Fundamental Chapter 40: Fluid Electrolyte and Acid Base Balance

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: A) phlebitis. B) an infiltration. C) a systemic blood infection. D) rapid fluid administration.

A) 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.

Potassium is needed for neural, muscle, and: A) optic function. B) auditory function. C) cardiac function. D) skeletal function.

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

Which is a common anion? A) magnesium B) potassium C) chloride D) calcium

C) chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

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? A) 1,500 mL B) 1,800 mL C) 2,300 mL D) 2,600 mL

D) 2,600 mL Explanation: The average adult daily fluid source is: 1,300 mL from ingested water, 1,000 mL from ingested food, and 300 mL from metabolic oxidation, totaling 2,600 mL fluid.

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? A) "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)." B) "We do not record fluids absorbed into undergarments." C) :If the undergarment is soiled, document this fact but do not estimate its contents." D) "You only record urine output in an adult undergarment; you do not record diarrhea output."

A) "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)." Explanation: Fluid output is the sum of liquid eliminated from the body, including urine, emesis (vomitus), blood loss, diarrhea, wound or tube drainage, and aspirated irrigations. In cases in which an accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, diapers, or dressings, and subtracts the weight of a similar dry item. An estimate of fluid loss is based on the equivalent: 1 lb (0.47 kg) = 1 pint (475 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? A) 83 mL/hr B) 103 gtts/hr C) 100 mL/hr D) 13 mL/hr

A) 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. 1000/ 12= 83.333333

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? A) Avoid salty or excessively sweet fluids. B) Use regular gum and hard candy. C) Eat crackers and bread. D) Use an alcohol-based mouthwash to moisten your mouth.

A) Avoid salty or excessively sweet fluids. Explanation: 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.

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)? A) Changing the dressing on a client's peripheral IV site B) Initiating a client's transfusion of packed red blood cells C) Deaccessing a client's implanted port D) Removing a client's PICC in anticipation of the client's discharge

A) 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 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? A) Discontinue the IV. B) Attempt to aspirate. C) Flush with 3-mL normal saline. D) Slow the rate of infusion by 50%.

A) Discontinue the IV. Explanation: Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor. Aspiration is never performed from a peripheral IV. Flushing or slowing the infusion will not alleviate this problem.

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? A) Muscle weakness, fatigue, and dysrhythmias B) Nausea, vomiting, and constipation C) Diminished cognitive ability and hypertension D) Muscle weakness, fatigue, and constipation

A) Muscle weakness, fatigue, and dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. 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.

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? A) Remove the IV catheter and reinsert another in a different location. B) Decontaminate the visible portion of the catheter, and then gently reinsert. C) Apply a new dressing and observe for signs of infection over the next several hours. D) Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.

A) Remove the IV catheter and reinsert another in a different location. Explanation: An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

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? A) Stop the transfusion immediately. B) Infuse saline at a rapid rate. C) Prepare to give an antihistamine. D) Administer oxygen.

A) 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.

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? A) cardiac irregularities B) muscle weakness C) increased intracranial pressure (ICP) D) metabolic acidosis

A) 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 client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? A) decreased blood volume and intracellular dehydration B) increased blood volume and intracellular dehydration C) increased blood volume and extracellular overhydration D) decreased blood volume and extracellular overhydration

A) decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? A) As fast as the client can tolerate B) 1 unit over 2 to 3 hours, no longer than 4 hours C) 75 mL/hr for the first 15 minutes, then 200 mL/hr D) 200 mL/hr

B) 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 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: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr A) 60 gtt/min B) 100 gtt/min C) 160 gtt/min D) 600 gtt/min

B) 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 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? A) 30 drops/mL B) 60 drops/mL C) 90 drops/mL D) 120 drops/mL

B) 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).

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? A) Select a primary tubing of about 37 inches (94 cm) long. B) Ensure that the prescribed solution the expected color and consistency. C) Use half-instilled IV solutions before infusing a new one. D) Avoid replacing IV solutions every 24 hours.

B) Ensure that the prescribed solution the expected color and consistency. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution's color and consistency matches that expected based on the prescription, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

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

B) 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.

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: A) an access route to administer medications intravenously. B) replacement of fluids for those lost from vomiting and diarrhea. C) an access route to replace fluids in combination with blood products. D) intravenous fluids to be administered on an outpatient basis.

B) replacement of fluids for those lost from vomiting and diarrhea. 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 from vomiting and diarrhea.

The primary extracellular electrolytes are: A) potassium, phosphate, and sulfate. B) magnesium, sulfate, and carbon. C) sodium, chloride, and bicarbonate. D) phosphorous, calcium, and phosphate.

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

Which fluid should be administered slowly to prevent circulatory overload? A) 0.9% NaCl B) 0.45% NaCl C) lactated Ringer's D) 5% dextrose in 0.9% NaCl

D) 5% dextrose in 0.9% NaCl Explanation: When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 5% dextrose in 0.9% NaCl and 5% dextrose in lactated Ringer's.

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? A) Packed red blood cells B) An isotonic solution C) A hypertonic solution D) A hypotonic solution

D) 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.

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? A) Calcium B) Chloride C) Phosphorous D) Potassium

D) Potassium Explanation: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. Signs of potassium defecit, or hypokalemia, include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? A) An implanted central venous access device (CVAD) B) A peripheral venous catheter inserted to the antecubital fossa C) A peripheral venous catheter inserted to the cephalic vein D) A midline peripheral catheter

A) 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 preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? A) The client has anti-A antibodies. B) The client has anti-B antibodies. C) The client has both anti-A and anti-B antibodies. D) The client is a universal donor.

A) The client has anti-A antibodies. Explanation: Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction. Clients with type O blood are universal donors.

A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which statements accurately describe this process? Select all that apply. A) The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. B) The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. C) The thyroid gland secretes aldosterone, a mineralocorticoid hormone that helps the body conserve sodium, helps save chloride and water, and causes potassium to be excreted. D) The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. E) Thyroxine, released by the adrenal glands, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output. F) The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.

A) The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. B) The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. D) The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. F) The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.

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: A) electrolytes. B) nonelectrolytes. C) colloid solution. D) interstitial fluid.

A) electrolytes. Explanation: The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: A) hyponatremia. B) hypernatremia. C) hyperkalemia. D) hypokalemia.

A) hyponatremia. Explanation: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

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

B) "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 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? A) 3,750 B) 3,000 C) 1,000 D) 500

B) 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 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. A) Prescribing the kind of IV solution. B) Deciding the location of the IV catheter. C) Deciding the size of the IV catheter. D) Administering the IV solution. D) Determining the amount of IV solution.

B) Deciding the location of the IV catheter. C) Deciding the size of the IV catheter. D) Administering the IV solution. Explanation: The nurse is responsible for deciding the location and size of the IV catheter, as well as for administering the solution. The primary care provider is responsible for prescribing the kind and amount of solution.

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? A) Notify the primary care provider immediately because these are signs of speed shock. B) Notify the primary care provider immediately for possible fluid overload. C) Check all clamps on the tubing and check tubing for any kinking. D) Place the client in the Trendelenburg position to keep the client's airway open.

B) 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.

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? A) B positive B) O negative C) A positive D) AB negative

B) 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. B positive, A positive, and AB negative are not considered compatible in this scenario.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? A) Slow the rate of IV fluids. B) Remove the IV. C) Apply a warm compress. D) Elevate the arm.

B) 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.

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) an 18-gauge needle. B) a winged infusion needle. C) an intermittent infusion device. D) a central venous access.

B) 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.

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? A) pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) B) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) C) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) D) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)

B) 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.

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? A) "I need to drink no more than 1,000 mL/day" B) "I should drink 1,500 mL/day of fluid." C) "I should drink 2,500 mL/day of fluid." D) "I should drink more than 3,500 mL/day of fluid."

C) "I should drink 2,500 mL/day of fluid." Explanation: 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 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)? A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis

C) 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.

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. Which action should the nurse take? A) Reassure the client that the feelings are associated with anxiety and will pass. B) Confirm the shortness of breath by listening to the client's lungs. C) Stop the transfusion and notify the health care provider. D) Increase the rate of infusion to restore blood volume more quickly.

C) Stop the transfusion and notify the health care provider. Explanation: Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion. 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, and to notify the health care provider. Reassuring the client will not help if the client is experiencing a blood reaction. Increasing the rate of the administration will make the potential reaction worse if this is a transfusion reaction. Listening to the client's lungs is not the priority action.

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? A) isotonic B) hypotonic C) hypertonic D) plasma

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

D) 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. 250 ml x 20 gtt/ml= 5,000 5000 / 100min= 50 gtt/min

Which actions would a nurse perform after selecting a site and palpating accessible veins in order to start an IV infusion? Select all that apply. A) Clean the entry site with saline, followed by an alcohol swab according to agency policy. B) Place the dominant hand about 4 in (10 cm) below the entry site to hold the skin taut against the vein. C) Enter the skin gently with the catheter held by the hub in the non-dominant hand, bevel side down, at a 10- to 30-degree angle. D) Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein. E) When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into the vein until the hub is at the venipuncture site. F) Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle.

D) Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein. E) When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into the vein until the hub is at the venipuncture site. F) Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle. Explanation: The needle or catheter is advanced into the vein once the sensation of "give" can be felt when the needle enters the vein. This allows the needle or catheter to enter the vein with minimal trauma and deters passage of the needle through the vein. The tourniquet is released once there is a flashback of blood because the tourniquet causes increased venous pressure, resulting in automatic backflow. Placing the access device well into the vein helps to prevent dislodgement. The site is cleansed with an antiseptic solution such as chlorhexidine, or according to facility policy. The nurse should use the non-dominant hand placed about 1 or 2 inches (2.5 or 5 cm) below the entry site, holding the skin taut against the vein to allow for easier insertion of the IV needle/catheter.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? A) Allow nothing by mouth. B) Give the client a glass of orange juice with added sugar. C) Encourage fluid intake. D) Start an IV of normal saline as prescribed.

D) 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 client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: A) hypocalcemia. B) hypothyroidism. C) hypoglycemia. D) hypokalemia.

D) hypokalemia. Explanation: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.