(NUR 100) Prep U CH 40 fluid, electrolyte and acid-base balance

A client who is receiving total parenteral nutrition and lipids asks the nurse why the solution looks like milk. What is the most appropriate nursing response?

"The white milky solution contains lipids, or fat, to provide extra calories." A parenteral lipid emulsion is a mixture of water and fats in the form of soybean or safflower oil, egg yolk phospholipids, and glycerin. Lipid solutions, which look milky white, are given intermittently with TPN solutions. They provide additional calories and promote adequate blood levels of fatty acids. Lipids cannot be mixed with TPN, as the lipid molecules tend to break or separate. All other options are incorrect.

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?

Acute Confusion related to cerebral edema Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.

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) Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.

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 Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

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 Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another spot The nurse should inspect the IV site for presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleaning with alcohol or chlorhexidine is not recommended and does not reduce the phlebitis. The nurse does not need to call the physician for anti-inflammatory medications.

Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid.

Which client has more extracellular fluid?

Newborns Newborns have more extracellular fluid than intracellular fluid.

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?

Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing The tubing is contaminated and, if the nurse continues to use the current tubing, the bag's contents will become contaminated during infusion. This action will result in harming the client and can increase the risk of an systemic infection, resulting form poor medical and surgical aseptic techniques.

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.

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?

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.

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

A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?

replace fluid and electrolytes the therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost due to the NPO order, and the loss of fluid and electrolytes due to the nasogastric suctioning.

A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?

to prevent compromising circulation The nurse looks for a large vein when using a needle with a large gauge to prevent compromising circulation. To reduce the potential for blood clots and restrict a client's mobility, the nurse does not use foot or leg veins. The nurse avoids using veins on the inner surface of the wrist to prevent pain and discomfort.

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate?

"Granulocytes are a type of white blood cell that can help fight infection." Granulocytes are a type of white blood cell that are used to fight infection. All other options are incorrect statements related to granulocytes.

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." Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be reinfused. Reference:

the nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr

100 gtt/min 100gtt/min is the correct rate. 1000 mL divided by 10 hours = 100 mL per hour x 60 gtt/minute, divided by 60 minutes/hour.

the client has vancomycin 250 mL intravenously prescribed daily. The vancomycin is to be administered over 90 minutes through an IV administration pump. How many mL/hr would the nurse set the IV administration pump to administer the vancomycin? Record your answer using a whole number.

167 The nurse calculates the rate as mL/hr for the IV administration pump. The nurse converts 90 minutes to 1.5 hours and performs the following calculation: 250 mL divided by 1.5 hours. This equals 167 mL/hr. The nurse sets the pump for 167 mL/hr.

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. 1,000 mL/day and 1,500 mL/day are too low, and 3,500 mL/day is too high.

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 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

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 Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients?

cardiac volume intolerance The older adult client is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. Older adults typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.

confusion respiratory muscle weakness ventricular dysrhythmia With hypophosphatemia, findings include neuromuscular dysfunction; weakness, especially respiratory muscles; fatigue; myocardial depression; ventricular dysrhythmias; rhabdomyolysis; confusion, coma; decreased oxygen delivery to tissues; renal loss of bicarbonate, calcium, magnesium, and glucose; bone changes (osteomalacia); and endocrine changes (insulin resistance). Abdominal distention and constipation are more commonly associated with hypokalemia.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

hyponatremia Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.