MODULE 10: Ch. 42 (Fluid & Electrolytes) - FLUID BALANCE
The nurse is monitoring a patient for possible adverse effects while receiving a unit of blood. What common manifestations does the nurse assess the patient for?
-Itching -HYPOtension -dyspnea -fever
Fluid volume excess (FVE) can be caused by what problems?
-Taking in too much fluid -Retaining too much fluid
Upon receiving the shift report, the nurse knows to monitor the patient with which condition for fluid volume excess (FVE)?
Cirrhosis of the liver with low albumin
A patient has developed fluid volume excess. The nurse is aware that the increase in the patient's interstitial fluids can lead to which manifestation?
Dependent edema
The nurse is assigned to a patient who is receiving 0.9% Normal Saline IV fluid. The nurse will need to monitor the patient for what IV solution-related complication?
Hypernatremia (NS is isotonic solution, that contains sodium and chloride electrolytes. it can cause abnormal elevations in serum sodium levels)
In a patient with fluid volume deficit, which clinical manifestation would be due to decreased interstitial fluid?
decreased skin turgor
Which patients would be possible candidates for blood or blood product administration?
-A patient with missing clotting factors -A patient with drug-related destruction of red blood cells -A patient with abdominal bleeding from trauma -A patient who has had recent major surgery
Which patients are likely experiencing fluid volume deficit?
-An 86-year-old woman with a fever who has dry mucous membranes and decreased urination -An infant with diarrhea who has increased respiratory rate, tachycardia, and sunken fontanel -A 40-year-old woman with bleeding who has a weak, thready pulse and decreased skin turgor
A patient has developed edema. Which descriptions are accurate regarding this manifestation?
-Caused by excessive fluid in the interstitial space. -Dependent edema occurs in the sacral area of patient on bedrest. -Edematous tissue is quite fragile.
The nurse has received a "force fluids" order for a patient with a fluid volume deficit. Which actions taken by the nurse would be beneficial for meeting the patient's fluid replacement needs?
-Ensuring the pitcher of water at the patient bedside is refilled as required -Providing ways to record intake of fluids to meet required levels -Tapering off fluid intake so the least amount is ingested before bedtime -Reminding the patient to drink throughout the day
The nurse is assigned to a patient who is to have a central venous catheter (CVC) inserted. What are the major uses of this type of IV catheter?
-Long term IV therapies -Short-term INTENSIVE therapies -HYPERtonic solutions
The nurse is developing a 24-hour fluid budget for a patient with 1000 mL fluid restriction. The fluid budget will need to include which set of factors?
-Medication -IV fluids -Between meal fluid sipping -breakfast, lunch, and dinner
The nurse is preparing to tally up a patient's fluid intake at the end of the shift. Which substances should be included in the fluid intake tally?
-Nasogastric tube irrigations -Enteral tube feeding -free water gastric tube flushes -IV medications
A patient with an IV crystalloid solution infusing, reports to the nurse that the IV site hurts. On examination of the site, the nurse notes localized redness and swelling and it is warm to touch. The nurse recognizes that these are signs and symptoms that may indicate what IV site complications?
-Phlebitis -Cathetered-related infection
Which information describes the unique features of isotonic type of fluid volume excess (FVE)?
-Retention of water and sodium are equal. -There is no change in serum osmolality.
The nurse is developing an educational program for the staff. Which information regarding hypotonic fluid volume excess (FVE) should be included?
-Retention of water is greater than sodium. -Serum osmolality decreases. -There is an increased circulating volume.
The nurse is tallying up a patient's intake and output at the end of the shift. Which patient-related data would require entry of fluid output information on the EHR?
-The patient has a nasogastric tube attached to wall suction. -The patient has a Foley catheter in place. -The patient has a surgical wound drain on his abdomen.
The nurse has become concerned that a patient may be developing a fluid volume imbalance. Which data reflect the priority assessments that the nurse should monitor on this patient?
-The patient's pulse and blood pressure -The patient's weight changes over the past day -The patient's intake and output balance over the past 48 hours
What are the nurse's responsibilities regarding IV fluid administration?
-Verify that the fluid is appropriate for the patient. -Evaluate the effectiveness of IV therapy. -Monitor the patient for complications of IV therapy. -Comply with the 6 rights of safe medication administration.
Which statements by the nursing student regarding an isotonic fluid deficit demonstrate correct understanding of the condition?
-Water and sodium are lost together equally. -Serum osmolality does not change.
The nurse has received an order to start IV fluids on a patient. In choosing the IV site, what questions should the nurse consider in making this decision?
-What is the condition of the patient's veins? -What is the patient's age? -For about how long is the patient to receive IV therapy? -What is the patient's diagnosis?
A patient has just returned from surgery. Which patient factors, if present, increases the risk for fluid volume deficit?
-a draining wound -dressing changes for severe burns -nausea and vomiting
Which conditions increase the risk for development of hypertonic fluid volume deficit (FVD)?
-diabetic insipidus -osmotic diuretics -hypertonic intravenous fluids
A patient with vomiting and diarrhea has developed rapid onset isotonic fluid volume deficit. The patient can be expected to have which lab data results?
-elevated RBC -Increase BUN and creatinine
An acutely ill patient is brought into the urgent treatment center by a family member. Which patient assessments would suggest a significant fluid volume deficit?
-elevated serum BUN and creatinine -rapid, weak, thready pulse -Dry, cracked lips and furrows on the tongue
The nurse has been assigned to an adult patient with isotonic fluid volume deficit and performing her shift assessment on the patient. The nurse can anticipate which clinical findings?
-hypotension -flat neck vein when supine -low urine output
The nurse suspects that a patient has developed a hypertonic fluid volume deficit from receiving a large volume of hypertonic IV fluids. The nurse should expect to see which lab test result?
-increase BUN and creatinine -elevated serum osmolality
A student nurse is studying fluid imbalances, including unique and common features. The student would include what information regarding the feature that hypotonic and isotonic FVE have in common?
-increase circulating volume
Since a patient was admitted, her baseline weight has decreased from 160 pounds to 152 pounds, a 5% total body weight loss. The nurse is aware that on the dehydration severity scale, the patient falls into which category?
-moderate dehydration
A patient with heart failure has developed the clinical manifestations of fluid volume excess. What features of FVE would the nurse expect to be present?
-no change in serum osmolality -equal gain on water and sodium
A patient who received an excessive volume of hypotonic IV fluid has developed the signs and symptoms of hypotonic FVE. Which neurologic clinical manifestations are consistent with this fluid imbalance?
-seizures -confusion -
After completing the nursing assessment, the nurse writes the nursing diagnosis label, Readiness for Enhanced Fluid Balance. What are the defining characteristics of this diagnostic label?
-stabe daily weights -moist mucous membranes -intake equals output -no manifestation of fluid volume deficit
Which statements accurately describe hypertonic fluid deficit?
-there is greater water loss than solute loss -it results in shrinkage of cells
A patient has been admitted to the hospital for treatment of severe fluid volume excess related to syndrome of inappropriate antidiuretic hormone (SIADH). What unique features of fluid volume excess will the nurse expect?
-water gain is excess of sodium -decrease serum osmolality -signs of cerebral edema
The nurse is preparing to administer a blood product. The nurse will prime the IV tubing with what IV solution?
0.9 % Normal Saline (Normal saline is the only IV solution that is used to run with blood)
Match each laboratory test with the information it provides.
1) Blood urea nitrogen, Creatinine --> Indicator of overall renal function 2)Serum osmolality --> Helps determine hydration status, useful in managing fluid requirements 3)RBC, H&H --> Measure of the oxygen carrying capacity of the blood 4) Urine osmolality --> Measure of the concentration of solutes in the urine
Match each IV fluid name to its corresponding category.
1) Hypotonic crystalloid --> 0.45% Normal Saline (0.45% NS) 2)Isotonic crystalloid --> 5% Dextrose and Water (D5W) 3) Hypertonic crystalloid --> 5% Dextrose and 0.9% Normal Saline (D5 0.9 NS)
Match the clinical manifestations to their fluid excess category.
1) Increased interstitial fluid volume --> Edema of the ankles and feet 2)Increased circulating fluid volume --> Bounding peripheral pulses and hypertension 3)Pulmonary cellular edema --> Shortness of breath, cough
Match the nursing diagnosis with the supporting evidence.
1)Excess Fluid Volume --> Edema, dyspnea, sudden weight gain 2)Deficient Fluid Volume --> Dry skin and mucous membranes, sudden weight loss, decreased urine output 3)Risk for Fluid Imbalance --> About to undergo a major surgical procedure 4)Decreased Cardiac Output --> Low blood pressure, tachycardia, dyspnea, fatigue
The provider orders that a patient be given 1000 mL of IV normal saline to run over 10 hours. The drop factor of the selected tubing is 15. What is the correct rate of infusion in drops per minute?
25 drops/minute
What is the maximum time that a blood product can be infused after leaving the blood bank?
4 hours (To assure that the blood is safe, it must be infused within 4 hours of leaving the blood bank.)
A patient is on a 1000 mL per day fluid restriction. At 3 pm, the patient has consumed 700 mL. What is the best plan for the remainder of the day to maintain that fluid restriction?
Allow 150 mL with dinner and 150 mL for medications and prior to going to sleep.
When administering blood to a patient, the nurse knows that the most vigilant monitoring of the patient must take place. When must this monitoring happen?
As the transfusion is started and within the first 15 minutes (Most adverse transfusion reactions occur in the first 15 minutes of blood administration.)
The provider has ordered that a patient be 1000 mL of IV normal saline to run over 12 hours. What is the first step in the calculation of the rate of infusion?
Calculate the hourly volume of normal saline the patient should receive.
The nurse is assessing a 35-year-old patient who is at risk for developing fluid volume excess. Which data would support the presence of FVE in an adult patient?
Crackles auscultated in lung bases
A nurse has been assigned to care for four patients. Which patient condition would the nurse recognize as at risk for fluid volume deficit (FVD)?
Hemorrhage
The nurse is preparing to start a blood transfusion. The nurse is aware that the most common cause of adverse blood transfusion events is what procedural step failure?
Inappropriate identification prior to blood administration
A patient has developed edema as a result of fluid volume excess. The nurse is aware that the underlying cause of this fluid imbalance is which primary cause of edema?
Increased hydrostatic pressure
A patient has developed neurologic manifestations related to hypertonic fluid volume deficit. The nurse is aware that these manifestations are caused by what underlying problem?
Increased serum osmolality causes water to shift out of brain cells by osmosis
The nurse receives an order to infuse 1000 mL of D5W at 125 mL continuously. Which of the following actions by the nurse indicates correct interpretation of this order?
Infusing D5W at a rate of 125 mL/hr until the health care provider changes the order
When addressing fluid restriction in a patient with fluid volume excess, what actions should the nurse take to ensure the patient is responsible and comfortable meeting the fluid restriction goals?
Involve the patient, if possible, and plan to space small amounts of fluid intake throughout the day.
The nurse suspects that a patient receiving an IV infusion of D5 0.45% NS is developing intracellular dehydration and circulatory overload. The nurse is aware that this IV solution can cause these complications due to what tonicity?
It is a HYPERtonic solution.
Which instruction to nursing assistive personnel (NAP) reflects the nurse's correct understanding of the NAP's role in caring for a patient receiving intravenous (IV) fluids by gravity drip?
Let me know when you notice that the IV bag contains less than 100 mL.
The nurse notes that an assigned adult patient has experienced a 5% weight gain over the last 24 hours. Taking the patient's data into consideration, the nurse concludes that it is fluid weight gain. What degree of excess does this patient have?
Moderate FVE
A patient has just returned to the hospital room following surgery. Which postoperative factor places the patient at risk for fluid volume deficit (FVD)?
Patient has a nasogastric tube that is draining.
Blood has been ordered and the nurse is reviewing who must check and verify the blood. Verification is required by which people?
Personnel in the blood bank Nurse who picks up the blood from the blood bank Two nurses at the patient's bedside before initiating transfusion
A patient who has been ill with vomiting and diarrhea has experienced a rapid weight loss of 8% of total body weight. How would this be categorized on the dehydration scale?
Severe dehydration
The nurse is assessing a patient with fluid volume deficit (FVD). Which clinical manifestation would suggest that the patient is experiencing hypertonic FVD?
The patient has become confused
The nurse is inspecting an infant to identify a suitable IV site. In infants, the most common location for an IV site is which vein location?
The vein in the middle of the scalp
Which action by the nurse helps to ensure patient safety when administering IV fluids by gravity to very young children?
Using a volume-control device for the infusion
A nurse is obtaining a health history on a newly-admitted patient. Which patient responses should alert the nurse to the possibility of a fluid volume imbalance?
Weight gain of 2 kg since yesterday morning
During the morning patient assessment the nurse finds bounding peripheral pulses and jugular venous distention. The nurse is aware that these are clinical manifestations caused by what type of fluid imbalance?
increased circulating volume