Nu 230 therapeutics Chapter 32: Fluid, Electrolytes, and Acid-Base

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance?

"How much do you typically urinate during the day?"

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply.

-Ask provider to order a low-salt diet. -Administer furosemide as ordered. -Reduce infusing fluid volume as ordered. -Treat the underlying condition that contributes to increased fluid volume.

A nursing instructor is preparing a class presentation for a group of nursing students on fluid balance and developmental considerations. What would the instructor likely include when describing newborns and infants? Select all that apply.

-Water makes up a larger percentage of their body weight. -Greater amounts of water are found in the extracellular fluid compartment. -Insensible fluid losses are greater in this age group.

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

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?

3.5 cm H2O

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

A nurse is reviewing the arterial blood gas results of a client. Which pH value would the nurse document as indicating acidosis?

7.30

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

The nurse is working with a colleague and observes the colleague changing the bag of a client's IV solution as pictured above. What is the nurse's most appropriate response?

Encourage the colleague to hang the bag on the IV pole before spiking it.

A health care provider writes a prescription to "force fluids." What will be the first action the nurse will take in implementing this prescription?

Explain to the client why this is needed.

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?

Hyperphosphatemia

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.

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 inserting a medication lock for a client receiving intermittent intravenous antibiotics. To prevent the locked intravenous catheter from becoming obstructed between uses, which action will the nurse take during this procedure?

Slowly remove the syringe before the fluid is completely instilled.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take?

Stop the transfusion and notify the health care provider.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?

Stop the transfusion.

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?

cardiac irregularities

Which is a common anion?

chloride

The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which will the nurse document on the I&O record? Select all that apply.

client drinking milk client's urination vomiting infusion of intravenous solution

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

By which route do oxygen and carbon dioxide exchange in the lung?

diffusion

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

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes.

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

fluid volume excess.

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 likely to find?

hypokalemia

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

intracellular fluid (ICF)

ECF volume is usually

the normal pressure is approximately 4 to 11 cm H2O.

Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. Which action should the nurse take?

Encourage the intake of salty liquids like broth and tomato juice.

The health care provider is concerned that the client has hypokalemia. During the physical examination, which question should the nurse ask the client?

"Have you been experiencing muscle weakness or leg cramps?"

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?

Apricots

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

Arterial blood gas

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?

Avoid salty or excessively sweet fluids.

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?

Compare the total intake and output of fluids for the 24 hours.