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A healthcare provider is planning to transfuse a patient with a unit of packed red blood cells. Which solution should the healthcare provider hang with the transfusion?
0.9% sodium chloride Normal saline consists of 0.9% NaCl and is considered isotonic. Normal saline is used for replacement of fluid, sodium, and chloride. It is the only fluid used to begin or finish blood transfusions. 5% dextrose in water, 5% dextrose in 0.9% sodium chloride, and 5% dextrose in lactated Ringer's solution are not compatible for transfusion with blood or blood products. They may cause the red blood cells to clump together.
Which of these patients do you expect will need teaching regarding dietary sodium restriction?
A 65-year-old recently diagnosed with heart failure Heart failure commonly causes extracellular fluid volume (ECV) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water. Dietary sodium restriction is important with heart failure because Na+ holds water in the extracellular fluid, making the ECV excess worse.
Which interventions does the nurse perform when inserting a peripheral intravenous (IV) catheter? Select all that apply.
Apply a tourniquet to the arm using a quick-release knot. Raise the bed to a working height and lower the side rails. Palpate the vein for its size, sponginess, and straightness. Before inserting a peripheral IV catheter, the nurse follows certain ordered steps to allow safe fluid infusion as well as prevent complications. A tourniquet is applied 4 to 6 inches above the site, as the hand and forearm contain larger veins, namely, the cephalic, basilic, and median cubital veins. The tourniquet restricts the blood flow to the extremity to promote vein engorgement, but should not be so tight that it causes the patient discomfort. Therefore, a quick-release knot should be used. The bed is raised to a working height and the side rails lowered to prevent discomfort and possible injury. The nurse palpates the selected vein to determine the size, depth, and direction of the vein, which facilitates accuracy during the procedure. The selected vein should be well dilated and bouncy in nature and should be larger to prevent the risk of hematoma. The site is cleaned with a proper antiseptic solution to prevent the spread of microorganisms. It is not necessary to clean the site in any specific direction. The infusion site is selected on the patient's nondominant arm instead of the dominant arm to allow the patient to perform other daily living activities like bathing and dressing.
A patient with blood type A is in need of packed red cells on an emergency basis, but none of the donors of this type are available. How can the nurse provide better health care to the patient?
Arrange to provide red blood cells of group O The patient requires red blood cells on an emergency basis, and none of the donors of this blood type are available. Therefore, the patient may be managed by transfusion of red cells of blood group O as it carries minimum risk. Red blood cells of blood group AB should not be given to patients with blood group A as they cause mismatching. Autologous transfusion takes a few weeks; therefore, it is not suitable on an emergency basis. If the patient did not require blood on an emergency basis, then it would be appropriate to wait until the blood group A donor is found.
The nurse is performing an intravenous (IV) flush in a patient who is receiving intravenous therapy. In which order does the nurse perform the interventions for this procedure?
Fill a syringe with sterile saline solution for injection. Cleanse the port with an antiseptic or an alcohol wipe. Insert the blunt cannula of the saline solution syringe into the port. Inject the solution over 1 minute into the IV access port. Look for leakage, inflammation, and swelling at the site. When flushing an IV catheter, the nurse first fills the syringe with appropriate sterile saline solution for injection. The nurse next wipes the insertion port with an antiseptic or alcohol solution to prevent the spread of microorganisms. The nurse wears clean gloves to prevent contamination during the administration. The nurse then inserts the blunt cannula or the needle of the saline solution syringe into the port on the extension tubing and unclamps the tubing. After that, the nurse slowly injects the solution into the intravenous access port over 1 minute. While flushing the IV line, the nurse checks for signs of redness, leakage, or swelling at the site. To ensure safe administration, the nurse stops flushing the IV catheter immediately if any complication occurs.
The nurse assesses that a patient has tachycardia, increased body temperature, and decreased blood pressure. On further assessment, the nurse finds the patient's pulse rate to be weak on palpation. Which complication should the nurse expect to find in this patient based on these findings?
Fluid volume deficit Tachycardia, which is increased heart rate, is the first indication of a fluid volume deficit. To ensure adequate oxygenation of the tissues, the heart rate accelerates to maintain the normal cardiac output. Fluid volume deficit leads to a weak pulse on palpation, and it also reduces the blood pressure due to a decrease in the circulating volume of the blood. Fluid volume excess increases blood pressure and body temperature and causes a strong bounding pulse. Metabolic acidosis occurs due to loss of bicarbonate ions and an increase in acids produced as byproducts of a metabolic process and causes Kussmaul respirations. Respiratory alkalosis is not associated with the symptoms of increased heart rate, increased body temperature, and decreased blood pressure; it occurs due to hyperventilation and excess exhalation of carbon dioxide.
A client is admitted to the hospital with a heart rate of 166 beats/min, increased thirst, restlessness, and agitation. Which electrolyte imbalance does the nurse suspect?
Hypernatremia These symptoms are indicative of hypernatremia. Clinical manifestations of hypomagnesemia are seen in the neuromuscular, central nervous, and intestinal systems. Hypercalcemia manifests with an altered level of consciousness that can range from confusion and lethargy to coma, and severe hypercalcemia depresses electrical conduction, slowing heart rate. Hyperphosphatemia causes few direct problems with body function (although hypocalcemia is usually also present).
A 70-year-old woman is admitted to the hospital with heart failure, shortness of breath (SOB), and 3+ pitting edema in her lower extremities. Her current medications are furosemide (Lasix), digoxin (Lanoxin), and an angiotensin-converting enzyme (ACE) inhibitor (Lotensin). She states that she stopped taking her Lasix because she did not think that it was helping her heart failure. Her health care provider orders furosemide (Lasix) 5 mg IV push. Which client assessment determines that the medication is working?
Increased urine output When giving Lasix, the nurse monitors the client for response to drug therapy, especially weight loss and increased urine output. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the most important assessment to be monitored. Urinary output is most important. Lasix may cause a decrease in heart rate as it lowers the client's body fluid, but this effect would take some time to note. Weight loss, rather than weight gain, is often the effect of Lasix, but it does not occur immediately.
A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. The nurse interprets these laboratory values to indicate:
Metabolic acidosis The low pH indicates acidosis. The low PaCO2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO3- indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus metabolic acidosis is the correct interpretation.
When planning care for a client with hypercalcemia, which intervention does the nurse consider?
Monitor cardiac rhythm for changes. Hypercalcemia increases the risk for cardiac dysrhythmias. It does not impair gas exchange so oxygen saturation does not need to be routinely monitored. There is a greater tendency to clot, especially with slow venous perfusion, so invasive procedures do not need to be avoided and increased activity (not restriction) is recommended.
A nurse is caring for an 89-year-old patient. The patient is very weak and refuses to eat. When preparing to insert the IV line, which site should the nurse select first considering the patient's age?
Most distal appropriate site on the inner arm Choosing the most distal appropriate site on the inner arm first will allow the use of a proximal site later, if the patient needs venipuncture site change. Veins on the hands and feet should be avoided for venipuncture in older adults because of the increased chances of thrombophlebitis.
The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)?
Offering fluids to drink every hour Encouraging a client to take oral fluids is within the scope of practice for UAP. Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor should be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.
The nurse is assessing a group of patients for the risk of fluid and electrolyte imbalance. Which patients are considered to be at an increased risk? Select all that apply.
Older adult patients Infants Patients who take herbals Older adults have proportionately less body water and are at increased risk of fluid and electrolyte imbalance. Infants are more susceptible to fluid volume deficits or dehydration because of their high percentage of total body water. Some herbal supplements have side effects that affect fluid and electrolyte balance, including aloe, artichoke, celery, dandelion, ginseng, and licorice. Overweight patients are not considered to be at increased risk unless there is an underlying disease process. Healthy adult patients have a stable fluid and electrolyte balance unless there is an underlying disease process.
A nurse is caring for an 89-year-old patient. The patient is very weak and refuses to eat. The nurse selects a vein and is performing a venipuncture. Arrange the steps in the correct order for performing a venipuncture.
Palpate the vein for resilience. Clean the site with chlorhexidine Stabilize the vein below insertion site. Puncture the vein with a catheter at a 10- to 30-degree angle. Look for blood return. If blood returns, stop inserting the needle. Advance catheter into the vein until the hub is near insertion. Venipuncture is a technique in which a vein is punctured through the skin using a sharp rigid stylet. Before performing a venipuncture, palpate the vein for resilience. Clean the selected site with chlorhexidine to prevent infection. Stabilize the vein below the insertion site and puncture the vein using a catheter at a 10- to 30-degree angle. When the catheter enters the vein, check for blood return in the flashback chamber. Advance the catheter in the vein until the hub is near insertion.
While interpreting the arterial blood gas findings of a patient, the nurse concludes that the patient has moderate hypoxemia. Which assessment finding led the nurse to reach this conclusion?
Pao2 level of 50 mm Hg Decreased oxygen concentration in the arterial blood indicates hypoxemia. A Pao2 level in the range of 40 to 60 mm Hg (and thus a Pao2 level of 50 mm Hg) indicates moderate hypoxemia. A Pao2 level of 30 mm Hg indicates severe hypoxemia. The normal levels of Pao2 are 80 to 100 mmHg. A Paco2 level of 40 mm Hg is a normal finding and does not indicate hypoxemia. Paco2 is the partial pressure of carbon dioxide in arterial blood. The normal range of Paco2 is 35 to 45 mm Hg. A PaCO2 level of 50 mm Hg indicates hypercapnia rather than hypoxemia.
A patient with gastroenteritis experiences light-headedness on sitting upright. On assessment, the blood pressure is 90/50 mm Hg in the supine position, pulse rate is 110 beats/min, and the oral mucous membranes are dry. How should the nurse promote fluid and electrolyte balance in the patient? Select all that apply.
Provide oral fluids Administer 0.9% NaC The patient is exhibiting signs and symptoms of extracellular fluid depletion due to fluid loss related to gastroenteritis. The management involves providing oral fluids at the preferred temperature to replenish the lost fluids. To prevent hypokalemia, 0.9% NaCl is administered with KCl supplementation. Fluids should not be given beyond the patient's tolerability. Antidiarrheal agents should be given only on receiving prescription from the primary health care provider. A comfortable environment is helpful in patients with nausea due to gastric irritation; however, it may not help to correct the fluid and electrolyte imbalance in the patient.
While administering medications to a hospitalized patient via the intravenous (IV) route, the nurse finds that the patient's pulse rate is 140 beats/min and blood pressure is 170/90 mm Hg. The nurse also finds that the patient is restless and has distended neck veins. What does the nurse interpret from these findings?
Pulmonary edema A rapid flow rate of IV solution can cause pulmonary edema. The manifestations of pulmonary edema are an increased pulse rate and increased blood pressure. The neck veins may also become distended, and crackles can be found in the lung bases. Intravenous therapy may also cause phlebitis, which manifests as reddened areas, tenderness, and burning pain. The signs of infiltration include leakage at the IV site, firmness of the extremity, tenderness, and cool and blanched skin around the IV site. Extravasation occurs if a vesicant or an irritating solution leaks into the subcutaneous tissues from the IV catheter. The signs of extravasation include blistering, tenderness, and discomfort at the IV site.
A severely dehydrated client requires a rapid infusion of normal saline and needs a midline IV placed. Which staff member does the emergency department (ED) charge nurse assign to complete this task?
RN with certified registered nurse infusion (CRNI) certification who is assigned to the ED for the day. The nurse with CRNI certification is most likely to be able to quickly insert a midline catheter for a client who is dehydrated. The chemotherapy nurse and the ED nurse have the appropriate scope of practice, but will not be as skilled in inserting a midline IV catheter. The medical-surgical nurse may be skilled at inserting short peripheral catheters, but will not be skilled in inserting midline IV catheters.
A patient who was started on intravenous (IV) fluids to correct dehydration develops shortness of breath. On auscultation, the nurse finds crackles in the dependent portion of the lungs and dependent edema. Which interventions are appropriate in correcting the fluid and electrolyte imbalance in the patient? Select all that apply.
Reduce the IV flow rate. Notify the primary healthcare provider. Administer diuretics if prescribed. The patient's presentation is suggestive of overload due to IV fluids. The flow rate of the intravenous solution should be reduced to prevent further worsening of circulatory overload. The primary healthcare provider should be notified to obtain further instructions. Diuretics should be administered to promote excretion of excess fluids through urine. Aspiration of fluids from the lungs may not help as there is fluid excess. The head end of the bed should be elevated to promote chest expansion and breathing.
When caring for a patient undergoing intravenous therapy, the nurse observes redness and swelling around the IV catheter insertion site. Purulent drainage is also present. What immediate actions should the nurse perform? Select all that apply.
Remove the catheter and preserve for culture. Start a new intravenous line in another extremity. Replace old IV tubing and solution with new. The assessment findings show a possibility of infection; therefore, the catheter should be removed and preserved for culture. Antibiotics can be prescribed based on the culture reports. As there is redness and swelling at the site, a new intravenous line should be started in a different extremity. Replace old IV tubing and solution with new. Applying pressure to the dressing over the site is performed in case of bleeding from the site and not because of infection. Raising the head of the bed and administering oxygen should be considered in case of circulatory overload of intravenous solution.
Which clinical manifestations does the nurse find in a patient with hypomagnesemia? Select all that apply.
Seizures Mood swings Tachyarrhythmias Hypomagnesemia is indicated by a serum magnesium level below 1.3 mEq/L. Magnesium is an important cation in the body that plays a major role in energy metabolism. Therefore, its deficiency may cause neurological disorders such as seizure. Hypomagnesemia affects brain function, which in turn can cause mood swings. Hypomagnesemia also alters cardiovascular function and can lead to tachyarrhythmia (an abnormally high heart rate). Hypophosphatemia and hypermagnesemia can lead to hypotension. Hypermagnesemia can lead to heart block.
The nurse is caring for an 89-year-old patient. The patient is very weak and refuses to eat. Intravenous therapy is planned to restore fluid and electrolyte balance. A nurse performs a venipuncture and initiates the prescribed fluid therapy. After a few hours, the nurse finds that the patient has developed phlebitis. What should the nurse do? Select all that apply.
Stop infusion and discontinue the IV line. Start a new IV line in another extremity Phlebitis is the inflammation of the inner layer of veins. In this case, the nurse should stop the infusion and discontinue the IV line. If continued IV therapy is necessary, the nurse should start a new IV line in the other extremity or at a proximal site. The nurse assesses the intactness of the IV system only if there is bleeding at the venipuncture site. The nurse applies a cold compress if there is infiltration or extravasation. Monitoring vital signs or lab reports of serum levels is done if there is a circulatory overload of IV solution.
A patient develops acute hemolytic transfusion reaction following transfusion with incompatible blood. What treatment strategies should be included in the patient's management? Select all that apply.
Stop the transfusion immediately. Remove tubing and replace with new IV tubing and normal saline solution. Send blood and urine to the lab. Document the reaction, subsequent treatment, and patient response. Stop the transfusion immediately. Remove tubing and replace with new IV tubing and normal saline solution. IV at keep-vein-open rate (KVO). Notify prescribing healthcare provider immediately. Notify blood bank. Monitor vital signs. Have emergency equipment available. Send remaining blood, blood tubing and filter, and a sample of patient's blood and urine to the lab. Document the reaction, subsequent treatment, and patient response.
A patient presents with muscle twitching and cramping. On examination, the healthcare provider diagnoses the patient with calcium deficiency. What dietary instructions should the nurse give to this patient? Select all that apply.
Supplement with vitamin D Increase the intake of dairy products. Increase the intake of tofu. Hypocalcemia, or low levels of calcium, can manifest as muscle twitching and cramping. The signs and symptoms can be treated by providing adequate calcium in the diet. Vitamin D facilitates the absorption of calcium from the intestines; therefore, vitamin D should be supplemented in the diet. Dairy products, tofu, rhubarb, and spinach are good sources of calcium, and their intake should be promoted. Tomatoes and bananas are rich in potassium, not calcium.
The nurse is caring for a patient with fluid volume excess. Which nursing interventions should help the patient eliminate the excess fluid? Select all that apply.
Teach the patient to refrain from adding salt to food. Permit the patient to have small amounts of ice chips. Educate the patient to stay away from canned foods. If the patient has fluid volume excess, the nurse should restrict the amount of fluid and sodium intake to prevent worsening the fluid excess. Therefore, the nurse should instruct the patient to refrain from adding salt to food. The nurse should also encourage the patient to take a small amount of ice chips instead of water. This restricts the amount of fluid intake, as 100 mL of ice chips is equal to 50 mL of water. Canned foods contain added sodium to prevent them from spoiling. Therefore, the nurse should instruct the patient to stay away from canned foods. The patient should not eat sugary foods because they stimulate the thirst sensation and thereby increase fluid intake. Frozen foods are acceptable.
The nurse is teaching a group of nursing students about the acid-base regulation process. What should the nurse teach the students regarding the excretion of carbonic acid from the body?
The lungs excrete carbonic acid. The lungs are responsible for the excretion of carbonic acid from the body in the form of exhaled carbon dioxide. Thus, the lungs help to maintain the acid-base balance of the body. The liver is not involved in the excretion of metabolic acids and carbonic acid, and has no role in acid-base balance of the body. Kidneys help in the excretion of all acids except for carbonic acid. They play an important role in fluid and electrolyte balance. The intestines are not involved in the excretion of metabolic acids and carbonic acid, and has no role in acid-base balance of the body.
The health care provider has placed a peripherally inserted central catheter (PICC) in a client. Which technique is used to confirm the location of the catheter tip?
X-ray A PICC is placed in the initial stages of treatment and the basilic vein is the vein of choice for this type of catheter. An x-ray view of the chest confirms the placement of the tip in the lower superior vena cava. Laser beams and infrared are not used to confirm tip placement. Laser beams and infrared are employed for the visualization of veins during catheterization. Surgical procedures are used for the insertion and removal of tunneled central venous catheters.
Which clinical manifestations does the nurse expect to find in a patient who has a febrile nonhemolytic reaction after receiving a blood transfusion? Select all that apply.
malaise a 2-degree (f) increase in temp A febrile nonhemolytic reaction is a reaction between the antibodies of the recipient and those from the blood donor's human leukocyte antigens. Chills and malaise are typical manifestations. A 2-degree (Fahrenheit) increase in body temperature is also commonly seen. Chest pain and facial flushing indicate an acute hemolytic reaction. Laryngeal swelling during blood transfusion indicates an allergic reaction.
The nurse is caring for a patient whose phosphate level is 1.6 mEq/L. Which food does the nurse expect to be included in the patient's diet plan?
milk A phosphate level below 1.7 mEq/L indicates hypophosphatemia, and therefore the patient needs to increase the phosphate levels in the body. Milk is a rich source of phosphorous and should be included in the patient's diet plan. Halibut is a good source of magnesium and is recommended in patients with hypomagnesemia. Cantaloupes are rich in potassium and are therefore recommended in patients who have hypokalemia. Green leafy vegetables are rich in magnesium content and are recommended in patients who have hypomagnesemia
The prescription for a client reads 3 L 5% D/0.45% NS to be infused over 30 hours. At what rate does the nurse administer the infusion?
100 mL/hr Divide the total amount of fluid in mL by the total number of hours prescribed. In this case, 3 L or 3000 mL/30 hours = 100 mL/hr.
Fluid homeostasis in the body is maintained by fluid intake and absorption, fluid distribution, and fluid output. How much fluid does an average adult lose through feces? Record your answer using a whole number. __________ mL
200 The fluid loss occurs through the skin, lungs, gastrointestinal tract, and kidneys. Even though the average fluid intake is 2500 mL, only 200 mL of fluid is lost through feces. The rest of the fluid is absorbed by the gastrointestinal system.
What is one of the causes of respiratory alkalosis?
Anxiety Hyperventilation is one cause of respiratory alkalosis, which can result from fear and anxiety. Kidney failure and diuretic therapy are not causes of respiratory alkalosis. The use of antacids can result in metabolic alkalosis.
The nurse is caring for a client with hypoxemia and metabolic acidosis. Which task can be delegated to the nursing assistant who is helping with the client's care?
Apply the pulse oximeter for continuous readings. Placing a peripheral pulse oximeter is a standardized nursing skill that is within the scope of practice for unlicensed personnel. Assessment and intravenous therapy are skills performed by the professional nurse. Titration of O2 requires assessment and intervention beyond the scope of practice of an unlicensed individual.
Which nursing interventions are included in a patient's care plan to prevent an air embolism during intravenous (IV) therapy? Select all that apply.
Clamp the IV catheter when changing the tubing. Prime all IV tubing with solution first. Air emboli occur due to the accidental entry of air into the bloodstream due to improper preparation of IV tubing or loose connections. To prevent this, the nurse clamps the IV catheter before changing the tubing. Priming all tubing with IV solution before attaching it to the catheter removes all air from the tubing and prevents its entry into the bloodstream. Placing the patient in a high Fowler's position helps during fluid overload. Monitoring the gravity flow sets during infusion is done to prevent speed shock in the patient. Applying ice to the extremity for 24 to 48 hours and elevating the extremity is helpful if extravasation occurs during the IV infusion.
The nurse checking an IV fluid order questions its accuracy. What does the nurse do first?
Contacts the health care provider who ordered it The nurse is responsible for accuracy and has the duty to verify the order with the health care provider who ordered it. Although the nurse can consult the charge nurse, this is not the definitive action that the nurse should take. Contacting the pharmacy is not the definitive action that the nurse should take. Giving (or starting) the fluid when the order is questionable is not appropriate.
Assessment findings consistent with intravenous (IV) fluid infiltration include: Select all that apply.
Edema and pain Pallor and coolness Inadvertent fluid leakage into the interstitial compartment around an IV site can cause swelling, pain from the pressure, pale color, and coolness of the infiltrated area.
Which electrolyte imbalance is the client with metabolic acidosis at risk to develop?
Hyperkalemia With an excess of extracellular hydrogen in acidosis and in an effort to maintain electroneutrality, hydrogen shifts into the cells causing potassium to shift out, resulting in hyperkalemia. The client with metabolic acidosis is not likely to develop hypophosphatemia, hypercalcemia, or hyponatremia.
A patient is receiving treatment for chronic diarrhea. The nurse advises the patient to eat food items rich in potassium. What is the reason behind promoting a potassium-rich diet?
Potassium improves smooth, skeletal, and cardiac muscle function Potassium is required for normal functioning of smooth, skeletal, and cardiac muscles as it helps to maintain resting membrane potential. Phosphate is required for production of ATP, not potassium. Potassium does not decrease muscle wasting. Magnesium acts as a cofactor for various enzymes.
The nurse is caring for a patient undergoing intravenous therapy. The nurse suspects that the patient is developing phlebitis. What are the findings that the nurse would observe in the patient? Select all that apply.
Red streak along the vein Tenderness and pain Palpable venous cord A defined red streak along the vein and palpable venous cord can be seen in case of phlebitis, due to inflammation of the inner layer of the vein. Tenderness and pain can be observed due to inflammation of the vein. Inflammation of the vein gives rise to warmth along the course of the vein, starting at the access site. Swelling at catheter-skin entry point is particularly noted in case of local infection at that point during infusion or after removal of the catheter. Fresh blood evident at the venipuncture site could be a sign of bleeding at the venipuncture site.
Which statement is true about the special needs of older adults receiving IV therapy?
Skin integrity can be compromised easily by the application of tape or dressings. Skin in older adults tends to be thin. Tape or dressings used with IV therapy can compromise skin integrity. Placement on the back of the dominant hand is contraindicated because hand movement can increase the risk of catheter dislodgement. An angle smaller than 25 degrees is required for venipuncture success in older adults. This technique is less likely to puncture through the older adult client's vein. Clipping the hair around the insertion site typically is necessary only for younger men.
A patient has a partial pressure of carbon dioxide (PaCO2) of 30 mm Hg. What does this value indicate about the patient's condition?
The PaCO2 is lower than normal. PaCO2 is the measure of the partial pressure of carbon dioxide in the blood and measures how well the lungs are excreting carbon dioxide produced during cellular metabolism. The normal value ranges from 35 to 45 mm of Hg. The patient has a value lower than normal. A high PaCO2 indicates accumulation of carbon dioxide in the blood. When a patient hyperventilates, the PaCO2 value tends to increase. The PaCO2 value denotes lung function; the bicarbonate (HCO3-) indicates kidney function.
A nurse is teaching a group of patients about the importance of fluid and electrolyte balance in a health awareness program. Which common causes of hypokalemia would the nurse educate the patients about? Select all that apply.
diarrhea repeated vomiting hyperaldosteronism Hypokalemia is a low potassium concentration in the blood that results from the loss of potassium. This can occur in patients with diarrhea or repeated vomiting. Hyperaldosteronism can also cause hypokalemia. Acute oliguria decreases the loss of potassium from the body and results in increased concentration of potassium or hyperkalemia. A calcium-deficient diet can cause decreased intake and absorption of calcium, thus resulting in hypocalcemia.
What dietary instructions does the nurse give to a patient with a calcium level of 8.0 mg/dL?
"You should include dairy products in your diet." A level of 8.0 mg/dL indicates the patient has hypocalcemia, so the nurse instructs the patient to include calcium-rich foods such as dairy products in the diet. Potatoes are a rich source of potassium and should be avoided in case of hyperkalemia, not hypocalcemia. Cured meat is a rich source of sodium and thus should be included in the diet of a patient who has hyponatremia. Green leafy vegetables are rich in magnesium content and should be included in the diets of patients with hypomagnesemia.
A 5-year-old child is brought into the emergency department with persistent vomiting and diarrhea. The child's parents state that the child has lost 4 pounds since the symptoms began. Based on this information, approximately how much fluid has the child lost?
2 liters One pound of body weight is approximately equal to 500 mL of fluid. With a weight change of 4 pounds, the child has lost approximately 2 liters of fluid.
Which needle gauge will be best for the nurse to use when providing intravenous therapy for an elderly patient with dehydration?
24 gauge A 24-gauge needle work best for elderly patients. An elderly patient who is dehydrated will have smaller veins, and the smaller needle will be easier to insert. Needles that are 16- to 18-gauge are used for blood transfusions, for rapid infusion of fluids in patients with trauma, or for patients who have undergone surgery. Needles that are 20- to 22-gauge are generally used for general and intermittent solutions.
A client with hyperkalemia is being treated with drugs to improve the condition. Which potassium level indicates that therapy is effective?
7.6 mEq/L 5.6 mEq/L 4.6 mEq/L***** 2.6 mEq/L A potassium level of 4.6 mEq/L is a normal level, indicating that therapy was effective. Normal levels are 3.5 to 5.0 mEq/L. A potassium level of 2.6 mEq/L indicates hypokalemia. A potassium level of 5.6 mEq/L indicates hyperkalemia. A potassium level of 7.6 mEq/L indicates severe hyperkalemia.
The nurse is preparing a patient for blood transfusion. Which drugs should the nurse keep on standby for managing blood transfusion reactions? Select all that apply.
Antihistamines Corticosteroids Reactions may happen during blood transfusions, and the nurse should be prepared for them. Antihistamines and corticosteroids should be kept ready for reducing the intensity of transfusion reactions. Digoxin and thrombin are not helpful in managing transfusion reactions. Digoxin is a cardiac glycoside and is used in heart failure. Thrombin helps in clotting of the blood. Vasodilators have no role in the management of a transfusion reaction.
The nurse is caring for a patient who has an intravenous line for fluid therapy. Which potential complications should the nurse be vigilant about while assessing the patient? Select all that apply.
Bleeding Phlebitis Infection Bleeding at the venipuncture site is a potential complication of intravenous therapy, which can be noted as oozing or slow seepage of blood at the site. Phlebitis, which is characterized by tenderness, pain, or burning is an inflammation of the inner layer of a vein. Infection is a potential complication of intravenous therapy if aseptic measures were not taken during the procedure. Pallor is not a potential complication of intravenous therapy and can occur in other conditions like reduced hemoglobin. Jaundice, characterized by yellowish discoloration of skin, is not a potential complication of intravenous therapy and can occur in other conditions like hepatitis.
The nurse is caring for a patient who is receiving intravenous (IV) therapy. After a few minutes, the nurse finds that the patient has confusion, an increased heart rate, and a decreased blood pressure. The nurse also observes a bluish coloring in the patient's skin. Which condition does the nurse infer from these findings?
Catheter embolism Bluish coloring of the skin indicates cyanosis. An increased heart rate indicates tachycardia, and low blood pressure indicates hypotension. These symptoms together with confusion indicate a catheter embolism, which occurs due to a blockage of the blood vessel from a portion of the IV catheter that broke. Reddened areas and tenderness, warmth, and a burning sensation at the site of the infusion are signs of inflammation or phlebitis. Blanched skin at the IV insertion site indicates that the patient has an infiltration. An increased pulse rate and increased blood pressure indicate fluid overload, which can be caused by the rapid flow rate of IV solution.
Which defining characteristics are consistent with fluid volume deficit?
Dry mucous membranes, thready pulse, tachycardia The nursing diagnosis fluid volume deficit includes extracellular fluid volume (ECV) deficit, hypernatremia, and clinical dehydration. ECV deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, among other indicators. Weight loss of 1 lb (0.5 kg) in 1 week could indicate fat loss instead of fluid loss. ECV deficit causes dark yellow urine rather than pale yellow, which is normal.
You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid?
Fluid that has sodium (salt) in it Body fluid losses remove sodium-containing fluid from the body and can cause extracellular fluid volume deficit unless both the sodium and the water are replaced.
A client is admitted from the emergency department for intravenous (IV) fluids to treat dehydration caused by several days of vomiting and diarrhea. The client's admission venous blood work reveals a pH of 7.27 and bicarbonate of 26 mEq/L; potassium and chloride levels are within normal ranges. The provider has ordered adding bicarbonate to the IV fluids. Which action by the nurse is correct?
Hold the bicarbonate and report the laboratory values to the provider. Bicarbonate is not given for metabolic acidosis unless the client's bicarbonate levels are low. This client's levels are within normal limits. Normal renal function is necessary if potassium is added to IV fluids. The client has normal potassium and chloride levels, so potassium is not needed at this time.
The nurse observes that a patient appears to be hallucinating. On assessment, the nurse determines that the patient is always thirsty, has an elevated body temperature, and has a low level of consciousness. Which condition does the nurse suspect in this patient?
Hypernatremia Hypernatremia indicates increased sodium levels, which may alter brain functioning. This may manifest as hallucinations, thirst, and decreasing levels of consciousness. Elevated temperature is also a clinical manifestation of hypernatremia. Hypokalemia causes irregular pulse, anorexia, nausea, vomiting, and constipation. Hypercalcemia causes decreased muscle strength, pathological fractures, and renal calculi. Hypophosphatemia presents with muscle weakness, decreased deep tendon reflexes, and bone pain.
While reviewing the urine test results of a patient who performs rigorous exercises, the nurse finds that the urine is unclear and yellowish in color. What does the nurse suggest to the patient?
Increase the intake of water and sports beverages. Unclear and yellowish urine indicates dehydration. Therefore, the nurse recommends that the patient increase the intake of water and sports beverages to maintain clear colored urine. Patients should consume water before, during, and after rigorous exercise, as it causes significant loss of fluids and electrolytes. Beverages such as Gatorade are appropriate as they help to sustain fluid and serum electrolytes during exercise. Propel is also an electrolyte solution, which contains carbohydrates and helps to maintain fluid balance during exercise.
A nurse is examining a patient who is suspected of having fluid, electrolyte, and acid-base imbalances. What inquiries would help the nurse obtain a relevant history? Select all that apply.
Obtain a history of medication or herbal remedies used. Inquire whether the patient is on any weight-loss diet plan. Inquire about the type of fluids the patient drinks daily. Asking the patient about a history of any medications or herbal remedies is very important. This is because medications such as antacids, diuretics, and laxatives can have an effect on fluid, electrolyte, and acid-base balance. Weight-loss diet plans can cause deficiencies in certain electrolytes and also lead to ketoacidosis. Drinking certain types of fluids including colas and fruit juices can have an effect on fluid, electrolyte, and acid-base balance. Details about the patient's sleep patterns and sexual behavior are not relevant to fluid, electrolyte, and acid-base imbalance.
When caring for a client with kidney failure who has metabolic acidosis, which symptom does the nurse expect as evidence of the body's compensatory effort?
Rapid and deep respirations Kussmaul respirations (rapid, deep respirations) represent the body's attempt to compensate for metabolic acidosis. The skin is warm, dry, and flushed in metabolic acidosis. Cardiovascular symptoms may occur, but are manifestations of acidosis, not evidence of compensation.
The RN is caring for a client admitted with dehydration who requires a blood transfusion. Which nursing action does the RN delegate to unlicensed assistive personnel (UAP)?
Obtaining baseline vital signs before blood administration UAP education includes assessment of vital signs, so obtaining vital signs is within their scope of practice. IV starts, evaluating client symptoms, and explaining the purpose of a blood transfusion require broader education and scope of practice and should be done by licensed staff members.
The nurse is caring for a client with dehydration. Which task can be delegated to unlicensed assistive personnel (UAP)?
Offering 2-4 ounces of fluid to the client every hour. Unlicensed assistive personnel (UAP) can aid in encouraging clients who are dehydrated to consume the necessary fluids. Calculating IV fluid rates, administering medications, and performing assessments are out of the scope of practice for UAPs.
The nurse is reviewing lab values for a client recently admitted to the medical-surgical unit. Which lab result is severely abnormal?
Potassium, 3.5 mEq/L Sodium, 137 mEq/L Chloride, 107 mEq/L Magnesium, 6.2 mEq/L **** A magnesium level of 6.2 mEq/L is greatly elevated. Clients with severe hypermagnesemia are in grave danger of cardiac arrest. The normal magnesium level is 1.3-2.1 mEq/L. The sodium and potassium results are within normal limits. The chloride level is just slightly elevated, with the normal range being between 98-106 mEq/L.
The trauma nurse is caring for a client who sustained thoracic trauma with multiple rib fractures and flail chest. Which intervention may be considered to promote gas exchange and prevent respiratory acidosis in this client?
Ventilatory assistance Flail chest/thoracic trauma restricts respiratory expansion, leading to respiratory acidosis. Ventilatory support may be needed. Supplemental oxygen will likely be needed, but improving ventilation best promotes gas exchange. IV bicarbonate is not utilized with respiratory acidosis. A nasogastric tube is not indicated.
A patient has developed circulatory overload. Which therapies should the nurse expect the patient to be prescribed? Select all that apply.
oxygen diuretic
