PrepU ch 40 Fluid, Electrolyte and Acid-Base Balances
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 location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
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 most likely find?
Hypokalemia
A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot?
Infant
As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?
Not wearing gloves when performing the intervention
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
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?
O negative
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
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 nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate?
Remove the IV catheter and reinsert another in a different location.
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?
Sodium is regulated by the renin-angiotensin-aldosterone system.
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
The process of filtration begins at the:
glomerulus
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's:
low calcium.
A decrease in arterial blood pressure will result in the release of:
renin
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"Fluid in the tissue space between and around cells."
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?
"I received a blood transfusion in the United Kingdom."
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas
Which is a common anion?
Chloride
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?
2500 mL/day
A physician 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
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?
60 drops/mL
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
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?
"I should drink 2,500 mL/day of fluid."
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels
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 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.
A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?
Flush the IV with 3 mL of normal saline.
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client?
Gauze dressing
A nurse is reviewing the client's serum electrolyte levels which are as follows: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)
Hypokalemia
Which statement accurately describes appropriate nursing interventions in unexpected situations when removing a peripherally inserted central catheter (PICC)?
If a portion of the catheter breaks when removing it, apply a tourniquet to the upper arm and notify the health care provider.
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.
Which nursing actions would be performed when preparing an IV solution and tubing to initiate intravenous therapy? Select all that apply.
Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.
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
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 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
A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply.
Pulse rate 90 bpm Blood pressure 104/68 mm Hg
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed.
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.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:
a winged infusion needle.
How is control over the extracellular concentration of potassium within the human body is exerted?
aldosterone.
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phosphorus
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
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
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.
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?
every 72 hours
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:
fluid overload.
A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?
fluid volume excess and acidosis
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?
hemolytic transfusion reaction: incompatibility of blood product
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?
renal failure
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
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?
Tighten the roller clamp to stop the infusion.
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?
hypertonic
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?
intacellular
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?
pH: 7.60; PaCO2: 64; HCO3: 42
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?
"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."
The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply.
-Rate of the IV solution -Location of the IV catheter access -Client's reaction to the procedure -Type of IV solution -Gauge and length of the IV catheter
What commonly used intravenous solution is hypotonic?
0.45% NaCl
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
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?
Sacral area
The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?
The client has anti-A antibodies.
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client?
hypertonic solution
A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by:
increasing ventilation through the lungs.
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?
infants
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
isotonic
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
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
total parenteral nutrition.
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?
3000
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)
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?
"I've been taking antacids almost every 2 hours over the past several days."
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration.
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?
1+
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply.
-clients with major trauma or burns -clients with liver and renal failure -clients with inflammatory bowel disease
Which explanations from the student about fluid and electrolyte balance demonstrate that learning has taken place regarding the function of water? Select all that apply.
-provides a medium for transporting substances throughout the body -facilitates cellular metabolism and proper cellular chemical functioning -helps maintain normal body temperature -facilitates digestion and promotes elimination
The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?
25
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Ensure that the prescribed solution is clear and transparent.
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?
Metabolic alkalosis
A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?
Stop the transfusion and infuse normal saline using a new administration set.
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
an infant age 4 months
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:
hypokalemia
The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to:
increase in fat cells.
A client with renal disease requires IV fluids. It is important for the nurse to:
place the fluids on an electronic device.
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:
the band members should drink large amounts of water.
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 is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?
Discontinue the infusion and record the volume left in the blood bag.
The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?
hypertonic
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
A nurse is presenting an in-service program to a group of graduate nurses about blood component therapy. The nurse determines that the education was successful when the group identifies which complication as the primary cause of transfusion-related client death in the United States?
Transfusion-related acute lung injury
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?
Notify the primary care provider immediately for possible fluid overload.
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