Chapter 41: Fluid, Electrolyte, and Acid-Base Balance
What commonly used intravenous solution is hypotonic?
0.45% NaCl
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?
2,500 mL/day * From 1,800 to 3,000 mL/day with a similar volume of fluid loss.
Which is a common anion?
chloride
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 arrythmias
The nurse working at the blood bank is speaking with a potential blood donor client. The client has been living in South America where there was a Zika outbreak. Which statement by the nurse is most appropriate?
"Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions." * The FDA recommends deferral of people from donating blood if they have been to areas with active Zika virus transmission, potentially have been exposed to the virus, or have had a confirmed Zika virus infection
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"Fluid in the tissue space between and around cells." Intracellular fluid: "Fluid inside cells." Extracellular fluid: "Fluid outside cells." Intravascular fluid: "Watery plasma, or serum, portion of blood."
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?
"Let me refer you to the blood bank so they can provide you with information." * the client's own blood may be reinfused.
Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply.
0.9% NaCl (normal saline) -- ISTONIC Lactated Ringer's solution -- ISOTONIC 5% dextrose in 0.9% NaCl -- 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
A health care provider 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 * 250 mL/100 min *20 gtt/1 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 * 250 mL/1 hr * 1 hr/60 min * 20 gtt/1 mL
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
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 * SWELL *
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)
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas (ABGs)
A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate?
Avoid use of a tourniquet.
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 * POTASSIUM *
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. Deciding the location of the IV catheter. Administering the IV solution.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels * Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
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 providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?
Hyperphosphatemia
A client is hypotensive secondary to hypovolemia resulting from dehydration. Based on the nurse's knowledge about intravenous solutions, the nurse would expect the health care provider to prescribe which type of solution?
Isotonic
Because metabolism continually produces acids, maintenance of pH within these incredibly narrow limits depends on two processes: buffering and compensation. Which statement describes a function of buffering?
It helps to prevent large changes in pH by absorbing or releasing H+ ions.
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?
O negative
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. * Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.
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 * Phlebitis: inflammation of a vein
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?
Potassium * hypokalemia- muscle weakness, fatigue, arrhythmias * Diuretics, commonly given to treat high blood pressure and heart failure
A client has been diagnosed with excessive levels of aldosterone. The nurse's assessment will include what value?
Potassium level * Aldosterone regulates the extracellular concentration of potassium. An excess would create a risk for hypokalemia. Acid-base balance, thirst level and calcium would be affected to a lesser degree.
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. * The priority action is to remove the IV and restart another IV using a different vein.
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?
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.
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?
Restart infusion in another vein and apply a warm compress. * the nurse should apply a warm compress after restarting the IV.
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. * THEN nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion
A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action?
The nurse should carefully remove the tape from the outside to the insertion point while supporting the catheter. Gloves should be worn.
What is the priority goal for the activity in which the nurse is engaging, related to the administration of a 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.
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 * Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels.
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 * Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume.
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 * Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended.
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.
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: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes * The tourniquet should not be applied for longer than 1 minute "CORRECT TECHNIQUE" asking the client to pump their fist several times asking if the client is right or left handed palpating the veins on the nondominant hand
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. * In addition to increased plasma levels of antidiuretic hormones, plasma levels of albumin decrease, so that the distribution of extracellular fluid changes, vascular volume decreases, and interstitial volume increases. Complications often lead to ascites. Complications from cardiac failure can be described as the secretion of aldosterone, and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess. Hyperkalemia and hypocalcemia are common, and metabolic acidosis occurs with acute kidney injury. Complications associated to respiratory failure include a disruption of acid-base balance and a disruption in this organ's ability to excrete carbon dioxide; this causes the pH of the person's blood to fall.
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