PrepU Chapter 40: Fluid, Electrolyte, and Acid-Base Balance

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? -83 mL/hr -103 gtts/hr -100 mL/hr -13 mL/hr

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.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? -Apply pressure to insertion site for at least 3 minutes. -Ask client to perform Valsalva maneuver. -Instruct client to remain flat for 30 minutes. -Apply petroleum-based ointment and sterile occlusive dressing.

Apply pressure to insertion site for at least 3 minutes. Explanation: The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.

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

Decreased potassium levels Explanation: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

The nurse is preparing to insert a peripheral IV in the cephalic vein of the client's mid-forearm region. Where should the nurse apply a tourniquet?

The nurse should apply a tourniquet 3 to 4 in (7.5 to 10 cm) above the venipuncture site to obstruct venous blood flow and distend the vein.

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? -muscle twitching -distended neck veins -fingerprinting over sternum -nausea and vomiting

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.

The process of filtration begins at the:

glomerulus.

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) -hyponatremia -hypokalemia -hypercalcemia -hypermagnesemia

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.

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? -Sepsis -Phlebitis -Infiltration -Air embolism

Phlebitis. Explanation: Sepsis Phlebitis Infiltration Air embolism

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: -an 18-gauge needle. -a winged infusion needle. -an intermittent infusion device. -a central venous access.

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.

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

"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).

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

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.

A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)? -Changing the dressing on a client's peripheral IV site -Initiating a client's transfusion of packed red blood cells -Deaccessing a client's implanted port -Removing a client's PICC in anticipation of the client's discharge

Changing the dressing on a client's peripheral IV site. Explananiton: Changing a peripheral IV dressing poses a lower risk to the client's safety than the other listed nursing actions and this would be the safest task to delegate. It would be inappropriate to delegate a blood transfusion, deaccess an implanted port, or remove a PICC to an LPN.

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? -Slow the rate of IV fluids. -Remove the IV. -Apply a warm compress. -Elevate the arm.

Remove the IV. Explanation: The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

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: - an 18-gauge needle. -a winged infusion needle. -an intermittent infusion device. -a central venous access.

-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.

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

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.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by: -increasing ventilation through the lungs. -increasing the excretion of HCO3− into the urine. -decreasing the excretion of H+ ion into the urine. -preventing excretion of acids into the urine

increasing ventilation through the lungs. Explanation: The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. To compensate for respiratory alkalosis, the kidneys increase the excretion of HCO3− to the urine. Kidneys compensate for respiratory acidosis by increasing the excretion of H+ ion into the urine. The kidneys respond to metabolic alkalosis by retaining acid and excreting HCO3−.

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? -pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) -pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) -pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) -pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)

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.

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply.

-Deciding the location of the IV catheter. -Deciding the size of the IV catheter. -Administering the IV solution.

When considering client safety, what is the primary purpose of the action demonstrated by the nurse involved in preparing for the administration of a prescribed IV solution? -Priming of IV tubing -Introducing solution into the tubing -Preventing embolus -Visually assessing solution

-Preventing embolus Explanation: The nurse is engaged in a technique that removes air from the tubing. If not removed from the tubing, large amounts of air can act as an embolus. While the process demonstrated does allow for the other actions, they are not associated with the primary purpose: removing air from the tubing.

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? -Respiratory alkalosis -Metabolic alkalosis -Respiratory acidosis -Metabolic acidosis

Metabolic alkalosis Explanation: Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.

A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action?

The nurse should carefully remove the tape from the outside to the insertion point while supporting the catheter. Gloves should be worn.

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? -interstitial -extracellular -intracellular -intravascular

intracellular Explanation: Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment.

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? 1+ 2+ 3+ 4+

1+ Explanation: The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

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 peripheral venous catheter inserted to the antecubital fossa -A peripheral venous catheter inserted to the cephalic vein -A midline peripheral catheter

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.

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. -Use regular gum and hard candy. -Eat crackers and bread. -Use an alcohol-based mouthwash to moisten your mouth.

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.

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action? -Discontinue the IV. -Attempt to aspirate. -Flush with 3-mL normal saline. -Slow the rate of infusion by 50%.

Discontinue the IV. Explanation: Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor. Aspiration is never performed from a peripheral IV. Flushing or slowing the infusion will not alleviate this problem.

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? -Bowel motility will be restored within 24 hours after beginning supplemental K+. -ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. -ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. -Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Explanation: 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.

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 Explanation: Infants have a far greater volume of total fluid as a percentage of body weight than other children . 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.

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?

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.

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? -Calcium -Chloride -Phosphorous -Potassium

Potassium Explanation: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. Signs of potassium defecit, or hypokalemia, include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? -Remove the IV catheter and reinsert another in a different location. -Decontaminate the visible portion of the catheter, and then gently reinsert. -Apply a new dressing and observe for signs of infection over the next several hours. -Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.

Remove the IV catheter and reinsert another in a different location. Explanation: An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

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

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.

Edema happens when there is which fluid volume imbalance? -extracellular fluid volume deficit -water deficit -water excess -extracellular fluid volume excess

extracellular fluid volume excess. Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

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? -maintenance of cell size -maintenance of blood volume -transportation of nutrients -removal of waste

maintenance of cell size. Explanation: The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.

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. -Twist the tubing around a pencil. -Tap the tubing below the air bubbles. -Milk the air in the direction of the drip chamber.

-Tighten the roller clamp to stop the infusion. Explanation: The priority nursing action is to tighten the roller clamp on the tubing as this action prevents forward movement of air. All other options are appropriate to remove the air once the tubing has been clamped.

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? -"I have never given blood before." -"I received a blood transfusion in the United Kingdom." -"My blood type is B positive." -"My spouse would also like to donate blood."

"I received a blood transfusion in the United Kingdom." Explanation: Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? -"I was breathing so fast because I was so anxious and in so much pain." -"I've been taking antacids almost every 2 hours over the past several days." -"I've had a fever for the past 3 days that just doesn't seem to go away." -"I've had a GI virus for the past 3 days with severe diarrhea."

"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.

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

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

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority? -Apply a tourniquet to the client's upper arm. -Apply pressure to the site with sterile gauze until hemostasis is achieved. -Have the client perform the Valsalva maneuver. -Measure the catheter and compare it with the length listed in the chart.

Apply a tourniquet to the client's upper arm. Explanation: In the event that a portion of the catheter breaks off during removal of a PICC, the nurse should immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of the piece of catheter into the right atrium. The other actions should be performed during a routine PICC removal. Use of the Valsalva maneuver by the client during expiration reduces the risk for air embolism. Measurement and inspection of the PICC following removal ensures that the entire catheter was removed. Application of adequate pressure with sterile gauze following PICC removal prevents hematoma formation.

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

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.

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?

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.

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

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.

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

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.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? -cardiac irregularities -muscle weakness -increased intracranial pressure (ICP) -metabolic acidosis

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.

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 12 hours -every 24 hours -every 36 hours -every 72 hours

every 72 hours. Explanation: IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first. IV tubings are not replaced after every solution is over or after every 12, 24, or 36 hours.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: -phlebitis. -an infiltration. -a systemic blood infection. -rapid fluid administration.

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.

A decrease in arterial blood pressure will result in the release of: -protein. -thrombus. -renin. -insulin.

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

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? -Elevate the client's head. -Restart infusion in another vein and apply a warm compress. -Position the client on the left side. -Apply antiseptic and a dressing.

-Restart infusion in another vein and apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

The nurse has inserted a peripheral intravenous catheter. When applying a transparent dressing, what is the nurse's best action?

The transparent dressing should be placed in such a manner as to allow full coverage and visibility of the insertion site, without excessively covering the tubing.

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

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.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? -Elevate the client's head. -Restart infusion in another vein and apply a warm compress. -Position the client on the left side. -Apply antiseptic and a dressing

Restart infusion in another vein and apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

How is control over the extracellular concentration of potassium within the human body is exerted? -aldosterone. -albumin. -progesterone. -testosterone.

aldosterone. Explanation: Aldosterone exerts major control over the extracellular concentration of potassium. It also enhances renal secretion of potassium.

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

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.

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

Decreased potassium levels. Explanation: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

The nurse is preparing to flush a client's peripheral venous access device. Which observable intervention best assures continued effective venous access at this location? -Wearing gloves when preforming the intervention -Using a 10 ml syringe to introduce the flushing solution -Aspirating to determine positive blood return -Anchoring extension tubing near entry site with tape

-Anchoring extension tubing near entry site with tape Explanation: The weight of the tubing is sufficient to pull the device out of the vein if it is not well anchored. Looping the extension tubing near the entry site and anchoring it with tape (nonallergenic) close to the site will best assure it will remain in the vein thus maintaining effective venous access. The use of personal protective equipment (gloves) during the intervention acts as a protective barrier against microorganism introduction. The proper force when using a 10 ml syringe for flushing helps control the amount of intravascular pressure the flush will create. Aspiration of the vein prior to flushing helps determine the existence of vein patency. While all actions are appropriate, effective anchoring of the tubing at the insertion site will be assure continued access to the vein.

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? -Stop the transfusion and infuse normal saline using a new administration set. -Check the client's vital signs. -Stop the transfusion and infuse normal saline using the blood tubing. -Notify the health care provider of the client's response.

-Stop the transfusion and infuse normal saline using a new administration set. Explanation: A client who reports difficulty breathing during a blood transfusion may be having a transfusion reaction. The first action is to stop the transfusion and infuse normal saline using a new administration set. Changing the administration set prevents the client from receiving more of the blood that is causing the reaction. After stopping the transfusion and infusing normal saline using a new administration set, the nurse should check the client's vital signs and notify the health care provider of the reaction.

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply. -The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. -A symptom of fluid overload is distended neck veins. -The client will likely develop a fever in the presence of fluid overload. -Fluid overload is more likely in very young children. -The infusion rate must be carefully monitored during the administration of blood.

-The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. -A symptom of fluid overload is distended neck veins. -Fluid overload is more likely in very young children. -The infusion rate must be carefully monitored during the administration of blood. Explanation: Fluid overload can occur if blood components are infused too quickly or too voluminously. Transfusion-associated circulatory overload is more likely in the very young client or the older adult with poor cardiac or renal function. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds. Circulatory overload can be minimized by infusing packed RBCs (rather than whole blood) and volume-reduced platelets for high-risk clients, then carefully monitoring the infusion rate of blood components.

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

-Water moves from an area of lower solute concentration to an area of higher solute concentration. Explanation: Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the reabsorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.

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

-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.

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? -hypervolemia -hypovolemia -edema -circulatory overload

-hypovolemia Explanation 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 nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? -increased hydrostatic pressure -decreased colloid oncotic pressure -blockage of the lymph nodes -increased capillary permeability

-increased hydrostatic pressure Explanation: 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 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? -maintenance of cell size -maintenance of blood volume -transportation of nutrients -removal of waste

-maintenance of cell size Explanation: The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.

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 -nausea, vomiting, and constipation -diminished cognitive ability and hypertension -muscle weakness, fatigue, and constipation

-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.

The nurse is caring for a client with end-stage renal disease who voided 200 mL in the past 24 hours. The primary care provided ordered for a fluid restriction based on measurable urine output from the previous 24 hours added to insensible fluid losses. How much should the nurse provide for the 24-hour fluid allowance? 1,300 mL 1,100 mL 1,000 mL 900 mL

1,300 mL Explanation: Insensible losses are the amount of fluids lost daily from lungs, skin, respirations, and feces. These are estimated using average adult daily fluid sources (1,300-mL ingested water, 1,000-mL ingested food, 300-mL metabolic oxidation) and losses (1,500-mL kidneys, 600-mL skin, 300-mL lungs, 200-mL gastrointestinal). Plus, this client has 200-mL urine output. 200 mL (urine) + 600 mL (skin) + 300 mL (lungs) + 200 mL (GI, feces) = 1,300 mL.

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? -Packed red blood cells -An isotonic solution -A hypertonic solution -A hypotonic solution

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.

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? -It helps to prevent large changes in pH by absorbing or releasing H+ ions. -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. -The renal system excretes acids and bases from the body as needed. -The kidneys influence the maintenance of the normal acid-base balance by changing the rate of excretion or retention of H+ and HCO3 ions.

It helps to prevent large changes in pH by absorbing or releasing H+ ions. Explanation: Buffers are substances that help to prevent large changes in pH by absorbing or releasing H+ ions. Successful buffering causes extra H+ ions from the weak acids of the buffer pairs to be released into the blood. The function of lungs being responsible for controlling the amount of carbon dioxide in the blood describes respiratory compensation. The function of kidneys influencing the maintenance of the normal acid-base balance describes renal compensation.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take? -Reassure the client that the feelings are associated with anxiety and will pass. -Confirm the shortness of breath by listening to the client's lungs. -Stop the transfusion and notify the health care provider. -Increase the rate of infusion to restore blood volume more quickly.

Stop the transfusion and notify the health care provider. Explanation: Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion. The nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed, and to notify the health care provider. Reassuring the client will not help if the client is experiencing a blood reaction. Increasing the rate of the administration will make the potential reaction worse if this is a transfusion reaction. Listening to the client's lungs is not the priority action.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? -Stop the transfusion immediately. -Infuse saline at a rapid rate. -Prepare to give an antihistamine. -Administer oxygen.

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.

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

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools. Explanation: 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 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: -electrolytes. -nonelectrolytes. -colloid solution. -interstitial fluid.

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.

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? -hypertonic -colloid -isotonic -hypotonic

isotonic Explanation: Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.