NURS (FUNDAMENTAL): Ch 39 NCLEX Fluid, Electrolyte, and Acid-Base Balance

A client's intake and output is being measured and recorded each shift. The client has had the following intake: 3 oz apple juice 4 oz tea 5 oz pureed chicken 2 oz mashed potatoes 4 oz orange gelatin 2 oz vanilla ice cream What amount would the nurse document as fluid on the intake sheet?

390 ml Intake measurements include all oral and parenteral fluids. Oral fluids include any liquids ingested or any foods that become liquid at room temperature. Gelatin and ice cream are examples of solid foods to include. Pureed foods is not considered fluid intake nor is mashed potatoes. Based on the measurements, the client consumed 13 oz of fluid. One ounce is equal to 30 ml, so 13 oz of fluid is equal to 390 mL

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.

Ans: 50 gtts/min.

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? 1 2 3 4

Grade 2 Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 inch and with purulent drainage.

What is the rate of administration for packed red blood cells? a) 1 unit over 2 to 3 hours, no longer than 4 hours b) 200 mL/hr c) IV push over 3 minutes d) As fast as the patient can tolerate

a) 1 unit over 2 to 3 hours, no longer than 4 hours Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours. Answer A describes platelets, answer C represents cryoprecipitate, and answer D describes fresh-frozen plasma.

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? a) 50 gtt/min b) 20 gtt/min c) 40 gtt/min d) 30 gtt/min

a) 50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

Which is a common anion? a) Chloride b) Calcium c) Potassium d) Magnesium

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

During a blood transfusion, a patient displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect? a) Hemolytic transfusion reaction: incompatibility of blood product b) Febrile reaction: fever develops during infusion c) Allergic reaction: allergy to transfused blood d) Bacterial reaction: bacteria present in the blood

a) Hemolytic transfusion reaction: incompatibility of blood product

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? a) maintenance of cell size b) removal of waste c) maintenance of blood volume d) transportation of nutrients

a) maintenance of cell size

A nurse is caring for a patient who has fluid imbalance related to the development of ascites. Which imbalances would the nurse monitor for in this patient? Select all that apply. a) Extracellular fluid volume deficit b) Protein deficit c) Metabolic alkalosis d) Sodium deficit e) Plasma-to-interstitial fluid shift f) Metabolic acidosis

a, b, d, e. Patients with fluid loss due to ascites are at risk for extracellular fluid volume deficit, protein deficit, sodium deficit, and plasma-interstitial fluid shift.

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. a) 5% dextrose in water (D5W) b) 0.9% NaCl (normal saline) c) Lactated Ringer's solution d) 0.33% NaCl (¹∕³-strength normal saline) e) 0.45% NaCl (½-strength normal saline) f) 10% dextrose in water (D10W)

a, d, e 5% dextrose in water (D5W), 0.33% NaCl (¹∕³-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 10% dextrose in water (D10W) is used in peripheral parenteral nutrition (PPN).

Which client has more extracellular fluid? a) Adolescent man b) Newborn c) Female school-age child d) Adult woman

b) Newborn

Major control over the extracellular concentration of potassium within the human body is exerted by: a) albumin. b) aldosterone. c) testosterone. d) progesterone.

b) aldosterone.

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 of the following interventions should the nurse perform for this complication? a) Position the client on the left side. b) Apply antiseptic and a dressing. c) Apply a warm compress. d) Elevate the client's head.

c) Apply a warm compress.

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? a) excessive use of laxatives b) increased cardiac output c) renal failure d) diaphoresis

c) renal failure Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

The primary extracellular electrolytes are: a) phosphorous, calcium, and phosphate. b) potassium, phosphate, and sulfate. c) sodium, chloride, and bicarbonate. d) magnesium, sulfate, and carbon.

c) sodium, chloride, and bicarbonate. The primary extracellular electrolytes are sodium, chloride, and bicarbonate.

When providing chemotherapeutic agents, which catheter is accessed with a noncoring needle? a) Peripheral central catheter b) Hickman catheter c) Groshong catheter d) Implanted venous access

d) Implanted venous access

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? a) Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. b) Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. c) Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. d) Discontinue the infusion immediately, apply warm, moist compresses to the site, and restart the IV at another site.

a) Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? a) ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. b) ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. c) Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet. d) Bowel motility will be restored within 24 hours after beginning supplemental K+.

a) ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.

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? a) Isotonic b) Colloid c) Hypertonic d) Hypotonic

a) Isotonic

A nurse is preparing a presentation for a group of older adults at a local senior center about the importance of fluid intake. As part of the presentation, the nurse plans to discuss how the intake and output of fluids is typically balanced each day. When describing the normal daily output of fluids, which component would the nurse identify as accounting for the smallest amount of fluid output? a) Perspiration b) Feces c) Exhaled air d) Urine

a) Perspiration Normal urine output for 24 hours is approximately 1,500 mL if intake is normal. Loss of fluid through the skin as perspiration accounts for an average daily loss of 100 to 200 mL of fluid. In addition to perspiration, insensible fluid loss through the skin amounts to about 300 to 400 mL per day. Loss of fluid through the gastrointestinal system in the form of feces is usually minimal, approximately 200 mL per day. Loss of water through respiration is approximately 300 mL per day.

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? a) Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. b) Stop the transfusion immediately and keep the vein open with normal saline, notify the physician stat, administer antihistamine parenterally as needed. c) Stop the transfusion immediately and keep the vein open with normal saline, notify the physician, and treat symptoms. d) Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the physician, administer antibiotics stat.

a) Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

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? a) calcium and phosphorus b) potassium and sodium c) chloride and magnesium d) potassium and chloride

a) calcium and phosphorus The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances.

Potassium is needed for neural, muscle, and: a) cardiac function. b) optic function. c) skeletal function. d) auditory function.

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

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

a) hypokalemia. 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.

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 would the nurse most likely address? a) increased hydrostatic pressure b) decreased colloid oncotic pressure c) increased capillary permeability d) blockage of the lymph nodes

a) increased hydrostatic pressure The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply. a) respiratory muscle weakness b) confusion c) ventricular dysrhythmia d) constipation e) abdominal distention

a, b, c With hypophosphatemia, findings include neuromuscular dysfunction; weakness, especially respiratory muscles; fatigue; myocardial depression; ventricular dysrhythmias; rhabdomyolysis; confusion, coma; decreased oxygen delivery to tissues; renal loss of bicarbonate, calcium, magnesium, and glucose; bone changes (osteomalacia); and endocrine changes (insulin resistance). Abdominal distention and constipation are more commonly associated with hypokalemia.

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. a) Diffusion b) Active transport c) Filtration d) Acid-base balance e) Osmosis

a, b, c, e Osmosis, filtration, diffusion, and active transport maintain fluid homeostasis. Acid-base balance concerns chemical reactions in the body that influence metabolism.

A nurse is providing care to a client with an ECF volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply. a) orthostatic hypotension b) dry mucous membranes c) decreased urine output d) slow-filling peripheral veins e) poor skin turgor

a, c, d The signs and symptoms of an ECF volume deficit reflect decreases in fluid volume in the vascular and interstitial spaces. The signs and symptoms of a decrease in vascular volume include orthostatic or postural changes in pulse rate and blood pressure (i.e., an increase in pulse rate and decrease in blood pressure when the person moves from a lying to a standing position); weak, rapid pulse; decreased urine output; and slow-filling peripheral veins. The signs and symptoms of decreased interstitial volume include dry mucous membranes and poor skin turgor.

A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. a) "Try to drink at least six to eight glasses of water each day." b) "Try to limit your fluid intake to one quart of water daily." c) "Limit sugar, salt, and alcohol in your diet." d) "Report side effects of medications you are taking, especially diarrhea." e) "Temporarily increase foods containing caffeine for their diuretic effect." f) "Weigh yourself daily and report any changes in your weight."

a, c, d, f Generally, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

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? a) "I was breathing so fast because I was so anxious and in so much pain." b) "I've been taking antacids almost every 2 hours over the past several days." c) "I've had a fever for the past 3 days that just doesn't seem to go away." d) "I've had a GI virus for the past 3 days with severe diarrhea."

b) "I've been taking antacids almost every 2 hours over the past several days." Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.

Which of the following clients would be a candidate for total parenteral nutrition? a) A postoperative appendectomy client b) A client with colitis and bloody diarrhea c) A client with diabetic ketoacidosis d) A client receiving intravenous antibiotics

b) A client with colitis and bloody diarrhea

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? a) Risk for Infection related to inadequate personal hygiene b) Acute Confusion related to cerebral edema c) Pain related to surgical incision d) Constipation related to immobility

b) Acute Confusion related to cerebral edema Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? a) Encourage foods and fluids with high sodium content. b) Administer oral K supplements as ordered. c) Caution the patient about eating foods high in potassium content. d) Discuss calcium-losing aspects of nicotine and alcohol use.

b) Administer oral K supplements as ordered. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? a) Yogurt b) Banana c) Milk d) Turkey

b) Banana Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded? a) Frozen fluids b) Fruit consumption c) Parenteral fluids d) Sips of water

b) Fruit consumption Any water consumption must be recorded in order to closely monitor a patient who has congestive heart failure. Many of these patients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.

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 most likely find? a) Hypomagnesemia b) Hypokalemia c) Hyperchloremia d) Hypernatremia

b) Hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.

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? a) Circulatory overload b) Hypovolemia c) Hypervolemia d) Edema

b) Hypovolemia The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a) Explaining the mechanisms involved in transporting fluids to and from intracellular compartments b) Keeping fluids readily available for the patient c) Emphasizing the long-term outcome of increasing fluids when the patient returns home d) Planning to offer most daily fluids in the evening

b) Keeping fluids readily available for the patient Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

A nurse carefully assesses the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following? a) Kidneys b) Lungs c) Adrenal glands d) Blood vessels

b) Lungs The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as a) Volume expander b) Total parenteral nutrition c) Blood transfusion therapy d) Cellular hydration

b) Total parenteral nutrition Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use a(an) a) 18-gauge needle b) Winged infusion needle c) Central venous access d) Intermittent infusion device

b) Winged infusion needle Winged infusion needles are short, beveled needles with plastic flaps or wings. They may be used for short-term therapy or when therapy is given to a child or infant.

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? a) metabolic acidosis b) cardiac irregularities c) increased intracranial pressure (ICP) d) muscle weakness

b) cardiac irregularities Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias.

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's: a) high magnesium. b) low calcium. c) high sodium. d) low potassium.

b) low calcium. Normal total serum calcium levels range between 8.9 and 10.1 mg/dL.

A decrease in arterial blood pressure will result in the release of: a) insulin. b) renin. c) protein. d) thrombus.

b) renin Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant? a) bounding pulse b) weight gain of 0.75 kg in a day c) increased blood pressure d) slightly distended neck veins

b) weight gain of 0.75 kg in a day Although increased blood pressure, bounding pulse, and distended neck veins are signs of ECF volume excess, rapid weight gain (more than 0.5 kg per day) is the most significant symptom indicating ECF volume excess. A weight gain of 1 kg reflects retention of 1 L of ECF. Additionally, because the veins are very distensible, large volumes of fluid can be retained without any increase in blood pressure or changes in pulse or neck veins.

What nursing interventions would be appropriate for a patient diagnosed with deficient fluid volume? (Select all that apply.) a) Monitoring edema b) Intravenous therapy c) Electrolyte management d) Nutrition management e) Fluid restriction f) Hypervolemia management

b, c, d

The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L. Which finding would the nurse expect to assess? Select all that apply. a) Polydipsia b) Cardiac dysrhythmia c) Polyuria d) Muscle weakness e) Diarrhea

b, e The client's potassium level suggests hyperkalemia, which is manifested by anxiety; irritability; gastrointestinal hyperactivity (diarrhea and intestinal cramping); tall, peaked T waves on electrocardiogram; and cardiac dysrhythmias. Muscle weakness, polyuria and polydipsia would be noted with hypokalemia.

A nurse identifies a nursing diagnosis of Excess Fluid Volume related to heart failure as evidenced by edema and weight gain. The nurse reviews the client's laboratory test results. Which plasma osmolality value would support the nurse's nursing diagnosis? a) 310 mOsm/kg b) 280 mOsm/kg c) 260 mOsm/kg d) 300 mOsm/kg

c) 260 mOsm/kg Normal osmolality is 280 to 300 mOsm/kg. Plasma osmolality decreases in water excess and elevates in water deficit. Therefore a result of 260 mOsm/kg would support the diagnosis of excess fluid volume.

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? a) 1+ pitting edema b) 2+ pitting edema c) 3+ pitting edema d) 4+ pitting edema

c) 3+ pitting edema 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. +4 is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? a) 500 b) 3,750 c) 3,000 d) 1,000

c) 3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

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

c) An implanted central venous access device (CVAD) Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy.

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? a) Bread products b) Processed meat c) Apricots d) Dairy products

c) Apricots Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

A nurse is flushing a patient's implanted port after administering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse's next action based on these findings? a) Gently push down on the needle and flush it a second time. b) Stop flushing and remove the needle; notify the primary care provider. c) Ask the patient to perform a Valsalva maneuver; change the patient position. d) Close the clamp; wait 3 minutes, try flushing the port again.

c) Ask the patient to perform a Valsalva maneuver; change the patient position. If a port flushes but does not have a blood return, the nurse should ask the patient to perform a Valsalva maneuver, have the patient change position or place the affected arm over the head, or raise or lower the head of the bed. If these measures do not work, the nurse should remove the needle and reaccess the device with a new needle.

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? a) Eat crackers and bread. b) Use an alcohol-based mouthwash to moisten your mouth. c) Avoid salty or excessively sweet fluids. d) Use regular gum and hard candy.

c) Avoid salty or excessively sweet fluids.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level? a) Fluid volume excess b) Tetany c) Cardiac dysrhythmias d) Pulmonary embolus

c) Cardiac dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

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? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

c) Metabolic acidosis A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L. For what manifestations will you be alert? a) Diminished cognitive ability and hypertension b) Nausea, vomiting, and constipation c) Muscle weakness, fatigue, and dysrhythmias d) Muscle weakness, fatigue, and constipation

c) Muscle weakness, fatigue, and dysrhythmias Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

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? a) A systemic blood infection b) Rapid fluid administration c) Phlebitis d) An infiltration

c) Phlebitis Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? a) Sodium b) Chloride c) Potassium d) Phosphorous

c) Potassium

When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing: a) anaphylaxis. b) allergic reaction. c) fluid overload. d) pulmonary embolism.

c) fluid overload.

A 70-year-old client is scheduled for a colonoscopy and is prescribed a bowel preparation solution. The nurse would be alert for which potential imbalance? Select all that apply. a) Hypophosphatemia b) Hypercalemia c) Hypocalcemia d) Hyperphosphatemia e) Hypokalemia f) Hyperkalemia

c, d, e Older adults are at increased risk for electrolyte imbalances during and after bowel preparation for procedures such as a colonoscopy or barium enema. Research has shown that bowel preparation solutions in clients over age 65 years are associated with vascular volume deficit, hyperphosphatemia, hypokalemia, and hypocalcemia.

What is the lab test commonly used in the assessment and treatment of acid-base balance? a) Chemistry I b) Complete blood count c) Urinalysis d) Arterial blood gas

d) Arterial blood gas ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine.

The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients? a) Increase in nephrons in the kidneys b) An increased sense of thirst c) Increased renal blood flow d) Cardiac volume intolerance

d) Cardiac volume intolerance The elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. The elderly typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.

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

d) Ensure that the prescribed solution is clear and transparent. 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 primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

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 most likely find? a) Hypomagnesemia b) Hypernatremia c) Hyperchloremia d) Hypokalemia

d) Hypokalemia

A nurse is reading a journal article about fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances? a) Adolescents b) Older adults c) Toddlers d) Infants

d) Infants Infants have a far greater volume of total fluid as a percentage of body weight than older individuals. However, this high percentage of fluid does not give infants a greater reserve against fluid deficit. Instead, it creates a vulnerability to fluid deficit due to the high percentage of fluid required for homeostasis. In addition, kidney immaturity and increased body surface area in relation to body size place infants at greater risk than older children or adults for fluid and electrolyte imbalances.

Because metabolism continually produces acids, maintenance of pH within these incredibly narrow limits depends on two processes: buffering and compensation. Which statement describes a function of buffering? a) The lungs, under the control of chemoreceptor areas in the brainstem respiratory center, are responsible for controlling the amount of carbon dioxide in the blood. b) The renal system excretes acids and bases from the body as needed. c) The kidneys influence the maintenance of the normal acid-base balance by changing the rate of excretion or retention of H+ and HCO3 ions. d) It helps to prevent large changes in pH by absorbing or releasing H+ ions.

d) It helps to prevent large changes in pH by absorbing or releasing H+ ions.

A nurse is assessing a client's fluid balance status. The nurse understands that which organ plays the major role in regulating fluid balance? a) Skin b) Lungs c) Intestines d) Kidneys

d) Kidneys Although the skin, gastrointestinal tract, and lungs play a role in fluid balance, the kidneys are the major organs regulating fluid balance, conserving or excreting water and electrolytes as necessary to maintain homeostasis.

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? a) Recording intake and output b) Testing skin turgor c) Reviewing the complete blood count d) Measuring weight daily

d) Measuring weight daily Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A client has the following arterial blood gas results: pH: 7.33 PaCO2: 42 mm Hg HCO3: 19 mEq/L PaO2: 95 mm Hg Which imbalance would the nurse suspect? a) Metabolic alkalosis b) Respiratory acidosis c) Respiratory alkalosis d) Metabolic acidosis

d) Metabolic acidosis The results reveal metabolic acidosis, which is characterized by a pH lower than 7.35 and a plasma HCO3 concentration lower than 22 mEq/L. Respiratory acidosis is indicated by a low pH accompanied by an increased arterial concentration of carbon dioxide, which often is clinically defined as a PaCO2 of greater than 45 mm Hg. Respiratory alkalosis is present when a high pH is accompanied by a blood carbon dioxide concentration lower than 35 mm Hg. Metabolic alkalosis is characterized by a pH higher than 7.45 and a plasma HCO3 concentration above 26 mEq/L.

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium? a) Insulin promotes the transfer of potassium from the extracellular fluid into skeletal muscle and liver cells. b) Aldosterone enhances renal excretion of potassium. c) A person loses approximately 30 mEq of potassium. d) Normal serum potassium ranges from 5.5 to 6.0 mEq/L.

d) Normal serum potassium ranges from 5.5 to 6.0 mEq/L. Normal serum potassium ranges from 3.5 to 5.0 mEq/L

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? a) Reposition the extremity and raise the height of the IV pole. b) Apply pressure to the dressing on the IV. c) Pull the catheter out slightly and reinsert it. d) Put on gloves; remove the catheter; apply pressure with a sterile pad.

d) Put on gloves; remove the catheter; apply pressure with a sterile pad. This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also apply pressure with a sterile gauze pad, secure the gauze with tape over the insertion site, and restart the IV in a new location.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? a) If sodium is low, it means that there is not enough water. b) Sodium is not regulated by natriuretic peptides. c) Normal serum sodium levels range from 145 to 155 mEq/L. d) Sodium is regulated by the renin-angiotensin-aldosterone system.

d) Sodium is regulated by the renin-angiotensin-aldosterone system.

Which statement most accurately describes the process of osmosis? a) Solutes pass through semipermeable membranes to areas of lower concentration. b) Plasma proteins facilitate the reabsorption of fluids into the capillaries. c) Water shifts from high-solute areas to areas of lower solute concentration. d) Water moves from an area of lower solute concentration to an area of higher solute concentration.

d) Water moves from an area of lower solute concentration to an area of higher solute concentration.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a) a 47-year-old who had a colon resection yesterday and is reporting pain b) a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today c) a 60-year-old who is 3 days post-myocardial infarction and has been stable. d) a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

d) a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).

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? a) muscle twitching b) nausea and vomiting c) fingerprinting over sternum d) distended neck veins

d) distended neck veins Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

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

d) replacement of fluids for those lost from vomiting and diarrhea The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

A client is diagnosed with body fluid hypoosmolality. Treatment involves restricting his intake of free water. Which fluids would the nurse most likely restrict? Select all that apply. a) Tomato juice b) Milk c) Broth d) Apple juice e) Tea

d, e Management of water excess typically involves free water restriction. Limited fluids include water, coffee, tea, and simple fruit juices such as apple juice. More concentrated fluids such as milk, broth, or tomato juice may be given