PrepU ch. 40 fluid, electrolyte, and acid-base balance

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? a.Allow nothing by mouth. b.Give the client a glass of orange juice with added sugar. c.Encourage fluid intake. d.Start an IV of normal saline as prescribed.

d. Start an IV of normal saline as prescribed. Explanation: To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, skill 40-1, p. 1605. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1605

The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse? Record your answer using a whole number.

25 Explanation: Amount to infuse in milliliters x rate of infusion in minutes / drop factor of tubing = drops per minute 150 mL x 60 minutes / 10 drop factor = 25 drops per minute Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1587. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1587

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.An implanted central venous access device (CVAD) b.A peripheral venous catheter inserted to the antecubital fossa c.A peripheral venous catheter inserted to the cephalic vein d.A midline peripheral catheter

a. An implanted central venous access device (CVAD) Explanation: 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. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1583. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1583

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? a.Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. b.Flush the IV with 3 mL of normal saline. c.Change from infusion with an electronic pump to infusion by gravity. d.Flush the IV with 2 mL of 100 U/mL heparin.

b. Flush the IV with 3 mL of normal saline. Explanation: If fluid is slow to infuse, the nurse should reposition the client's arm and/or flush the IV. Changing to IV infusion will not resolve the problem and heparin is not used for clearing peripheral IVs. Deep vein thrombosis is unrelated to slow IV fluid infusion. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1602-1610. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1602-1610

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 18-gauge needle. b.a winged infusion needle. c.an intermittent infusion device. d.a central venous access.

b. a winged infusion needle. Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1580. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1580

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.distended neck veins c.fingerprinting over sternum d.nausea and vomiting

b. distended neck veins Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's: a.low potassium. b.low calcium. c.high sodium. d.high magnesium.

b. low calcium. Explanation: Normal total serum calcium levels range between 8.9 and 10.1 mg/dL (2.225 to 2.525 mmol/L). Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1559. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1559

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.hypertonic b.colloid c.isotonic d.hypotonic

c. isotonic Explanation: Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

A nurse is presenting an in-service program to a group of graduate nurses about blood component therapy. The nurse determines that the education was successful when the group identifies which complication as the primary cause of transfusion-related client death in the United States? a.Transfusion-associated circulatory overload b.Septic reaction c.Hemolytic reaction d.Transfusion-related acute lung injury

d. Transfusion-related acute lung injury Explanation: Although transfusion-associated circulatory overload (TACO), septic reaction, and hemolytic reaction are possible complications of blood transfusion therapy, transfusion-related acute lung injury (TRALI) is the number one cause of client death related to blood transfusion in the United States. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1593. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1593

Edema happens when there is which fluid volume imbalance? a.extracellular fluid volume deficit b.water deficit c.water excess d.extracellular fluid volume excess

d. extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

The process of filtration begins at the: a.glomerulus. b.Loop of Henle. c.Bowman's capsule. d.collecting ducts.

a. glomerulus. Explanation: The process of filtration begins at the glomerulus. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1562. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1562

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

b. Metabolic alkalosis Explanation: Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1574. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1574

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? a.Increased sodium levels b.Increased potassium levels c.Decreased potassium levels d.Decreased oxygen levels

c. Decreased potassium levels Explanation: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1559. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1559

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. -Prescribing the kind of IV solution. -Deciding the location of the IV catheter. -Deciding the size of the IV catheter. -Administering the IV solution. -Determining the amount of IV solution.

-Deciding the location of the IV catheter. -Deciding the size of the IV catheter. -Administering the IV solution. Explanation: The nurse is responsible for deciding the location and size of the IV catheter, as well as for administering the solution. The primary care provider is responsible for prescribing the kind and amount of solution. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1602-1610. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1602-1610

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 a.60 gtt/min b.100 gtt/min c.160 gtt/min d.600 gtt/min

b. 100 gtt/min Explanation: 100gtt/min is the correct rate. 1000 mL divided by 10 hours = 100 mL per hour x 60 gtt/minute, divided by 60 minutes/hour. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1587. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1587

Which client would be a candidate for total parenteral nutrition? a.a client with diabetic ketoacidosis b.a postoperative appendectomy client c.a client with colitis and bloody diarrhea d.a client receiving intravenous antibiotics

c. a client with colitis and bloody diarrhea Explanation: Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing. A client with bloody diarrhea and colitis requires complete bowel rest. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1597. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1597

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 -Manufacturer of the IV catheter -Location of the IV catheter access -Client's reaction to the procedure -Type of IV solution -Gauge and length of the IV catheter

-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 Explanation: The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client's reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1611-1613. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1611-1613

The nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal pH. Place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2. 1-Carbon dioxide retention 2-Decreased respirations 3-Blood level of CO2 decreases 4-pH becomes more alkaline 5-H2CO3 level in the blood decreases 6-Carbonic acid formed

1-H2CO3 level in the blood decreases 2-pH becomes more alkaline 3-Blood level of CO2 decreases 4-Decreased respirations 5-Carbon dioxide retention 6-Carbonic acid formed Explanation: When respirations are increased, the H2CO3 level begins to decrease, causing the pH to become more alkaline. When the blood level of CO2 decreases, respirations slow, resulting in CO2 retention and the formation of carbonic acid, signaling stabilization of the pH balance. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1562-1563. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1562-1563

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? a.83 mL/hr b.103 gtts/hr c.100 mL/hr d.13 mL/hr

a. 83 mL/hr Explanation: When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (12). This is 83 mL/hr. Other options are incorrect. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1587. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1587

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? a.platelets b.granulocytes c.albumin d.cryoprecipitate

a. platelets Explanation: Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third-spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1593-1594. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1593-1594

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.Dairy products b.Apricots c.Processed meat d.Bread products

b. Apricots Explanation: Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1576. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1576

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? a."Fluid inside cells." b."Fluid outside cells." c."Fluid in the tissue space between and around cells." d."Watery plasma, or serum, portion of blood."

c. "Fluid in the tissue space between and around cells." Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood). Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1556

How is control over the extracellular concentration of potassium within the human body is exerted? a.aldosterone. b.albumin. c.progesterone. d.testosterone.

a. aldosterone. Explanation: Aldosterone exerts major control over the extracellular concentration of potassium. It also enhances renal secretion of potassium. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1560. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1560

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: a.cellular hydration. b.volume expander. c.total parenteral nutrition. d.blood transfusion therapy.

c. total parenteral nutrition. Explanation: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1597. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1597

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.Avoid salty or excessively sweet fluids. b.Use regular gum and hard candy. c.Eat crackers and bread. d.Use an alcohol-based mouthwash to moisten your mouth.

a. Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1578. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1578

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.Banana b.Milk c.Yogurt d.Turkey

a. Banana Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1576. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1576

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

a. Muscle weakness, fatigue, and dysrhythmias Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1566. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1566

The nurse is determining a site for an IV infusion. What guideline should the nurse consider? a.Scalp veins should be selected for infants because of their accessibility. b.Antecubital veins should be used for long-term infusions. c.Veins in the leg should be used to keep the arms free for the client's use. d.Veins in surgical areas should be used to increase the potency of medication.

a. Scalp veins should be selected for infants because of their accessibility. Explanation: Potential sites for neonates and children include: veins of the scalp (neonates under 6 months) because of the accessibility, and dorsal veins of the foot (toddlers). The antecubital veins are not a good choice for infusion because flexion of the client's arm can displace the IV catheter. The veins in the leg of an adult should not be used, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation and possible serious complications, such as deep vein thrombosis. Veins in surgical areas are not recommended and would not increase the potency of medication. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1585. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1585

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? a.Stop the transfusion immediately. b.Infuse saline at a rapid rate. c.Prepare to give an antihistamine. d.Administer oxygen.

a. Stop the transfusion immediately. Explanation: The nurse needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1622. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1622

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? a.The client has anti-A antibodies. b.The client has anti-B antibodies. c.The client has both anti-A and anti-B antibodies. d.The client is a universal donor.

a. The client has anti-A antibodies. Explanation: Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction. Clients with type O blood are universal donors. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1594. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1594

What is the priority goal for the activity in which the nurse is engaging (scanning barcode on IV solution bag), related to the administration of a prescribed IV solution? a.To assure the IV solution is appropriate for this administration b.To assure effective administration of the prescribed IV solution c.To provide for effective time management in the administration of the prescribed IV solution d.To demonstrate effective nursing care in the administration of the prescribed IV solution

a. To assure the IV solution is appropriate for this administration Explanation: The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is appropriate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, Skill 40-1: Preparing the IV Solution and Administration Set, p. 1603. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1603

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? a.an infant age 4 months b.an adolescent age 17 years c.a woman age 45 years d.a man age 50 years

a. an infant age 4 months Explanation: An infant has considerably more total body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits. An adolescent at 17 years is considered to have an adultlike body system similar to the 45-and 50-year-old. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1556

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

a. cardiac irregularities Explanation: 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. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1566. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1566

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? a.decreased blood volume and intracellular dehydration b.increased blood volume and intracellular dehydration c.increased blood volume and extracellular overhydration d.decreased blood volume and extracellular overhydration

a. decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1556

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: a.electrolytes. b.nonelectrolytes. c.colloid solution. d.interstitial fluid.

a. electrolytes. Explanation: The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1573. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1573

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: a.phlebitis. b.an infiltration. c.a systemic blood infection. d.rapid fluid administration.

a. phlebitis. Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1589-1590. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1589-1590

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." Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1574. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1574

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? a."Unfortunately, your own blood cannot be reinfused during surgery." b."Let me refer you to the blood bank so they can provide you with information." c."This surgery has a very low chance of hemorrhage, so you will not need blood." d."We now have artificial blood products, so giving your own blood is not necessary."

b. "Let me refer you to the blood bank so they can provide you with information." Explanation: Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be reinfused. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1621. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1621

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

b. Ensure that the prescribed solution is clear and transparent. Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1602. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1602

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action (nurse is changing site with no gloves)? a.Not performing the intervention under sterile conditions b.Not wearing gloves when performing the intervention c.By applying stabilizing pressure to the catheter d.By pulling the dressing toward the insertion site

b. Not wearing gloves when performing the intervention Explanation: The changing of a peripheral venous access site dressing requires the use of clean gloves to minimize the transmission of microorganisms during the procedure and to prevent the nurse from coming into contact with blood. The intervention does not require sterile precautions. The manner in which the nurse is applying stabilizing pressure to the catheter and pulling the adhered dressing toward the insertion site demonstrates appropriate technique. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, Skill 40-3, p. 1614. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1614

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? a.B positive b.O negative c.A positive d.AB negative

b. O negative Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. Rh-negative persons should never receive Rh-positive blood. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1594-1595. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1594-1595

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? a.Sepsis b.Phlebitis c.Infiltration d.Air embolism

b. Phlebitis Explanation: Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1590. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1590

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? a.hyponatremia b.hypokalemia c.hypercalcemia d.hypermagnesemia

b. hypokalemia Explanation: All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1565-1566. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1565-1566

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? a.pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) b.pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) c.pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) d.pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)

b. pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) Explanation: In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1572. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1572

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? a.albumin b.plasma c.granulocytes d.normal saline solution

b. plasma Explanation: The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells. Albumin pulls third-spaced fluid by increasing colloidal osmotic pressure but does not restore clotting factors. The infusion of granulocytes improves the ability of the body to overcome infection. Normal saline is an isotonic solution that replaces fluid loss but does not replace clotting factors. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, Administering Blood and Blood Products, p. 1593. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1593

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? a.1,000 mL/day b.1,500 mL/day c.2,500 mL/day d.3,500 mL/day

c. 2,500 mL/day Explanation: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. 1,000 mL/day and 1,500 mL/day are too low, and 3,500 mL/day is too high. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1573. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1573

What is the lab test commonly used in the assessment and treatment of acid-base balance? a.Complete blood count b.Basic metabolic panel c.Arterial blood gas d.Urinalysis

c. Arterial blood gas Explanation: 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. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1572. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1572

Which finding best indicates to the nurse that the client has a therapeutic outcome from a recent blood transfusion? a.Steady gait while ambulating b.Blood pressure increases to 90/48 mm Hg c.No signs of chills, fever, or shortness of breath d.Slight flushing of the face

c. No signs of chills, fever, or shortness of breath Explanation: Chills, fever, and shortness of breath are all possible indications of a transfusion reaction to the blood and require emergent response such as stopping the transfusion of blood. A blood pressure reading of 90/48 mm Hg is too low and would require quick intervention. facial flushing is a sign of possible transfusion reaction and would necessitate intervention. Evaluating the client's gait is not an primary assessment for evaluating the therapeutic outcome of a blood transfusion. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1620-1624. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1620-1624

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 (nurse is looking at watch to time for number of drops), what is best action by the nurse to provide the appropriate drops per minute of medication? a.Administer 10 gtt/min over 30 seconds b.Ensure 50 gtt/min is given over 1 minute c.Regulate flow to allow 25 gtts every 15 seconds d.Adjust clamp below drip chamber so 75 gtts is provided in 15 seconds

c. Regulate flow to allow 25 gtts every 15 seconds Explanation: Administration may be achieved by gravity infusion, which requires the nurse to calculate the infusion rate in drops per minute. If using a gravity or free-flowing IV, calculate the drip rate required to achieve the desired infusion rate. A standard formula using dimensional analysis method to calculate is gtts/min (drops per min) is below. 1000 mL X 1 hour X 60 gtt = gtt/min = 60000 = 100 gtt/min (Why = Cancel units = mL units cancel each other, hours cancel each other, left with the units = gtts/min) 10 hours 60 min mL 600 The nurse can consider placing a time tape on the infusion bag to monitor hourly infusion rates and serve as a quick reference to monitor the rate at which the solution is entering the client. The tape gives an hourly indication of where the fluid level should be at a given time to avoid fluid infusing too quickly. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, Guidelines for Nursing Care 40-2, p. 1587. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1587

Which is a common anion? a.magnesium b.potassium c.chloride d.calcium

c. chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1557. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1557

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? a.allergic reaction: allergy to transfused blood b.febrile reaction: fever develops during infusion c.hemolytic transfusion reaction: incompatibility of blood product d.bacterial reaction: bacteria present in the blood

c. hemolytic transfusion reaction: incompatibility of blood product Explanation: The listed symptoms occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever; hypertension; dry, flushed skin; and abdominal pain occur. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1597. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1597

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? a.hyperphosphatemia b.hyperchloremia c.hypokalemia d.hypomagnesemia

c. hypokalemia Explanation: 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 extracellular fluid (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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1565. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1565

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.diaphoresis c.renal failure d.increased cardiac output

c. renal failure Explanation: 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

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

c. renin. Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1559. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1559

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

c. sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1558. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1558

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.Packed red blood cells b.An isotonic solution c.A hypertonic solution d.A hypotonic solution

d. A hypotonic solution Explanation: Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. Hypertonic solutions draw water out of body cells while isotonic solutions have little effect on the distribution of body fluids. Blood transfusions do not cause the entry of water into body cells. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1579. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1579

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? a.muscle cramping and tetany b.nausea, vomiting, and constipation c.diminished cognitive ability and hypertension d.muscle weakness, fatigue, and constipation

d. muscle cramping and tetany Explanation: Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. 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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1566. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1566