Fundamentals of Nursing: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance
Major control over the extracellular concentration of potassium within the human body is exerted by insulin and d) Aldosterone
Aldosterone Explanation: Two hormones exert major control over the extracellular concentration of potassium: insulin and aldosterone. Aldosterone enhances renal secretion of potassium.
What is the rate of administration for packed red blood cells?
Correct response: 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 physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?
Correct response: 25 Explanation: 150 (mL) x 60 (minutes) / 10 (drop factor) = 25 drops per minute
Which of the following fluids should be administered slowly to prevent circulatory overload?
Correct response: 5% 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.
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?
Correct response: 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.
The oncoming nurse is assigned to the following patients. Which patient should the nurse assess first? a) A newly admitted 88-year-old with a two-day history of vomiting and loose stools
Correct response: A newly admitted 88-year-old with a two-day history of vomiting and loose stools Explanation: Young children, elderly people, and people who are ill are especially at risk for hypovolemia.
Which client will have more adipose tissue and less fluid?
Correct response: A woman Explanation: Women have a lower fluid content because they have more adipose tissue then men.
A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular
Correct response: An implanted central venous access device (CVAD) Explanation: Implanted CVADs are ideal for long-term uses such as chemotherapy.
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 interventions should the nurse perform for this complication?
Correct response: Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV.
A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?
Correct response: Apricots Explanation: Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Correct response: Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis.
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?" Which of the following would the nurse include as a suggestion for this client?
Correct response: 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.
Potassium is needed for neural, muscle, and
Correct response: Cardiac function Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
Correct response: Cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials.
Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client 's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client?
Correct response: ECF deficient fluid volume Explanation: The most appropriate nursing diagnosis is ECF deficient fluid volume deficit because the client has the defining characteristics of the diagnosis. Impaired skin integrity is associated with edema and diarrhea.
A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV?
Correct response: Ensure that the prescribed solution is clear and transparent. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached.
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 which of the following?
Correct response: Fluid volume excess Explanation: 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.
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 IV complication does this describe?
Correct response: Infiltration Explanation: Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall.
A severely malnourished client has been admitted to a health care facility. The nurse is preparing to administer total parenteral nutrition (TPN) to the client. How should the nurse administer the TPN solution?
Correct response: It is administered in a peripheral vein with its tip terminating in the superior vena cava. Explanation: TPN solution should be administered through a catheter inserted into the subclavian or jugular vein; the tip terminates in the superior vena cava.
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?
Correct response: It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order. Explanation: The nurse's ongoing verification of the IV solution and the infusion rate with the physician's order is essential.
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation? \
Correct response: 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.
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 indicative of what?
Correct response: Phlebitis Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain.
A decrease in arterial blood pressure will result in the release of
Correct response: Renin Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release
A woman age 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 what?
Correct response: 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.
A nurse is assessing for the presence of edema in a client who is confined to bed after fracturing her femur. The nurse would pay particular attention to which area?
Correct response: Sacral area Explanation: The nurse should assess the sacral area in the client when determining the presence of edema.
The passageways of the kidney permit the urine to flow to the bladder and
Correct response: Selectively reabsorb or secrete substance to maintain fluids and electrolytes Explanation: The capillaries of the glomerulus are porous, and, as the blood passes through the glomerular capillaries, some constituents of the blood are filtered out
Which of the following statements accurately describes the role of antidiuretic hormone in the regulation of body fluids? When antidiuretic hormone is present,
Correct response: The renal tubules become permeable to water Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water.
A client who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor?
Decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume.
The primary extracellular electrolytes are:
Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.
Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?
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 50-year-old client with hypertension is being treated with a diuretic. The client complains of muscle weakness and falls easily. The nurse should assess which electrolyte? a) Potassium
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. (less)
A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation? .
Reapply the dressing and notify the physician for further instructions. Explanation: When a PICC line is not all the way out, the nurse should notify the physician.
Mr Powell, a dehydrated 35 year old has intravenous fluid running at 250 cc/h. for rapid rehydration. He is complaining of burning at the site. You see no redness, swelling, heat, or coolness upon inspection. You suspect
The fluid is infusing too rapidly. You should slow the infusion to 200 cc/h.
When 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 what? a) Hypothyroidism b) Hypoglycemia c) Hypokalemia d) Hypocalcemia
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.
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as
Total parenteral nutrition Explanation: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.