FLUID and ELECTROLYTES + other mini quiz
A 2-year-old child is admitted with gastroenteritis and dehydration. Intravenous fluids are prescribed. Which is the most appropriate site for the first intravenous insertion? 1 Scalp vein near the fontanel 2 Venous arch on top of the foot 3 Dorsal metacarpals of the hand 4 Basilic vein at the antecubital fossa
3 The choice of first insertion site should be distal (low) on the periphery of an extremity and progress proximally (upward) toward the trunk; the upper extremities are the most appropriate sites for intravenous insertions for adults and children older than 1 year. Scalp veins are used for infants only if peripheral veins are inaccessible. Foot veins should not be used once a child is walking. The antecubital fossa should be avoided because the arm will have to be immobilized to stabilize the intravenous insertion site to prevent an infiltration.
Which physiological alteration would be expected with a higher-than-normal red blood cell (RBC) count? 1 Increased blood pH 2 Decreased hematocrit 3 Increased blood viscosity 4 Decreased immune response
3 Viscosity, a measure of a fluid's internal resistance to flow, is increased as the number of red blood cells suspended in plasma increases. The number of cells does not affect the blood pH. The hematocrit will be higher. RBCs do not affect immunity.
The nurse is preparing to administer an intravenous piggyback antibiotic that has been newly prescribed. Shortly after initiation, the client becomes restless and flushed and begins to wheeze. After stopping the infusion, which priority action will the nurse take? 1 Notify the primary health care provider immediately about the client's condition. 2 Take the client's blood pressure. 3 Obtain the client's pulse oximetry. 4 Assess the client's respiratory status
4 The client is experiencing an allergic reaction. Severe allergic reactions commonly cause respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. The nurse must determine the client's status before notifying the primary health care provider. Vital signs, including blood pressure and pulse oximetry, are obtained after airway patency is ensured and maintained.
The nurse assesses bilateral +4 peripheral edema while assessing a client with heart failure and peripheral vascular disease. Which is the pathophysiological reason for the excessive edema? 1 Shift of fluid into the interstitial spaces 2 Weakening of the cell wall 3 Increased intravascular compliance 4 Increased intracellular fluid volume
1 Edema is defined as the accumulation of fluid in the interstitial spaces. When the heart is unable to maintain adequate blood flow throughout the circulatory system, the excess fluid pressure within the blood vessels can cause shifts into the interstitial spaces. Weakening of the cell wall may cause leakage of fluid, but this is not the pathological reason related to heart failure. Increased intravascular compliance would prevent fluid from shifting into the tissue. Intracellular volume is maintained within the cell and not in the tissue.
Which component of the client's nephron acts as a receptor site for the antidiuretic hormone to regulate water balance? 1 Collecting ducts 2 Bowman capsule 3 Distal convoluted tubule 4 Proximal convoluted tubule
1 The collecting ducts regulate water balance and act as a receptor site for antidiuretic hormone. The Bowman capsule collects glomerular filtrate and funnels it into the tubule. The distal convoluted tubule acts as a site for additional water and electrolyte reabsorption. The proximal convoluted tubule is the site for reabsorption of sodium, chloride, water, and urea.
A child who has a history of a 5-lb (2.3 kg) weight gain in 1 week and periorbital edema is admitted with a diagnosis of acute glomerulonephritis. How can the nurse obtain the most accurate information on the status of the child's edema? 1 Weighing daily 2 Observing body changes 3 Measuring intake and output 4 Monitoring electrolyte values
1 Weight monitoring is the most useful means of assessing fluid balance and changes in the edematous state; 1 L of fluid weighs about 2.2 lb (1 kg). Visual inspection is subjective and generally inaccurate. Measuring intake and output is not as accurate as daily weights; fluid may be trapped in the third compartment. Monitoring of electrolyte values is unreliable; they may or may not be altered with fluid shifts.
The nurse would assess for which electrolyte imbalance during the first 48 hours after a client has sustained a thermal injury? 1 Hypokalemia and hyponatremia 2 Hyperkalemia and hyponatremia 3 Hypokalemia and hypernatremia 4 Hyperkalemia and hypernatremia
2 Massive amounts of potassium are released from the injured cells into the extracellular fluid compartment; large amounts of sodium are lost in edema. Serum potassium will rise, leading to hyperkalemia. Serum sodium deficit will occur, leading to hyponatremia.
The nurse is caring for a client who is having diarrhea. Which client data would the nurse closely monitor to prevent an adverse outcome? 1 Skin condition 2 Fluid and electrolyte balance 3 Food intake 4 Fluid intake and output
2 Monitoring fluid and electrolyte balance is the most important nursing intervention because excess loss of fluid through the multiple loose bowel movements associated with diarrhea lead to alteration in fluid and electrolyte imbalance. Although skin may become excoriated with diarrhea, this is not a life-threatening condition and is not the nursing priority. Even though absorption of nutrients is decreased with diarrhea malnutrition, it is not a life-threatening condition and is not the priority nursing intervention. Fluid intake and output provides information about fluid balance only, without taking into consideration the loss of electrolytes that accompanies diarrhea and is not the best choice.
The nurse receives an order to prepare the solution for administering a cleansing enema to a 3-year-old child. Which is the volume of solution the nurse would prepare? 1 150 to 250 mL 2 250 to 350 mL 3 300 to 500 mL 4 500 to 750 mL
2 The nurse would prepare 250 to 350 mL of warmed solution for administering a cleansing enema in a toddler. The nurse would prepare 150 to 250 mL of warmed solution for infants. In school-aged children, the volume of warmed solution is 300 to 500 mL. In adolescents, the volume required is 500 to 750 mL.
Based on an electrocardiogram (ECG), a client is suspected to have hypokalemia. Which test will be used to confirm hypokalemia? 1 Complete blood count 2 Serum potassium level 3 Arterial blood gas panel 4 Urine osmolality test
2. Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L indicates hypokalemia. A complete blood count, an arterial blood gas panel, and urine osmolality testing have no significance in diagnosing a potassium deficit.
Which hormone aids in regulating intestinal calcium and phosphorous absorption? 1 Insulin 2 Thyroxine 3 Glucocorticoids 4 Parathyroid hormone
3 Adrenal glucocorticoids aid in regulating intestinal calcium and phosphorous absorption by increasing or decreasing protein metabolism. Insulin acts together with growth hormone to build and maintain healthy bone tissue. Thyroxine increases the rate of protein synthesis in all types of tissues. Parathyroid hormone secretion increases in response to decreased serum calcium concentration and stimulates the bones to promote osteoclastic activity.
The nurse is administering serum albumin intravenously to a client with ascites. In response to this therapy, which client problem would the nurse expect to decrease? 1 Confusion 2 Urinary output 3 Abdominal girth 4 Serum ammonia level
3 An increased serum albumin level increases the osmotic effect and pulls fluid back into the intravascular compartment. This will increase renal flow and urine output, with a resulting decrease in abdominal girth. Urinary output therapy will increase blood volume and blood flow to the kidney, thereby increasing urinary output. Albumin therapy has no effect on blood ammonia levels. An increased, not decreased, blood ammonia level causes hepatic encephalopathy.
Which nursing intervention is the priority for a client with stroke who is transitioned from the emergency department (ED) to other settings? 1 Monitoring vital signs 2 Reassuring the client and family 3 Assessing the level of consciousness 4 Monitoring specific client manifestations of stroke
3 Assessing the level of consciousness is the priority nursing action in the client with stroke and who is transitioned from the ED to other settings. Monitoring the vital signs, reassuring the client and family, and monitoring specific client manifestations of stroke are ongoing nursing interventions.
In which category of fluids would the nurse classify an intravenous solution of 0.45% sodium chloride? 1 Isotonic 2 Isomeric 3 Hypotonic 4 Hypertonic
3 Hypotonic solutions are less concentrated (contain less than 0.85 g of sodium chloride in each 100 mL) than body fluids. Isotonic solutions are those that cause no change in the cellular volume or pressure because their concentration is equivalent to that of body fluid. This relates to two compounds that possess the same molecular formula but that differ in their properties or in the position of atoms in the molecules (isomers). Hypertonic solutions contain more than 0.85 g of solute in each 100 mL.
Which medication can cause diabetes insipidus? 1 Cabergoline 2 Metyrapone 3 Demeclocycline 4 Aminoglutethimide
3 Prolonged administration of demeclocycline may cause diabetes insipidus, because this medication decreases the production of antidiuretic hormone by the kidneys. Cabergoline inhibits the release of growth hormone and prolactin by stimulating dopamine receptors in the brain. Metyrapone and aminoglutethimide decrease cortisol production.
Which goal would the nurse expect a client receiving treatment for bacterial cystitis to achieve before their discharge from the hospital? 1 Understand the need to drink 4 L of water per day to prevent dehydration. 2 Demonstrate an ability to identify dietary restrictions and plan menus. 3 Achieve relief of clinical symptoms and maintain kidney function. 4 Recognize signs of bleeding as a complication associated with this type of procedure
3 Relief of symptoms and continued urine output are measurable responses to therapy and are the desired outcomes. Four liters of water per day is too much fluid; 2 to 3 liters a day is recommended to flush the bladder and urethra. Dietary restrictions are not necessary with cystitis. Bleeding is not a complication associated with this treatment.
A client with chronic kidney disease selects treatment using continuous ambulatory peritoneal dialysis (CAPD). Which statement indicates the client understands the purpose of this therapy? 1 "The treatment provides continuous contact of dialyzer and blood to clear toxins by ultrafiltration." 2 "The treatment exchanges and cleanses blood by correction of electrolytes and excretion of creatinine." 3 "The treatment decreases the need for immobility, because the fluids clear the toxins in short and intermittent periods." 4 "The treatment uses the peritoneum as a semipermeable membrane to clear toxins by osmosis and diffusion."
4. Diffusion moves particles from an area of greater concentration to an area of lesser concentration. Osmosis moves fluid from an area of lesser concentration to an area of greater concentration of particles, thereby removing waste products into the dialysate, which is then drained from the abdomen. The principle of ultrafiltration involves a pressure gradient, which is associated with hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses the peritoneal membrane for indirect cleansing of the blood. Dialysate does not clear toxins in a short time; exchanges may occur four or five times a day.
Intravenous (IV) fluid replacement of 7200 mL during the first 24 hours has been prescribed for a client with severe burns. Fifty percent of fluid replacement will be administered in the first 8 hours; then the remaining 50% given over the next 16 hours. How many milliliters per hour will the nurse infuse during the first 8 hours?___ mL/h
Fifty percent of the total volume to be infused is 3600 mL (7200/2 = 3600). The total time of infusion for this volume is 8 hours. 3600 mL/8 hours = 450 mL/h.
An intravenous (IV) antibiotic in 50 mL of 0.9% sodium chloride needs to be administered over 20 minutes. The nurse will set the infusion pump to deliver how many milliliters per hour?___ mL/h
The volume to be infused is 50 mL. The time of infusion needs to be converted to mL/h for the infusion pump.
Which action would the nurse include in the plan of care for a client admitted with heart failure who has gained 20 pounds in 3 weeks? Select all that apply. One, some, or all responses may be correct. 1 Diuretics 2 Low-salt diet 3 Daily weight checks 4 Fluid restriction 5 Intake and output 6 Oxygen administration
all Interventions for a client with heart failure who has sustained a 20-pound weight gain would be focused on decreasing fluid retention. Interventions could include diuretic administration to increase fluid removal; a low-salt diet with fluid restriction; daily weight checks and measuring intake/output; and oxygen administration, particularly if the client has fluid in the lungs.
