RN 31 Ch 39 PrepU Fluid, Electrolyte, Acid-Base Balance

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 Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O 1489

What is the lab test commonly used in the assessment and treatment of acid-base balance? a)Arterial blood gas b) Chemistry c) CBC d) Urinalysis

Arterial Blood Gas The pH of plasma from an arterial blood sample indicates balance or impending acidosis or alkalosis.

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 transparen

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.

Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease

Increased plasma levels of antidiuretic hormone lead to water excess.

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

Offer the client sugar-free candy to help combat thirst To minimize thirst for clients on fluid restriction, offer sugar-free candy and gum to help minimize thirst. Salty or very sweet fluids should be avoided. Rinsing the mouth with water and then having the client spit it out before swallowing may be helpful. Alcohol-based mouthwashes should be avoided because they have a drying effect. A water-based gel, not petroleum based, can be applied to the client's lips to moisten and prevent drying and cracking. 1499

A nurse is caring for a client who is experiencing fluid volume deficit. Which signs should the nurse document as part of the assessment that correlates with a fluid volume defiicit? Select all that apply.

Reduced skin turgor Decreased blood pressure Decreased urine output Increased pulse rate Tachycardia or increased pulse rate is usually the earliest sign of decreased vascular volume associated with fluid volume deficit or dehydration. Pulse amplitude is decreased in fluid volume deficit. As a result of decreased vascular volume, the client would exhibit a decreased blood pressure, and the client would have a decrease in urine output. The client would exhibit a reduction in skin turgor due to lack of fluids in the skin and tissues. The respiratory rate is not affected by dehydration unless associated with respiratory acidosis or alkalosis.

A client's atrial pressure is known to be increased. What effect will this ultimately have on the client's sodium levels?

Sodium levels will decrease. When atrial pressure is increased, ANP released by the atrial and ventricular myocytes acts on the nephron to increase sodium excretion. Sodium levels consequently decrease. Sodium levels do not precisely match potassium levels.

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) Notify the primary care provider immediately for possible fluid overload. b) Check all clamps on the tubing and check tubing for any kinking. c) No intervention is necessary as this is a normal finding with IV infusion. d) Notify the primary care provider immediately because these are signs of speed shock.

a) Notify the primary care provider immediately for possible fluid overload.

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? a) 30 drops/mL b) 60 drops/mL c) 90 drops/mL d) 120 drops/mL

b) 60 drops/mL Explanation: 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).

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) Hypoglycemia b) Hypokalemia c) Hypothyroidism d) Hypocalcemia

b) Hypokalemia 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 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) Sodium b) Potassium c) Chloride d) Phosphorous

b) 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.

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) Eat crackers and bread. b) Use regular gum and hard candy. c) Avoid salty or excessively sweet fluids. d) Use an alcohol-based mouthwash to moisten your mouth

c) Avoid salty or excessively sweet fluids

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