prep-u Chapter 39: Fluid, Electrolyte, and Acid-Base Balance

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?

3.5 cm H2O

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50 gtt/min

A client has been prescribed three different intravenous medications. Two of the medications are not compatible with each other. Which type of IV access is appropriate?

7 French triple lumen central catheter

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)

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.

The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients?

Cardiac volume intolerance

A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? (Select all that apply.)

Clients with liver and renal failure Clients with inflammatory bowel disease Clients with major trauma or burns

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?

Ensure that the prescribed solution is clear and transparent.

A nurse is measuring intake and output for a client who has congestive heart failure. What does not need to be recorded?

Fruit consumption

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: 3.89 mg/dL (1.6 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 5.75 mg/dL (1.8 mEq/L)

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

A client has the following arterial blood gas results: pH: 7.33 PaCO2: 42 mm Hg HCO3: 19 mEq/L (19 mmol/L) PaO2: 95 mm Hg Which imbalance would the nurse suspect?

Metabolic acidosis

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

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.

Nutrition management Intravenous therapy Electrolyte management

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.

Which nursing actions would be performed when preparing an IV solution and tubing to initiate intravenous therapy? Select all that apply.

Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.

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.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?

Tighten the roller clamp to stop the infusion.

When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which guideline should the nurse follow?

Use distal veins before proximal veins.

Which client would be a candidate for total parenteral nutrition?

a client with colitis and bloody diarrhea

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?

every 72 hours

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:

fluid overload.

A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances?

fluid volume excess and acidosis

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

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

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?

perspiration

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

remove the IV.

The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?

"Watery plasma, or serum, portion of blood."