(skills/fundamentals) Lippincott Ch 40: Fluid, Electrolyte, and Acid Base Balance

normal saline

-Stop blood transfusion immediately with adverse transfusion reaction: hives, anaphylaxis, fever, back pain, shock, or respiratory difficulty. -Start IV with ________ _________ -Call Provider

peripheral venous catheter

-catheter placed in a peripheral vein (cephalic, saphenous, femoral, auricular) -short (<3 in) -brief dwell time (< 1 week) -not considered to be central lines

Tunneled Central Venous Catheter

-this catheter is implanted into the internal or external jugular or subclavian vein. -The length of this catheter is >8 cm (approximately 90 cm, on average), depending on patient size -intended for long-term use

hypotonic

0.45% Normal Saline (1/2 NS), 0.22% Normal Saline (1/4 NS), and 0.33% Normal Saline (1/3 NS) are examples of ___________ solutions.

isotonic

0.9% Normal Saline (NS), 5% Dextrose in Water (D5W), and Lactated Ringers (LR or RL) are examples of ____________ solutions.

hypertonic

3% Saline, 5% Saline, 10% Saline, 5% Dextrose in 0.9% Saline (5DNS), 5% Dextrose in 0.45% Saline (5D1/2NS), and 5% Dextrose in Ringers Lactacte (5DLR) are examples of ____________ solutions.

d (The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.)

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: a) hypocalcemia. b) hypothyroidism. c) hypoglycemia. d) hypokalemia.

b

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? a) As fast as the client can tolerate b) 1 unit over 2 to 3 hours, no longer than 4 hours c) 75 mL/hr for the first 15 minutes, then 200 mL/hr d) 200 mL/hr

b, d (Tubing for a transfusion is primed with normal saline, not lactated Ringer's. Vital information is checked with the assistance of another nurse. Blood pressure and heart rate are not expected to rise after the infusion begins and the infusion should be at a slow rate for the first few minutes. There is no need to collect cultures unless the client experiences a suspected transfusion reaction.)

A client has been prescribed 2 units of packed red blood cells. A type and cross-match has been performed and the first unit has arrived on the floor from the blood bank. When administering this client's blood transfusion, the nurse should perform which actions? Select all that apply. a) Obtain appropriate tubing and prime it with normal saline or lactated Ringer's. b) Ask another nurse to assist with confirming the order, blood group, and other vital information. c) Take baseline vital signs and expect slight increases in blood pressure and heart rate after the infusion begins. d) Start the administration slowly for the first 15 minutes of the transfusion. e) Collect the last 5 mL of the packed cells and send to the laboratory for culturing.

b (The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.)

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? a) Slow the rate of IV fluids. b) Remove the IV. c) Apply a warm compress. d) Elevate the arm.

a (The basilic vein is used most often, but the median cubital and cephalic veins in the antecubital area also can be used. Scalp veins are appropriate for peripheral venous access in infants under 9 months of age.)

A client is scheduled for insertion of a peripherally inserted central catheter. When assisting with the procedure, the nurse would expect that which site would most likely be used? a) Basilic vein b) Cephalic vein c) Median cubital vein d) Scalp vein

a (Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third-spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia.)

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? a) platelets b) granulocytes c) albumin d) cryoprecipitate

a (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 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? a) An implanted central venous access device (CVAD) b) A peripheral venous catheter inserted to the antecubital fossa c) A peripheral venous catheter inserted to the cephalic vein d) A midline peripheral catheter

a,b,c,d,e

A client with emphysema has aPaCO2 is 80 mm Hg on an arterial blood gas report. Which action(s) will the nurse take? Select all that apply. a) Auscultate lung sounds b) Monitor arterial blood gasses c) Elevate head of bed d) Monitor oxygen saturation e) Provide breathing treatments and medications as prescribed

a. (The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.)

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? a) Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. b) Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. c) Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. d) Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

d (Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.)

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a. Recording intake and output. b. Testing skin turgor. c. Reviewing the complete blood count. d. Measuring weight daily.

a,c,d,f (In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.)

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. a. "Try to drink at least six to eight glasses of water each day." b. "Try to limit your fluid intake to 1 quart of water daily." c. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." e. "Temporarily increase foods containing caffeine for their diuretic effect." f. "Weigh yourself daily and report any changes in your weight."

d (The foot is a potential IV insertion site for neonates and infants, but it should not be used once a child can walk.)

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? a) Preschool-aged child b) School-aged child c) Toddler d) Infant

a (If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first.)

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? a) Remove the IV from the site and start at another location. b) Immediately notify the primary care provider. c) Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. d) Aspirate the catheter and attempt to flush again.

a. (The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.)

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? a) Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. b) Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. c) Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. d) Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

d, e (these are hypotonic)

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. a. 5% dextrose in 0.9% NaCl b. 0.9% NaCl (normal saline) c.Lactated Ringer's solution d. 0.33% NaCl (⅓-strength normal saline) e. 0.45% NaCl (½-strength normal saline) f. 5% dextrose in Lactated Ringer's solution

b

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? a) "Infiltration is the inflammation of the vein, while phlebitis is a localized irritation." b) "Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." c) "Infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed." d) "Infiltration occurs when an IV is improperly placed, and phlebitis indicates circulatory overload."

implanted port

A small chamber attached to an indwelling line that is surgically implanted under the skin in the upper chest or arm.

medulla

CO2 level is sensed by chemoreceptors in the ____________ which causes an increase or decrease in respiratory rate

smaller

Fat cells contain little water, whereas lean tissue is rich in water. Thus, the more obese a person is, the ___________ the person's percentage of total body water is when compared with body weight. -obese people are at increased risk for dehydration.

antecubital

For IV Therapy: Do not use the ____________ veins if another vein is available. They are not a good choice for infusion because flexion of the patient's arm can displace the IV catheter over time.

22-26

HCO3- (amount of bicarbonate in arterial blood) should be _______ - ______ mmol/L

nondominant

In general, either arm may be used for IV therapy. Usually the _________________ arm is selected for patient comfort and to limit movement in the impacted extremity.

nonelectrolytes

In the human body, urea and glucose are examples of ___________________.

kidney

Increased creatinine and BUN are found with impaired __________ function.

20. 1

Normal ECF has a ratio of ________ parts bicarbonate to _____ part carbonic acid. The exact quantities are unimportant for acid-base balance as long as they remain in this ratio.

35-45

PaCO2 (pressure of CO2 dissolved in arterial blood) should be _______ - ________ mmHg

70-100

PaO2 (pressure of O2 dissolved in arterial blood) should be _______ - ________ mmHg

alkalosis

S/S of respiratory or metabolic __________ include: - inability to concentrate -lightheadedness -hypoventilation to compensate -anxiety and irritability -hypokalemia -mental confusion -hyperreflexia (muscle twitching) -tremors, muscle cramps, numbess

acidosis

S/S of respiratory or metabolic __________ include: -change in LOC (drowsiness, disorientation, unconsiousness) -dizziness -hyperreflexia (muscle twitching) -hyperkalemia -warm, flushed skin -headache -rapid, shallow respirations

93-98

SaO2 (arterial oxygen saturation) should be _____- _______%

infiltration

Signs of ___________ at IV site: -pale, blanched skin -leaking fluid -cool to touch -Swelling -pain at infusion site -significant decrease in the flow rate

phlebitis

Signs of ___________ at IV site: -redness -warmth -pus -slight edema of the vein above the insertion site -streak formation

a

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? a) calcium and phosphorus b) potassium and sodium c) chloride and magnesium d) potassium and chloride

Nontunneled Percutaneous Central Venous Catheter

These catheters can have double, triple, or quadruple lumens and are >8 cm, depending on patient size. -They are introduced through the skin into the internal jugular, subclavian, or femoral veins. -mainly used short-term critical access with patients who are unstable -high risk for complications, particularly infection -shorter dwell time (<14 days).

c (ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level.)

What is the lab test commonly used in the assessment and treatment of acid-base balance? a) Complete blood count b) Basic metabolic panel c) Arterial blood gas d) Urinalysis

c (A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis.)

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

third spacing

_________ __________ occurs when there is an abnormal accumulation of fluid from the intravascular space into the interstitial space or transcellular space. Also called edema. (examples: ascites, pleural effusion)

respiratory alkalosis

__________ ___________ is due to loss of CO2 from the lungs due to hyperventilation, pain, nicotine overdose, and increased metabolic states.

respiratory acidosis

__________ ___________ is due to retention of CO2 by the lungs caused by acute and chronic respiratory disease, decreases respiratory stimuli, and CNS depression (anesthesia or overdose)

metabolic acidosis

__________ ___________ is due to too much H+ caused by diabetic ketoacidosis, hypermetabolism, hyperkalemia, and renal failure, and too little HCO3- caused by dehydration, liver failure, and diarrhea.

midline

___________ catheters are inserted peripherally into the upper arm into the basilic, cephalic, or brachial veins. -These catheters are longer (>3 in) than peripheral venous catheters. -not considered to be central lines and should not be used to infuse vesicants, hyperosmolar, or irritating solutions. -Recommendations for dwell time at a particular insertion site vary from 1 to 4 weeks

Potassium

____________ is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

isotonic

____________ solutions are given to increase extracellular fluids because the patient has lost the fluids through blood loss, dehydration through vomiting or diarrhea, or surgery.

hypertonic

____________ solutions are given to treat hyponatremia and cerebral edema.

a

____________ tend to have less muscle and more fat, therefore their total body water (TBW) is lower. a. women b. men

hypotonic

_____________ solutions are contraindicated for patients with increased intracranial pressure (ICP), burns, and trauma.

hypotonic

_____________ solutions are given to hydrate a patients cells. Cells become dehydrated through diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemia.

metabolic alkalosis

_______________ __________ is due to too little H+ caused by vomiting, NGT suctioning, hypokalemia, and diuretics, and too much HCO3- caused by overuse of antacids.

half

a blood infusion should be started within a _______ hour of receiving blood on unit

PICC (peripherally inserted central catheter)

a type of CVAD (central venous access device) (>20 cm depending on patient size) that can be introduced into a peripheral vein (usually the basilic, median cubital, brachial, or cephalic veins. -A specially trained registered nurse or other advanced practice professional can insert this type of catheter. -for patients requiring long-term IV therapy (6 weeks to 6 months)

7.35-7.45

arterial blood pH should be _________ - _________

less

older adults have ________ total body water than younger adults. -at risk for dehydration.

hypotonic

side effects of ____________ solutions include cell lysis and depletion of circulatory system fluid.

hypertonic

side effects of ____________ solutions is cell shrinkage, fluid overload, and edema.

1.003-1035

specific gravity of urine should be _________-__________

sodium (Na+)

the chief ECF ion is ____________.

potassium (K+)

the chief ICF ion is ___________.

4.5-5.1

the normal serum level of Ca2+ is ______ to _______ mEq/L

97-107

the normal serum level of Cl- is ______ to _______ mEq/L

25-29

the normal serum level of HCO3- is ______ to _______ mEq/L

3.5-5

the normal serum level of K+ is ______ to _______ mEq/L

1.3-2.3

the normal serum level of Mg2+ is ______ to _______ mEq/L

135-145

the normal serum level of Na+ is ______ to _______ mEq/L

2.5-4.5

the normal serum level of PO4- is ______ to _______ mEq/L

packed red blood cells (PRBCs)

this blood product is administered to increase the number of RBCs after trauma or surgery, or to treat severe anemia.

Fresh Frozen Plasma (FFP)

this blood product is particularly useful in emergencies that involve massive blood loss because it will restore both coagulation factors and blood volume.

cryoprecipitate

this blood product is used to treat bleeding due to hemophilia, disseminated intravascular coagulation, or depletion of coagulation factors such as fibrinogen following massive blood loss

true

true or false: to measure fluid loss in a patient who wears adult absorbent undergarments, Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb= 1 pint.

6

urine pH should be around ____.