NUR 1050 Fundamentals II CH 40 Fluid, Electrolyte, & Acid base balance
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?
"I've been taking antacids almost every 2 hours over the past several days."
A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply.
"Try to drink at least six to eight glasses of water each day." "Limit sugar, salt, and alcohol in your diet." "Report side effects of medications you are taking, especially diarrhea." "Weigh yourself daily and report any changes in your weight."
A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply.
0.33% NaCl (⅓-strength normal saline) 0.45% NaCl (½-strength normal saline)
What commonly used intravenous solution is hypotonic?
0.45% NaCl
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?
1 unit over 2 to 3 hours, no longer than 4 hours
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?
1+
When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document?
2
A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented?
3+ pitting edema
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 hypotonic solution
A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?
Administer oral K supplements as ordered.
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?
An implanted central venous access device (CVAD)
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?
Apply pressure to insertion site for at least 3 minutes.
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas
A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate?
Avoid use of a tourniquet.
The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV?
Change the site every three to four days.
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.
Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?
Discontinue the IV and relocate it to another spot.
The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?
Discontinue the infusion and record the volume left in the blood bag.
A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms?
Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately.
A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement?
Keeping fluids readily available for the patient.
A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the:
Lungs
A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess?
Moist crackles heard upon auscultation
Which finding best indicates to the nurse that the client has a therapeutic outcome from a recent blood transfusion?
No signs of chills, fever, or shortness of breath
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?
Notify the primary care provider immediately for possible fluid overload.
A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings?
Put on gloves; remove the catheter
The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply.
Rate of the IV solution Location of the IV catheter access Client's reaction to the procedure Type of IV solution Gauge and length of the IV catheter
A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms?
Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed.
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?
The renal system retains more water.
A student has joined the marching band at high school. The band begins practicing outside during hot summer weather. Which health promotion information will the school nurse teach the students?
The student should drink large amounts of water on practice days.
Which statement most accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute concentration.
Which client would be a candidate for total parenteral nutrition?
a client with colitis and bloody diarrhea
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
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 winged infusion needle.
Which hormone regulates the extracellular concentration of potassium within the human body?
aldosterone
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
calcium and phosphorus
Potassium is needed for neural, muscle, and:
cardiac function.
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?
hemolytic transfusion reaction: incompatibility of blood product
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find?
hypokalemia
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
isotonic
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?
muscle cramping and tetany
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:
phlebitis.
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes
A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?
plasma
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?
renal failure
A decrease in arterial blood pressure will result in the release of:
renin.
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform?
Weigh the client's wet linen or dressing.
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
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 100 gtt/min
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?
hypovolemia
The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by:
increasing ventilation through the lungs.
A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed?
Hypertonic
A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.Place your answer on the line provided below.
50gtts
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?
60 drops/mL
A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?
83 gtt/min
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
an infant age 4 months
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?
cardiac irregularities
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins
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?
hypertonic
The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to:
increase in fat cells.
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address?
increased hydrostatic pressure
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"Fluid in the tissue space between and around cells."
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client?
Gauze dressing
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?
O negative
The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?
Phlebitis
A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation?
Remove the IV from the site and start at another location.
What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?
To assure the IV solution is appropriate for this administration
Which is a common anion?
chloride
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
The process of filtration begins at the:
glomerulus.
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?
ordering type of solution, additive, amount of infusion, and duration
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?
pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
total parenteral nutrition.
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?
"I should drink 2,500 mL/day of fluid."
The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by the students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply.
"The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." The adrenal glands regulate blood volume by secreting aldosterone." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst."
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?
"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)."
A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted?
10- to 15-degree angle
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?
3,000
Total parenteral nutrition is hypertonic. What is the percentage of dextrose in these solutions?
50% dextrose
The nurse is preparing to flush a client's peripheral venous access device. Which observable intervention best assures continued effective venous access at this location?
Anchoring extension tubing near entry site with tape
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?
Avoid salty or excessively sweet fluids.
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)?
Changing the dressing on a client's peripheral IV site
A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?
Flush the IV with 3 mL of normal saline.
A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status?
HCO3: 25 mEq/L (25 mmol/L)
The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?
Hypertonic
A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?
Infants
A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status?
Measuring weight daily.
Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L?
Metabolic acidosis
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)?
Metabolic alkalosis
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?
Metabolic alkalosis
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
Offer small amounts of preferred beverage frequently.
The nurse is caring for a client who has a prescription for a peripheral intravenous (IV) infusion of a liter of 0.9 sodium chloride solution over 10 hours by gravity infusion. The drop factor is 60 gtts/mL. After reviewing the image, what is best action by the nurse to provide the appropriate drops per minute of medication?
Regulate flow to allow 25 gtts every 15 seconds
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?
Remove the IV catheter and reinsert another in a different location.
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 intervention should the nurse perform for this complication?
Restart infusion in another vein and apply a warm compress.
A nurse is reviewing the client's serum electrolyte levels which are as follows:
Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance? hypokalemia
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?
Stop the transfusion immediately.
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?
The client has anti-A antibodies.
A nurse is preparing to re-site a client's IV during the client's hospital stay following a mastectomy. What accurately describes an assessment that should be made before starting the infusion?
The nurse should assess the preferred site, ideally the dorsal and ventral surfaces of the upper extremities.
The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply.
osmosis filtration diffusion active transport
A nurse is calculating the output of a client with renal failure and takes into account all modes of fluid loss. When addressing the client's insensible fluid loss via respiration, which amount would the nurse anticipate as the usual average?
300 mL/day
A client is scheduled to receive a blood transfusion. The blood is ready and the nurse, along with another licensed staff member, are at the client's bedside to verify the information. They would compare the laboratory blood record with which information for verification? Select all that apply.
Client's name Client's identification number Blood unit number Blood ABO group
A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply.
Metabolic alkalosis Hypokalemia
