Wellness test 3- Fluid, Electrolyte, Acid base PrepU

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 is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."

The nurse is caring for a client with end-stage renal disease who voided 200 mL in the past 24 hours. The primary care provided ordered for a fluid restriction based on measurable urine output from the previous 24 hours added to insensible fluid losses. How much should the nurse provide for the 24-hour fluid allowance?

1,300 mL

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

2,500 mL/day

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids.

A client has been diagnosed with stage II breast cancer and will require 8 weeks of chemotherapy. Which intravenous access would the nurse anticipate?

Groshong catheter tunneled under the subclavian vein

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

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

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.

A decrease in arterial blood pressure will result in the release of:

Renin

Which age group is at risk for fluid and electrolyte imbalances resulting from fad dieting?

adolescents

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

Potassium is needed for neural, muscle, and:

cadriac function

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

Which is a common anion?

chloride (Cl-)

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 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

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

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 reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mmHg and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition?

metabolic alkalosis

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action? (touching the iv tape with bare hands)

not wearing gloves when preforming the intervention

When considering client safety, what is the primary purpose of the action demonstrated by the nurse involved in preparing for the administration of a prescribed IV solution?

preventing embolus

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000

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

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

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

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 (250 mL/ 60 minutes) (20) (4.1666)(20) = 83.3

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)

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

Arterial Blood Gas

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action?

Discontinue the IV

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.

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert?

Muscle weakness, fatigue, and dysrhythmias

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.

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

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.

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 who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parental nutrition