationale: Apricots are a rich source of potassium. Dairy products are rich sources of calcium.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level?

Answer: b. Cardiac dysrhythmias Rationale: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement?

Answer: b. Keeping fluids readily available for the patient. Rationale: Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake.

A nurse carefully assesses the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following?

Answer: b. Lungs Rationale: The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply.

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?

Answer: b. Replacement of fluids for those lost from vomiting and diarrhea. Rationale: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination.

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

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

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6 mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented?

Answer: c. 3+ pitting edema Rationale: 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection.

A nurse is flushing a patient's implanted port after administering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse's next action based on these findings?

Answer: c. Ask the patient to perform a Valsalva maneuver; change the patient position. Rationale: If a port flushes but does not have a blood return, the nurse should ask the patient to perform a Valsalva maneuver, have the patient change position or place the affected arm over the head, or ride or lower the head of the bed.

A client's most recent blood work indicated a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

Answer: c. Cardiac irregularities Rationale: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials.

A client admitted with heart failure requires careful monitoring of his fluid status. What assessment parameter will provide the nurse with the best indication of the client's fluid status?

Answer: c. Daily weights Rationale: Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client's daily weight may be the more accurate measurement of a client's fluid status.

A client who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor?

Answer: c. Decreased blood volume and intracellular dehydration. Rationale: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume.

A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?

Answer: c. Fluid volume excess and acidosis. Rationale: Fluid volume excess can be caused by malfunction of the kidneys (i.e., renal failure). The kidneys are also responsible for acid-base balance, and in the presence of renal failure, the kidneys cannot regulate hydrogen ions and bicarbonate ions, so the client develops metabolic acidosis.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by which of the following?

Answer: c. Increasing ventilation through the lungs. Rationale: The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3-, 14 mEq/L?

Answer: c. Metabolic acidosis Rationale: A low pH indicated acidosis. This, coupled with a low bicarbonate, indicated metabolic acidosis.

Which of the following statements most accurately describes the process of osmosis?

Answer: c. Water moves from an area of lower solute concentration to an area of higher solute concentration. Rationale: Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water.

Which of the following commonly used intravenous solutions is hypotonic?

Answer: d. 0.45% NaCl Rationale: 0.45% NaCl is hypotonic, while normal saline and Lactated Ringer's are isotonic. 5% dextrose in 0.45% NaCl is hypertonic.

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?

Answer: d. Apply a warm compress. Rationale: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV.

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?

Answer: d. Calcium and phosphorus Rationale: The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus.

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?

Answer: d. Hypokalemia Rationale: 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 assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a. Recording intake and output b. Testing skin turgor c. Reviewing the complete blood count (CBC) d. Measuring weight daily

Answer: d. Measuring weight daily Rationale: Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turbot is subjective, and the complete blood count (CBC) does not necessarily reflect fluid balance.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings?

Answer: d. Put on gloves; remove the catheter; apply pressure with a sterile pad. Rationale: This IV has been infiltrated. The nurse should put on gloves and remove the catheter.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis.

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. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids.

A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded?

Fruit consumption Explanation:

A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance?

Metabolic alkalosis Hypokalemia Explanation: If sufficient gastric juice (ECF with additional acid) is lost from the stomach, then consequently hydrogen, sodium, and chloride ions are depleted, increasing the risk of ECF volume deficit and/or metabolic alkalosis.

Which client has more extracellular fluid?

Newborn Explanation: Newborns have more extracellular fluid than intracellular fluid.

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 Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane.

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform?

Weigh the client's wet linen or dressing. Explanation: In cases in which accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, or dressings and subtracts the weight of a similar dry item.

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?

b) 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.

Potassium is needed for neural, muscle, and:

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 (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials.

A nurse is choosing a vein to start an IV infusion in a client. What are recommended veins to use when initiating an IV infusion? (Select all that apply.) metacarpal antecubital vein superficial veins on the dorsal aspect of the hand leg veins basilic veins cephalic vein

cephalic vein metacarpal basilic veins superficial veins on the dorsal aspect of the hand Explanation: The cephalic vein, accessory cephalic vein, metacarpal, and basilic vein are appropriate sites for infusion (INS, 2006).

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?

distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended.

The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.)

drinking milk urination vomiting infusion of intravenous solution Explanation: The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output.

Edema happens when there is which fluid volume imbalance?

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

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?

hypertonic Explanation: 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.

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?

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 nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?

pH: 7.60; PaCO2: 64; HCO3: 42 Explanation: In metabolic acidosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high HCO3, such as 64; and a high PaCO2, such as 42.

A decrease in arterial blood pressure will result in the release of:

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

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

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