Chapter 40 Electrolytes
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Acute Confusion related to cerebral edema
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas
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.
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 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
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?
"I received a blood transfusion in the United Kingdom."
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response?
"Let me refer you to the blood bank so they can provide you with information."
The nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal pH. Place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2.
-H2CO3 level in the blood decreases -pH becomes more alkaline -Blood level of CO2 decreases -Decreased respirations -Carbon dioxide retention -Carbonic acid formed
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?
1 unit over 2 to 3 hours, no longer than 4 hours
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?
2,600 mL
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
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?
83 mL/hr
A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply.
Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?
Discontinue the IV and relocate it to another spot.
A 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 is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Ensure that the prescribed solution is clear and transparent.
Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 5.75 mg/dL (1.8 mEq/L) Based on these levels, the nurse would identify which imbalance?
Hypokalemia
A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?
Infants
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
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
As observed the nurse changing a peripheral venous access site dressing is idemonstrating inappropriate technique by implementing which action?
Not wearing gloves when preforming the intervention
The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?
O negative
A 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 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?
Potassium
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration.
How is control over the extracellular concentration of potassium within the human body is exerted?
aldosterone.
Potassium is needed for neural, muscle, and:
cardiac 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
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 weights
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
dema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
The process of filtration begins at the:
glomerulus
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.
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:
phlebitis.
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes
A decrease in arterial blood pressure will result in the release of:
renin.
A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:
replacement of fluids for those lost from vomiting and diarrhea.
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
A student has joined the marching band at his high school. The band begins practicing outside in August. This student and other band members need to be instructed that:
the band members should drink large amounts of water.
A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect?
"You won't have to endure any more needlesticks."
A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?
Banana
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
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
total parenteral nutrition.
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?
50 gtt/min
A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?
60 drops/mL
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?
Apply a warm compress.
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