PrepU: Fluid, Electrolytes, and Acid-Base

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

"Fluid in the tissue space between and around cells."

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate?

"Granulocytes are a type of white blood cell that can help fight infection."

The health care provider is concerned that the client has hypokalemia. During the physical examination, which question should the nurse ask the client?

"Have you been experiencing muscle weakness or leg cramps?"

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

"I should drink 2,500 mL/day of fluid."

A client is prescribed a diuretic as part of the treatment plan for heart failure. The nurse educates the client about the drug and dietary measures to prevent complications. What statement made by the client indicates the need for further education?

"I will add spinach to my salads."

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?

"I've been taking antacids almost every 2 hours over the past several days."

The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction?

"The kidneys store and release antidiuretic hormone to increase water retention."

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

3,000

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

3.5cm H2O

A nurse is preparing to measure jugular venous distention in a client. To ensure accuracy, the nurse would elevate the head of the client's bed to:

45 degrees

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O?

55-year-old with congestive heart failure on furosemide

A nurse is reviewing the arterial blood gas results of a client. Which pH value would the nurse document as indicating acidosis?

7.30

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

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply.

Ask provider to order a low-salt diet. Administer furosemide as ordered. Reduce infusing fluid volume as ordered. Treat the underlying condition that contributes to increased fluid volume.

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?

Chapter 32: Fluid, Electrolytes, and Acid-Base - Page 1043

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?

Compare the total intake and output of fluids for the 24 hours.

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?

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

A 70-year-old client is scheduled for a colonoscopy and is prescribed a bowel preparation solution. The nurse would be alert for which potential imbalance? Select all that apply.

Hypokalemia Hypocalcemia Hyperphosphatemia

Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease?

Increased plasma levels of antidiuretic hormone lead to water excess.

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.

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium?

Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L).

A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply.

Pulse rate 90 bpm Blood pressure 104/68 mm Hg

Arterial blood gases (ABGs) have been drawn on the client. The nurse reviews the results. pH is 7.31 PaO2 92 mm Hg (12.24 kPa) PaCO2 50 mm Hg (6.65 kPa) HCO3 28 mEq/L (28 mmol/L) How will the nurse interpret these ABG results? Select all that apply.

Respiratory acidosis Partial compensation

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?

Risk for Deficient Fluid Volume

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?

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

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?

To assure the IV solution is appropriate for this administration

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?

Verify the prescription for type of solution and amount of infusion.

A nursing instructor is preparing a class presentation for a group of nursing students on fluid balance and developmental considerations. What would the instructor likely include when describing newborns and infants? Select all that apply.

Water makes up a larger percentage of their body weight. Greater amounts of water are found in the extracellular fluid compartment. Insensible fluid losses are greater in this age group.

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.

A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform?

Weigh the client's wet linen or dressing.

What is the initial purpose of the action in which the nurse is engaging, during the preparation for the administration of a prescribed IV solution?

allowing for effective access to the solution

A nurse is caring for a postoperative client who reports feeling dizzy when getting up from bed. The nurse suspects extracellular fluid (ECF) volume deficit and assesses the effect that position change has on pulse rate and blood pressure. What would the nurse interpret as indicative of ECF volume deficit?

an increase in pulse rate of more than 20 beats per minute

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?

apricots

What is the lab test commonly used in the assessment and treatment of acid-base balance?

arterial blood gas

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

avoid salty or excessively sweet fluids

A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate?

avoid use of a tourniqet

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?

banana

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?

calcium and phosphorous

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

Which is a common anion?

chloride

The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which will the nurse document on the I&O record? Select all that apply.

client drinking milk client's urination vomiting infusion of intravenous solution

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

daily weights

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?

diarrhea

By which route do oxygen and carbon dioxide exchange in the lung?

diffusion

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

distended neck veins

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

A health care provider writes a prescription to "force fluids." What will be the first action the nurse will take in implementing this prescription?

explain to the client why this is needed

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

fluid volume excess

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

fluid volume excess and acidosis

While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance?

how much do you typically urinate during the day?

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find?

hypokalemia

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance?

hypokalemia

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

hyponatremia

The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to:

increase in fat cells

A client has metabolic (nonrespiratory) acidosis. Which type of respirations would be assessed?

increased depth and rate

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

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?

increased respiratory rate

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by:

increasing ventilation through the lungs

A 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

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?

intracellular

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

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

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

offer small amounts of preferred beverage frequently

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

offer the client sugar-free to help combat thirst

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?

ordering type of solution, additive, amount of infusion, and duration

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

perspiration

A group of nursing students is reviewing information about the body's electrolytes. The students demonstrate understanding of the material when they identify which electrolyte as having a reciprocal relationship with calcium?

phosphorous

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?

plasma

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

remove the IV

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure

A client is brought into the emergency department with a suspected opioid overdose. The nurse would anticipate that the client would most likely experience which acid-base imbalance?

respiratory acidosis

A client's most recent arterial blood gases indicate a pH of 7.52 with decreased PaCO2 and decreased HCO3-. What is this client experiencing?

respiratory alkalosis with compensation

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.

respiratory muscle weakness confusion ventricular dysrhythmia

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

start and IV of normal saline as prescribed

The nurse is performing an assessment for an older adult client admitted with dehydration. When assessing the skin turgor of this client, which area of the body will be best for the nurse to assess?

sternum

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. What is the priority nursing action?

stop the transfusion

The nurse is assessing a client's fluid balance status. Which information will the nurse document about the client's hydration?

urinary output

A client has been admitted to the hospital with a diagnosis of acute renal failure, a health problem that necessitates vigilant monitoring of the client's fluid balance. What is the most accurate way that the care team can achieve this assessment goal?

weighing the client once per day

A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant?

weight gain of 0.75 kg in a day