Taylor Nursing Fundamentals CH40 - Fluid & Electrolytes

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Fluid outside cells." "Watery plasma, or serum, portion of blood." "Fluid in the tissue space between and around cells." "Fluid inside cells."

"Fluid in the tissue space between and around cells." Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

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 replace clotting factors that are altered from infection." "Granulocytes help to control bleeding associated with infection." "Granulocytes help third spacing of fluid that occurs with infection."

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

A nursing instructor is discussing administration of total parenteral nutrition (TPN) with a nursing student. Which statement by the student would require further teaching? "I will use tubing that contains a filter." "I will be sure to change the TPN tubing every other day." "I will use an infusion device to administer the TPN solution." "I will monitor the client's blood glucose levels."

"I will be sure to change the TPN tubing every other day." Explanation: TPN tubing should be changed daily to reduce the potential for infection. All other options are correct techniques for TPN administration.

The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction? "The lungs regulate metabolic acid-base disturbances by controlling carbon dioxide." "The heart circulates water and nutrients through the body." "The lungs remove water though exhalation." "The kidneys store and release antidiuretic hormone to increase water retention."

"The kidneys store and release antidiuretic hormone to increase water retention." Explanation: The pituitary glands store and release antidiuretic hormone rather than the kidneys. The other statements are correct regarding fluid and electrolyte balance.

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

1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

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? 3+ 1+ 4+ 2+

1+ Explanation: The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted? 30- to 35-degree angle 10- to 15-degree angle 20- to 25-degree angle 40- to 45-degree angle

10- to 15-degree angle Explanation: The IV catheter should be inserted at a 10- to 15-degree angle.

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? 1,500 mL/day 2,500 mL/day 3,500 mL/day 1,000 mL/day

2,00 mL/day

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? 3,750 500 3,000 1,000

3,000 Explanation: 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 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 12 cm H2O 9.5 cm H2O 5 cm H2O

3.5 cm H2O Explanation: The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? 20 gtt/min 30 gtt/min 40 gtt/min 50 gtt/min

50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

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? 30 drops/mL 90 drops/mL 60 drops/mL 120 drops/mL

60 drops/mL Explanation: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL)

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? 100 mL/hr 83 mL/hr 103 gtts/hr 13 mL/hr

83 mL/hr Explanation: When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (12). This is 83 mL/hr. Other options are incorrect

A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply. O AB B A

A B AB O Explanation: Persons with type AB blood are often called universal recipients, a fact that is rooted in their lack of agglutinins for either A or B antigens.

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? Packed red blood cells An isotonic solution A hypertonic solution A hypotonic solution

A hypotonic solution Explanation: Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. Hypertonic solutions draw water out of body cells while isotonic solutions have little effect on the distribution of body fluids. Blood transfusions do not cause the entry of water into body cells.

Which client will have more adipose tissue and less fluid? A woman A child An infant A man

A woman Explanation: Women have a lower fluid content because they have more adipose tissue then men.

The nurse is preparing to insert an intravenous catheter into an adult client. Place the following steps in the correct order. Use all options. 1 Insert the needle gently. 2 Release the tourniquet. 3 Stabilize the catheter or needle. 4 Place nondominant hand 1 to 2 in (2.5 to 5 cm) below the site and pull the skin taut. 5 Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the site. 6 Cleanse the site with chlorhexidine.

Apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the site. Cleanse the site with chlorhexidine. Place nondominant hand 1 to 2 in (2.5 to 5 cm) below the site and pull the skin taut. Insert the needle gently. Release the tourniquet. Stabilize the catheter or needle. Explanation: Interrupting the blood flow to the heart by applying a tourniquet causes the vein to distend. Distended veins are easy to see, palpate, and enter. Cleansing is necessary because organisms on the skin can be introduced into the tissues or the bloodstream with the needle. Chlorhexidine is the preferred antiseptic solution. Pressure on the vein and surrounding tissues using the nondominant hand helps prevent vein movement as the needle or catheter is being inserted. Inserting the needle or catheter gently minimizes trauma and deters passage of the needle through the vein. The tourniquet should be released after the needle is inserted, to restore normal blood flow, as it is no longer needed. Continue to stabilize the catheter or needle while flushing it with saline, to prevent trauma.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Apply petroleum-based ointment and sterile occlusive dressing. Apply pressure to insertion site for at least 3 minutes. Ask client to perform Valsalva maneuver. Instruct client to remain flat for 30 minutes.

Apply pressure to insertion site for at least 3 minutes. Explanation: The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.

A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate? Use the client's nondominant hand to hold the vein in place. Avoid use of a tourniquet. Consider venipuncture in the foot where veins are less visible. Select a large-gauge needle.

Avoid use of a tourniquet. Explanation: It may be possible and advantageous to avoid using a tourniquet when accessing a vein that is visually prominent on an older adult. Use of a tourniquet may result in bursting the vein, sometimes referred to as "blowing the vein," when it is punctured with a needle. Using a large-gauge needle may also "blow" the vein. A small gauge or butterfly should be used. Using veins in the foot is not appropriate nor is attempting to hold the vein in place.

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? An increased sense of thirst Cardiac volume intolerance Increase in nephrons in the kidneys Increased renal blood flow

Cardiac volume intolerance Explanation: 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 is taking a diuretic such as furosemide. When implementing client education, what information should be included? Decreased potassium levels Decreased oxygen levels Increased potassium levels Increased sodium levels

Decreased potassium levels Explanation: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

The nursing is caring for a client who has a peripheral intravenous (IV) catheter in place. The nurse is flushing the new IV tubing to hang the infusion. After reviewing the actions performed by the nurse in the image, which step should the nurse take next? Ensure there are no air bubbles in the tubing Discard the tubing, prime new tubing and administer the infusion at the prescribed rate of flow Place the contaminated tubing in a regular trash bag Obtain new IV tubing, prime the tubing and remember to charge the additional supplies to the client

Discard the tubing, prime new tubing and administer the infusion at the prescribed rate of flow Explanation: Intravenous site solutions should not become contaminated at any point prior to or during the priming process or when preparing to administer or connect an IV catheter to a client's IV site. The other answers are incorrect and not appropriate.

The nurse is preparing to change the IV tubing of a client receiving a peripheral venous IV infusion 5% dextrose and water based on the understanding that IV tubing is generally changed at which interval? Every 96 hours Every 60 hours Every 24 hours Every 48 hours

Every 96 hours. Explanation: Generally, IV tubing is changed every 72 to 96 hours. Changing the tubing helps to prevent contamination and bacterial growth.

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? Fluid Volume Deficit related to congestive heart failure, as evidenced by shortness of breath Congestive Heart Failure related to edema Fluid Volume Excess related to loss of sodium and potassium Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea

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

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 2 mL of 100 U/mL heparin. Flush the IV with 3 mL of normal saline. Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. Change from infusion with an electronic pump to infusion by gravity.

Flush the IV with 3 mL of normal saline. Explanation: If fluid is slow to infuse, the nurse should reposition the client's arm and/or flush the IV. Changing to IV infusion will not resolve the problem and heparin is not used for clearing peripheral IVs. Deep vein thrombosis is unrelated to slow IV fluid infusion.

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? Preschool-aged child Toddler School-aged child Infant

Infant Explanation: 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 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? School-age children Toddlers Infants Adolescents

Infants Explanation: Infants have a far greater volume of total fluid as a percentage of body weight than other children . However, this high percentage of fluid does not give infants a greater reserve against fluid deficit. Instead, it creates a vulnerability to fluid deficit due to the high percentage of fluid required for homeostasis. In addition, kidney immaturity and increased body surface area in relation to body size place infants at greater risk than older children or adults for fluid and electrolyte imbalances.

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. Intravenous therapy Electrolyte management Monitoring edema Fluid restriction Nutrition management Hypervolemia management

Intravenous therapy Electrolyte management Nutrition management Explanation: If a client is at a fluid volume deficit, intravenous therapy may be ordered by the primary care provider to replenish fluids and electrolytes, warranting fluid and electrolyte management. Nutrition management may help to increase and maintain electrolyte levels by adding foods high in certain electrolytes to the diet. Hypervolemia refers to fluid volume excess. Fluid restriction would be contraindicated because the client is already at a deficit. Edema would be monitored in the case of fluid volume excess.

A nurse is caring for a client who has recently suffered burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this client? 5% dextrose in 0.45% NaCl Lactated Ringer's 5% dextrose in 0.9% NaCl 0.9% NaCl (normal saline)

Lactated Ringer's Explanation: Lactated Ringer's solution is a roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43- ). It is used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea and in treating mild metabolic acidosis.

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? Respiratory acidosis Respiratory alkalosis Metabolic alkalosis Metabolic acidosis

Metabolic alkalosis Explanation: Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium? Aldosterone enhances renal excretion of potassium. Insulin promotes the transfer of potassium from the extracellular fluid into skeletal muscle and liver cells. A person loses approximately 30 mEq (30 mmol) of potassium. Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L).

Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L). Explanation: Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Ask the client every hour to drink more fluid. Leave water on the bedside table. Offer small amounts of preferred beverage frequently. Have a loved one tell the client to drink more.

Offer small amounts of preferred beverage frequently. Explanation: 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.

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 Infiltration Air embolism Sepsis

Phlebitis Explanation: Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. Gauge and length of the IV catheter Client's reaction to the procedure Location of the IV catheter access Rate of the IV solution Manufacturer of the IV catheter Type of IV solution

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 Explanation: The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client's reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

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? Slow the rate of IV fluids. Elevate the arm. Apply a warm compress. Remove the IV.

Remove the IV. Explanation: 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.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? Sodium is not regulated by natriuretic peptides. Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). If sodium is low, it means that there is not enough water. Sodium is regulated by the renin-angiotensin-aldosterone system.

Sodium is regulated by the renin-angiotensin-aldosterone system. Explanation: Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.

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? Infuse saline at a rapid rate. Administer oxygen. Prepare to give an antihistamine. Stop the transfusion immediately.

Stop the transfusion immediately. Explanation: The nurse needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? Urine becomes more diluted. The renal system retains more water. The client has a decreased sensation of thirst. The frequency of voiding increases.

The renal system retains more water. Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? Twist the tubing around a pencil. Milk the air in the direction of the drip chamber. Tap the tubing below the air bubbles. Tighten the roller clamp to stop the infusion.

Tighten the roller clamp to stop the infusion. Explanation: The priority nursing action is to tighten the roller clamp on the tubing as this action prevents forward movement of air. All other options are appropriate to remove the air once the tubing has been clamped.

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform? Weigh the volume of IV fluid before instilling. Weigh the client without soiled incontinence pads. Weigh the client before and after meals. Weigh the client's wet linen or dressing.

Weigh the client's wet linen or dressing. Explanation: In cases in which accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, or dressings and subtracts the weight of a similar dry item. The nurse does not weigh the client without soiled incontinence pads. The nurse does not weigh the client before and after meals to obtain an accurate assessment of the fluid output.

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 central venous access. an intermittent infusion device. an 18-gauge needle. a winged infusion needle.

a winged infusion needle. Explanation: Winged infusion needles are short, beveled needles with plastic flaps or wings. They may be used for short-term therapy or when therapy is given to a child or infant.

A client with dehydration will have an increase in: albumin glucose aldosterone potassium

aldosterone Explanation: The rennin-angiotensin-aldosterone and natriuretic peptide hormone systems regulate the volume within narrow limits by adjusting fluid intake and the urinary excretion of sodium, chloride, and water.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? an adolescent age 17 years an infant age 4 months a woman age 45 years a man age 50 years

an infant age 4 months Explanation: An infant has considerably more total body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits. An adolescent at 17 years is considered to have an adultlike body system similar to the 45-and 50-year-old.

A mother of an infant calls the pediatric nurse and asks which fluids she should provide her baby since he is suffering from diarrhea. The nurse would inform the mother not to give: bottled water. Pedialyte. breast milk. formula.

bottled water. Explanation: Hyponatremic seizures among infants fed with commercial bottled drinking water have been noted.

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? chloride and magnesium potassium and sodium calcium and phosphorus potassium and chloride

calcium and phosphorus Explanation: The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance.

Potassium is needed for neural, muscle, and: skeletal function. cardiac function. auditory function. optic function.

cardiac function. Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

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 eating a sandwich client's urination vomiting infusion of intravenous solution

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

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? daily BUN and serum creatinine monitoring daily electrolyte monitoring daily weights output measurements

daily weights Explanation: Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client's daily weight may be the more accurate measurement of a client's fluid status. Laboratory tests are helpful in assessing kidney function and electrolyte values, but do not provide the precise information on fluid losses or gains as is provided by a daily weight (at the same time, using the same scale). Output measurements are not meaningful without intake measurements.

Edema happens when there is which fluid volume imbalance? water deficit water excess extracellular fluid volume excess extracellular fluid volume deficit

extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? bacterial reaction: bacteria present in the blood febrile reaction: fever develops during infusion allergic reaction: allergy to transfused blood hemolytic transfusion reaction: incompatibility of blood product

hemolytic transfusion reaction: incompatibility of blood product Explanation: The listed symptoms occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever; hypertension; dry, flushed skin; and abdominal pain occur.

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 plasma hypotonic isotonic

hypertonic Explanation: Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.

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 hypotonic solution colloid solution isotonic solution

hypertonic solution Explanation: Hypertonic solutions are used in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. Hypotonic solutions are administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. However, these solutions are not related to clients with cerebral edema.

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? edema circulatory overload hypervolemia hypovolemia

hypovolemia Explanation: The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.

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? interstitial intracellular extracellular intravascular

intracellular Explanation: Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment.

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? maintenance of cell size removal of waste maintenance of blood volume transportation of nutrients

maintenance of cell size Explanation: The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.

The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply. osmosis acid-base balance filtration active transport diffusion

osmosis filtration diffusion active transport Explanation: Osmosis, filtration, diffusion, and active transport maintain fluid homeostasis. Acid-base balance concerns chemical reactions in the body that influence metabolism.

A client with renal disease requires IV fluids. It is important for the nurse to: check the intravenous rate once a shift. administer the fluids through the dialysis access. catch the rate up when it falls behind. place the fluids on an electronic device.

place the fluids on an electronic device. Explanation: An IV electronic infusion device usefully and accurately regulates the infusion rate, especially if fluid administration must be watched very carefully, such as when infusing fluid to a renal client or when administering certain medications.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? palpating the veins on the nondominant hand asking if the client is right or left handed asking the client to pump their fist several times placing the tourniquet on the upper arm for 2 minutes

placing the tourniquet on the upper arm for 2 minutes Explanation: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.

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? administer blood products provide protein supplements treat the client's infection replace fluid and electrolytes

replace fluid and electrolytes Explanation: 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.

The primary extracellular electrolytes are: sodium, chloride, and bicarbonate. magnesium, sulfate, and carbon. potassium, phosphate, and sulfate. phosphorous, calcium, and phosphate.

sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.

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 is medication that is mixed into the total parenteral nutrition." "The white milky solution is the total parenteral nutrition." "The white milky solution should be discarded and replaced with a clear solution." "The white milky solution contains lipids, or fat, to provide extra calories."

"The white milky solution contains lipids, or fat, to provide extra calories." Explanation: 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.

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: 600 gtt/min 100 gtt/min 160 gtt/min 60 gtt/min

100 gtt/min Explanation: 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.

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

An implanted central venous access device (CVAD) Explanation: 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.

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV? Clean the insertion site daily using sterile technique. Insert the largest gauge possible to maximize flow and minimize the risk of occlusion. Flush the catheter every six hours with hypertonic solution if the IV is not in constant use. Change the site every three to four days.

Change the site every three to four days. Explanation: Peripheral IV sites should be rotated every 72 to 96 hours, depending on the institutional protocol. IV insertion sites are not cleansed daily, but the site should be assessed per institutional protocol or every nursing shift. Flushes are not necessary every six hours. Hypertonic solution is not used for IV flushes. The smallest gauge that is practical should be inserted in order to minimize trauma.

A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)? Changing the dressing on a client's peripheral IV site Deaccessing a client's implanted port Removing a client's PICC in anticipation of the client's discharge Initiating a client's transfusion of packed red blood cells

Changing the dressing on a client's peripheral IV site Explanation: Changing a peripheral IV dressing poses a lower risk to the client's safety than the other listed nursing actions and this would be the safest task to delegate. It would be inappropriate to delegate a blood transfusion, deaccess an implanted port, or remove a PICC to an LPN.

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? Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV Call the primary care provider to see whether anti-inflammatory drugs should be administered. Discontinue the IV and relocate it to another site. Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.

Discontinue the IV and relocate it to another site. Explanation: The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.

A nurse is measuring intake and output for a client who has congestive heart failure. What does not need to be recorded? Sips of water Parenteral fluids Frozen fluids Fruit consumption

Fruit consumption Explanation: Any water consumption must be recorded in order to closely monitor a client who has congestive heart failure. Many of these clients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.

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 Occlusive dressing Sealed IV dressing Transparent semipermeable membrane dressing

Gauze dressing Explanation: A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. Transparent semipermeable membranes are a type of sealed IV dressing. Occlusive dressings would not be appropriate.

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 Respiratory alkalosis Metabolic acidosis Respiratory acidosis

Metabolic alkalosis Explanation: Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high.

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. Notify the primary care provider immediately because these are signs of speed shock. Check all clamps on the tubing and check tubing for any kinking. Place the client in the Trendelenburg position to keep the client's airway open.

Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify the primary care provider immediately because the client may be exhibiting signs of fluid overload. The Trendelenburg position is not used to rectify this complication, but to help raise the blood pressure of a client with hypotension.

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 fingerprinting over sternum nausea and vomiting muscle twitching

distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply. provides free hydrogen ions for cells acts as a solvent for electrolytes helps maintain normal body temperature supplies glucose for energy facilitates cellular metabolism

facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes Explanation: Water in the body functions primarily to provide a medium for transporting nutrients to cells and wastes from cells; to provide a medium for transporting substances such as hormones, enzymes, blood platelets, and red and white blood cells throughout the body; to facilitate cellular metabolism and proper cellular chemical functioning; to act as a solvent for electrolytes and nonelectrolytes; to help maintain normal body temperature; to facilitate digestion and promote elimination; and to act as a tissue lubricant. Water does not, by itself, provide hydrogen or glucose.

Which client has more extracellular fluid? female school-age child adolescent man newborn adult woman

newborn Explanation: Newborns have more extracellular fluid than intracellular fluid.

A decrease in arterial blood pressure will result in the release of: protein. insulin. renin. thrombus.

renin. Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply. abdominal distention confusion ventricular dysrhythmia constipation respiratory muscle weakness

respiratory muscle weakness confusion ventricular dysrhythmia Explanation: 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.

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 reduce the potential for blood clots to avoid restriction of mobility to prevent compromising circulation to prevent pain and discomfort

to prevent compromising circulation Explanation: 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 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?" "Have you been experiencing difficulty breathing?" "Have you been experiencing chest pain?" "Have you been having diarrhea?"

"Have you been experiencing muscle weakness or leg cramps?" Explanation: Hypokalemia is a potassium deficit. When the level of potassium decreases, potassium moves out of the cells, creating an intracellular potassium deficiency. Typical symptoms include muscle weakness and leg cramps. Hyperkalemia is likely to cause diarrhea. Hypokalemia is not known to cause chest pain or difficulty breathing, unless an arrhythmia occurs due to an imbalance in the potassium level.

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? "I have never given blood before." "My blood type is B positive." "I received a blood transfusion in the United Kingdom." "My spouse would also like to donate blood."

"I received a blood transfusion in the United Kingdom." Explanation: Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.

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 had a fever for the past 3 days that just doesn't seem to go away." "I've been taking antacids almost every 2 hours over the past several days." "I was breathing so fast because I was so anxious and in so much pain." "I've had a GI virus for the past 3 days with severe diarrhea."

"I've been taking antacids almost every 2 hours over the past several days." Explanation: Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.

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? "This surgery has a very low chance of hemorrhage, so you will not need blood." "We now have artificial blood products, so giving your own blood is not necessary." "Unfortunately, your own blood cannot be reinfused during surgery." "Let me refer you to the blood bank so they can provide you with information."

"Let me refer you to the blood bank so they can provide you with information." Explanation: 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.

A client is receiving a transfusion of packed red blood cells, and the nurse has obtained the first set of vital signs after initiating the transfusion. These closely match the pretransfusion vital signs with the exception of a 1°F (0.5°C) increase in the oral temperature. The client denies other symptoms and is not in distress. What is the nurse's most appropriate action? Discontinue transfusion immediately, and infuse normal saline with new tubing. Promptly discontinue the transfusion, and remove the client's IV. Administer acetaminophen as prescribed. Call the blood bank and obtain diagnostic tubes.

Administer acetaminophen as prescribed. Explanation: If the client's only sign or symptom is an increase in temperature, which is less than 2°F (1°C), there is no need to wholly discontinue the transfusion. The health care provider should be informed, however; and the client may receive acetaminophen or an antihistamine, as prescribed. A febrile reaction includes a fever of 2°F (1°C) or higher, tachycardia, and presence of headaches or backache.

The nurse is caring for a client with severe edema who has crackles in the lungs. Which nursing intervention is the priority for this client? Increase oral intake to flush excess fluids. Ask provider to order a low-salt diet. Administer furosemide as ordered. Treat the underlying condition that contributes to increased fluid volume.

Administer furosemide as ordered. Explanation: Control of edema, and thus restoration of fluid balance, can be accomplished by treating the disorder contributing to the increased fluid volume, restricting or limiting oral fluids, reducing salt consumption, discontinuing IV fluid infusions or reducing the infusing volume, and/or administering drugs that promote urine elimination. The priority is to administer the furosemide, as this will decrease the fluid volume and decrease the crackles in the lungs.

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority? Measure the catheter and compare it with the length listed in the chart. Apply a tourniquet to the client's upper arm. Apply pressure to the site with sterile gauze until hemostasis is achieved. Have the client perform the Valsalva maneuver.

Apply a tourniquet to the client's upper arm. Explanation: In the event that a portion of the catheter breaks off during removal of a PICC, the nurse should immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of the piece of catheter into the right atrium. The other actions should be performed during a routine PICC removal. Use of the Valsalva maneuver by the client during expiration reduces the risk for air embolism. Measurement and inspection of the PICC following removal ensures that the entire catheter was removed. Application of adequate pressure with sterile gauze following PICC removal prevents hematoma formation.

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? B positive O negative A positive AB negative

O negative Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. Rh-negative persons should never receive Rh-positive blood.

A client is admitted to the intensive care unit with a calcium level of 4.2 mg/dL. What is the priority action by the nurse? Administer lactated ringers solution at 125 mL/hr Prepare to administer calcium gluconate as prescribed Administer potassium chloride 20 mEq by mouth Perform repeat lab work

Prepare to administer calcium gluconate as prescribed Explanation: The client is experiencing a dangerously low calcium level. Normal calcium levels are between 8.5 and 10.2 mg/dL. Replacement of calcium with calcium gluconate IV would be the priority action as soon as it is prescribed. There is no indication that the potassium level is low. LR may be administered but is not a priority action. Lab work will be repeated after an intervention.

A client's atrial pressure is known to be increased. What effect will this ultimately have on the client's sodium levels? Sodium levels will match potassium levels. Sodium levels will remain unchanged. Sodium levels will rise. Sodium levels will decrease

Sodium levels will decrease. Explanation: When atrial pressure is increased, ANP released by the atrial and ventricular myocytes acts on the nephron to increase sodium excretion. Sodium levels consequently decrease. Sodium levels do not precisely match potassium levels.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Start an IV of normal saline as prescribed. Give the patient orange juice with additional sugar. Encourage the patient to increase fluid intake.

Start an IV of normal saline as prescribed. Explanation: To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.

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. Stop the transfusion and infuse normal saline using the blood tubing. Notify the health care provider of the client's response. Check the client's vital signs.

Stop the transfusion and infuse normal saline using a new administration set. Explanation: A client who reports difficulty breathing during a blood transfusion may be having a transfusion reaction. The first action is to stop the transfusion and infuse normal saline using a new administration set. Changing the administration set prevents the client from receiving more of the blood that is causing the reaction. After stopping the transfusion and infusing normal saline using a new administration set, the nurse should check the client's vital signs and notify the health care provider of the reaction.

A nurse is preparing to re-site a client's IV during the client's hospital stay following a mastectomy. What accurately describes an assessment that should be made before starting the infusion? The nurse should choose the client's dominant arm, if possible. The nurse should assess the preferred site, ideally the dorsal and ventral surfaces of the upper extremities. The nurse should assess the arms and hands for a potential site, preferably in the antecubital vein. The nurse should use the extremity on the same side as the mastectomy, if possible, to avoid immobilizing both extremities.

The nurse should assess the preferred site, ideally the dorsal and ventral surfaces of the upper extremities. Explanation: The nurse should initiate venipuncture on the dorsal or ventral surface of the upper extremities. The IV should not be located in the antecubital vein because this site is vulnerable to displacement. The nondominant arm should be used for convenience, and extremities compromised from a previous condition should be avoided.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? To assure effective administration of the prescribed IV solution To provide for effective time management in the administration of the prescribed IV solution To assure the IV solution is appropriate for this administration To demonstrate effective nursing care in the administration of the prescribed IV solution

To assure the IV solution is appropriate for this administration Explanation: The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is appropriate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.

Which statement most accurately describes the process of osmosis? Plasma proteins facilitate the reabsorption of fluids into the capillaries. Water moves from an area of lower solute concentration to an area of higher solute concentration. Solutes pass through semipermeable membranes to areas of lower concentration. Water shifts from high-solute areas to areas of lower solute concentration.

Water moves from an area of lower solute concentration to an area of higher solute concentration. Explanation: Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the reabsorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a 47-year-old who had a colon resection yesterday and is reporting pain a newly admitted 88-year-old with a 2-day history of vomiting and loose stools a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today a 60-year-old who is 3 days post-myocardial infarction and has been stable.

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Explanation: Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).

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? muscle weakness metabolic acidosis increased intracranial pressure (ICP) cardiac irregularities

cardiac irregularities Explanation: 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.

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 inflammatory bowel disease clients with liver and renal failure clients with major trauma or burns clients who are recovering from cataract surgery clients who have not eaten for a day

clients with major trauma or burns clients with liver and renal failure clients with inflammatory bowel disease Explanation: The nurse knows that clients with major trauma or burns, clients with liver and renal failure, and clients with inflammatory bowel disease are likely candidates for TPN. Clients who have not eaten for a day or clients recovering from cataract surgery are not likely candidates for TPN. Clients who have not eaten for 5 days and are not likely to eat during the next week are considered for TPN.

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: smaller stomach capacity. increase in fat cells. increase in muscle mass. decreased skin area.

increase in fat cells. Explanation: The decreasing percentage of body fluid in older adults is related to an increase in fat cells. In addition, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults. Older adults do not have an increase muscle mass, smaller stomach capacity, or decrease skin area.

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? nausea, vomiting, and constipation muscle weakness, fatigue, and constipation diminished cognitive ability and hypertension muscle cramping and tetany

muscle cramping and tetany Explanation: Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply. poor skin turgor orthostatic hypotension slow-filling peripheral veins decreased urine output dry mucous membranes

orthostatic hypotension decreased urine output slow-filling peripheral veins Explanation: The signs and symptoms of an ECF volume deficit reflect decreases in fluid volume in the vascular and interstitial spaces. The signs and symptoms of a decrease in vascular volume include orthostatic or postural changes in pulse rate and blood pressure (i.e., an increase in pulse rate and decrease in blood pressure when the person moves from a lying to a standing position); weak, rapid pulse; decreased urine output; and slow-filling peripheral veins. The signs and symptoms of decreased interstitial volume include dry mucous membranes and poor skin turgor.

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l) pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) Explanation: In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: an infiltration. rapid fluid administration. phlebitis. a systemic blood infection.

phlebitis. Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.

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 increased cardiac output excessive use of laxatives diaphoresis

renal failure Explanation: Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.