Prep U:40: 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."

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention

"I received a blood transfusion in the United Kingdom."

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 2,500 mL/day of fluid."

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

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

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

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend

2,500 mL/day

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

3,000 mL

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

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing

60 drops/mL Explanation: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL.

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

83 gtt/min

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate

83 mL/hr

Which actions would a nurse perform after selecting a site and palpating accessible veins in order to start an IV infusion? Select all that apply

Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein. When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into the vein until the hub is at the venipuncture site. Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle.

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)

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

Apply a warm compress.

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

Arterial blood gas

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern

Banana

A client is scheduled for insertion of a peripherally inserted central catheter. When assisting with the procedure, the nurse would expect that which site would most likely be used

Basilic vein

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included

Decreased potassium levels

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation

Discontinue the IV and relocate it to another site.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV

Ensure that the prescribed solution is clear and transparent.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect

Hemolytic transfusion reaction: incompatibility of blood product.

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 most likely find

Hypokalemia

A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 5.75 mg/dL (1.8 mEq/L)Based on these levels, the nurse would identify which imbalance

Hypokalemia

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 alkalosis

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing

Metabolic alkalosis

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert

Muscle weakness, fatigue, and dysrhythmias

As observed the nurse changing a peripheral venous access site dressing is idemonstrating inappropriate technique by implementing which action

Not wearing gloves when preforming the intervention

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations

Offer small amounts of preferred beverage frequently.

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

Phlebitis

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

Potassium

A nurse selects the basilic vein as the intended site for the insertion of an IV catheter. The nurse understands that which bone would act as natural splints to allow the client greater freedom of movement? Select all that apply

Radius • Ulna

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean

The client has anti-A antibodies.

A nurse is presenting an in-service program to a group of graduate nurses about blood component therapy. The nurse determines that the education was successful when the group identifies which complication as the primary cause of transfusion-related client death in the United States

Transfusion-related acute lung injury

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first

Verify the prescription for type of solution and amount of infusion.

The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate

Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL).

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

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 winged infusion needle.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor

decreased blood volume and intracellular dehydration

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

The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply

facilitates cellular metabolismhelps maintain normal body temperatureacts as a solvent for electrolytes

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of

hypokalemia.

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume

isotonic

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's

low calcium.

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

phlebitis.

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client

platelets

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

renin.

The primary extracellular electrolytes are

sodium, chloride, bicarbonate

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

stop the transfusion immediately.