fluid, electrolytes, acid-base balance
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
Fluid in the tissue space between and around cells 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 the interstitial fluid (fluid in the tissue space between and around cells) and Intravascular fluid (watery plasma or serum, portion of blood)
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
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
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 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 is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed. 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 added sugar may be given to a person with low blood sugar.
The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action?
Stop the transfusion. Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.
A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action?
The nurse should carefully remove the tape from the outside to the insertion point while supporting the catheter. Gloves should be worn.
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. orthostatic hypotension dry mucous membranes poor skin turgor decreased urine output slow-filling peripheral veins
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 writes a a problem-based care plan, citing the client's excess fluid volume. What risk factor does the nurse expect to assess in this client?
acute kidney injury Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive acute kidney failure. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.
A client is taking a diuretic that increases urinary output. What nursing concern is appropriate to base an educational plan?
decreased fluid volume risk An appropriate nursing concern for a client taking a diuretic that increases urinary output would be decreased fluid volume risk. The nurse will educate the client on the symptoms of dehydration, how to increase fluid intake, and the need to maintain a record of daily weights. Diuretics do not affect elimination or cause urinary retention. In addition, diuretics do not affect the skin.
Which body fluid is the fluid within the cells, constituting about 70% of the total body water?
intracellular fluid (ICF) Intracellular fluid is the fluid within the cells, constituting about 70% of total body fluid. Extracellular fluid is all fluid outside the cells and includes intravascular and interstitial fluids.
By which route do oxygen and carbon dioxide exchange in the lung?
oxygen and carbon dioxide exchange in the lung's alveoli and capillaries by diffusion Diffusion is the tendency of solutes to move freely throughout a solvent by moving from an area of higher concentration to an area of lower contraction
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." The specific types of granulocytes are neutrophils, eosinophils, and basophils. Granulocytes, specifically neutrophils, help the body fight bacterial infections.
While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance?
"How much do you typically urinate during the day?" Questions and leading statements about fluid balance are part of a comprehensive health history. Urinary output is one factor to consider in fluid balance. Bowel movements, especially if a client is having multiple loose stools a day, may affect fluid balance but is not the most appropriate question to ask. Leg cramps can occur when there is an electrolyte imbalance but is not the most appropriate question. Lastly, coffee can have diuretic-like properties but is also not the most appropriate question to ask to assess fluid balance.
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 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.
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas 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.
A group of nursing students is reviewing information about the body's electrolytes. The students demonstrate understanding of the material when they identify which electrolyte as having a reciprocal relationship with calcium?
Calcium and phosphorus typically show a reciprocal relationship such that an increase in one leads to a decrease in the other. Sodium is the major cation in the extracellular fluid. Sodium, potassium, and magnesium do not share a relationship with calcium
The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O?
55-year-old with congestive heart failure on furosemide Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O.
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?
Avoid use of a tourniquet. 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.
A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?
Compare the total intake and output of fluids for the 24 hours. The nurse must pay attention to certain parameters when assessing a client's fluid status. This means comparing the total intake and output of fluids for a given period of time. It is more accurate to compare the client's fluid intake with the previous time period than with another client. The nurse does not need to report that fluid to the health care provider's nurse but rather document the information in the client's health record and if there are differences then that information should be reported to the health care provider and the end-of-shift report.
A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they 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 Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.
A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply. respiratory muscle weakness confusion ventricular arrythmia abdominal distention constipation
respiratory muscle weakness confusion ventricular arrythmia With hypophosphatemia, findings include neuromuscular dysfunction; weakness, especially respiratory muscles; fatigue; myocardial depression; ventricular arrhythmias; 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 client is preparing for discharge to home following a diagnosis of hypoparathyroidism with associated low parathyroid hormone. Which food(s) will the nurse include when creating a diet-based teaching plan for the client? peanuts yogurt broccoli tofu peaches bananas
yogurt, broccoli, tofu The parathyroid produces the hormone parathormone (PTH), which regulates serum calcium levels. A low level of PTH results in hypocalcemia. The nurse's diet-based teaching plan should include foods that include high levels of calcium, such as dairy products like yogurt and cheese. Dark green vegetables like broccoli, spinach, or greens are important sources of calcium. Oysters, salmon, and sardines are also great sources of calcium.
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?" 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.
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?
"I should drink 2,500 mL/day of fluid." In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?
3.5 cm H2O The 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 nurse is preparing to measure jugular venous distention in a client. To ensure accuracy, the nurse would elevate the head of the client's bed to:
45 degrees When measuring jugular venous distention, the nurse would elevate the head of the client's bed to 45 degrees so that the sternal angle is 5 cm above the right atrium. Any other elevation would lead to inaccurate results.
A home care nurse is visiting a client with an acute kidney injury 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. To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?
ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac arrythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.
A health care provider writes a prescription to "force fluids." What will be the first action the nurse will take in implementing this prescription?
Explain to the client why this is needed. Several techniques are recommended to help the client drink greater than average amounts of fluids. The nurse should begin by explaining to the client in understandable terms the rationale for the increased fluids and the specific goal of taking the daily amount of fluids prescribed. The largest amount of fluid should be consumed during the day to decrease night waking to void. It is not necessary for the nurse to decide how much fluid to increase every 8 hours.
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?
Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended (bulging) Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.
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 the IV solution is appropriate for this administration 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 effective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.
The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:
fluid volume excess. A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess.
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find?
hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.
A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance?
hypokalemia All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia.
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address?
increased hydrostatic pressure The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.
