PrepU Quiz Ch. 39 Fluid, Electrolyte, and Acid-Base Balance

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels

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

Ensure that the prescribed solution is clear and transparent.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

Placing the tourniquet on the upper arm for 2 minutes

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?

Potassium

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 passageways of the kidney permit the urine to flow to the bladder and:

Selectively reabsorb or secrete substance to maintain fluids and electrolytes.

A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse?

Spinach

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 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

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

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 2500 mL/day of fluid."

Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply.

0.9% NaCl (normal saline) Lactated Ringer's solution 5% dextrose in 0.9% NaCl

What is the rate of administration for packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

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+

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

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

3.5 cm H2O

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing?

60 drops/mL

Which client will have more adipose tissue and less fluid?

A woman

Major control over the extracellular concentration of potassium within the human body is exerted by:

Aldosterone

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)

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

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

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

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

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

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

Fruit consumption

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

Isotonic

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of:

Phlebitis

Which client has more extracellular fluid?

Newborn

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 client who is receiving total parenteral nutrition and lipids asks the nurse why the solution looks like milk. What is the most appropriate nursing response?

"The white milky solution contains lipids or fat to provide extra calories."

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

Arterial blood gas

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

Cardiac volume intolerance

The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply.

Diarrhea Cardiac dysrhythmia

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?

Febrile reaction

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

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

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 caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?

pH: 7.60; PaCO2: 64; HCO3: 42

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

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

vomiting urination infusion of intravenous solution drinking milk

The nurse is calculating an infusion rate for the following order: Infuse 1000 ml of 0.9% Na Cl over 12 hours using an electronic infusion device. What is the infusion rate?

83 ml/hour

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?

"Let me refer you to the blood bank so they can provide you with information."

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 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.

What food would the nurse provide for a client who has hypokalemia?

Bananas

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea

Miss Roberts is admitted to the unit with a diagnosis of three days of continuous vomiting. You would suspect which of the following acid/base imbalances related to the loss of stomach acid?

Metabolic alkalosis

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 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