Chapter 40 Electrolytes
distended neck veins
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?
total parenteral nutrition.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
Water moves from an area of lower solute concentration to an area of higher solute concentration.
Which statement most accurately describes the process of osmosis?
Potassium
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?
Discontinue the IV.
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 is the nurse's most appropriate action?
Discontinue the IV and relocate it to another spot.
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?
Infants
A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?
placing the tourniquet on the upper arm for 2 minutes
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
Offer small amounts of preferred beverage frequently.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
Not wearing gloves when preforming the intervention
As observed the nurse changing a peripheral venous access site dressing is idemonstrating inappropriate technique by implementing which action?
aldosterone.
How is control over the extracellular concentration of potassium within the human body is exerted?
Muscle weakness, fatigue, and dysrhythmias
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?
cardiac function
Potassium is needed for neural, muscle, and:
Cardiac dysrhythmias
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 (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?
phlebitis.
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:
extracellular fluid volume excess
dema happens when there is which fluid volume imbalance?
60 drops/mL
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?
50 gtt/min
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?
Changing the dressing on a client's peripheral IV site
A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)?
Hypokalemia
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?
O negative
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?
sodium, chloride, and bicarbonate.
The primary extracellular electrolytes are:
Apply a warm compress.
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?
chloride
Which is a common anion?
Ensure that the prescribed solution is clear and transparent.
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
O negative
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?
-H2CO3 level in the blood decreases -pH becomes more alkaline -Blood level of CO2 decreases -Decreased respirations -Carbon dioxide retention -Carbonic acid formed
The nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal pH. Place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2.
daily weights
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?
hypokalemia.
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:
1 unit over 2 to 3 hours, no longer than 4 hours
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?
renin.
A decrease in arterial blood pressure will result in the release of:
Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing
A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take?
Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
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.
2,600 mL
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?
Banana
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?
83 mL/hr
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?
"I received a blood transfusion in the United Kingdom."
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?
glomerulus
The process of filtration begins at the:
Arterial blood gas
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Acute Confusion related to cerebral edema
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Metabolic alkalosis
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)?
decreased blood volume and intracellular dehydration
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
cardiac irregularities
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?
3,000
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?
Avoid salty or excessively sweet fluids.
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?
"You won't have to endure any more needlesticks."
A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect?
the band members should drink large amounts of water.
A student has joined the marching band at his high school. The band begins practicing outside in August. This student and other band members need to be instructed that:
replacement of fluids for those lost from vomiting and diarrhea.
A woman aged 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:
"Let me refer you to the blood bank so they can provide you with information."
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?