Taylor - Chapter 40: Fluid, Electrolyte, and Acid-Base Balance
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?
25 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
A nurse identifies a client is experiencing excess fluid volume related to heart failure and has edema and weight gain. The nurse reviews the client's laboratory test results. Which plasma osmolality value would support the clients situation? A. 260 mOsm/kg B. 280 mOsm/kg C. 310 mOsm/kg D. 340 mOsm/kg
A Normal osmolality is 280 to 300 mOsm/kg. Plasma osmolality decreases in water excess and elevates in water deficit. Therefore a result of 260 mOsm/kg would support the diagnosis of excess fluid volume.
Which statement most accurately describes the process of osmosis? A. Water moves from an area of lower solute concentration to an area of higher solute concentration. B. Solutes pass through semipermeable membranes to areas of lower concentration. C. Water shifts from high-solute areas to areas of lower solute concentration. D. Plasma proteins facilitate the reabsorption of fluids into the capillaries.
A 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.
The student nurse asks the instructor how buffer systems work in the body to maintain the pH of the blood. The instructor explains the buffer systems to the students. Which buffer systems will be discussed by the instructor? Select all that apply. A. Carbonic acid-sodium bicarbonate buffer system B. Phosphate buffer system C. Protein buffer system D. Potassium buffer system E. Respiratory buffer system
A, B, C
The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? A. isotonic B. hypotonic C. hypertonic D. hypotonic, followed by isotonic
C A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.
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 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.
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 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.
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. A. Hypervolemia management B. Fluid restriction C. Intravenous therapy D. Electrolyte management E. Monitoring edema F. Nutrition management
C, D, F If a client is at a fluid volume deficit, intravenous therapy may be ordered by the primary care provider to replenish fluids and electrolytes, warranting fluid and electrolyte management. Nutrition management may help to increase and maintain electrolyte levels by adding foods high in certain electrolytes to the diet. Hypervolemia refers to fluid volume excess. Fluid restriction would be contraindicated because the client is already at a deficit. Edema would be monitored in the case of fluid volume excess.
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? A. Transparent semipermeable membrane dressing B. Occlusive dressing C. Sealed IV dressing D. Gauze dressing
D A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. Transparent semipermeable membranes are a type of sealed IV dressing. Occlusive dressings would not be appropriate.
The process of filtration begins at the: A. glomerulus. B. Loop of Henle. C. Bowman's capsule. D. collecting ducts.
A
What commonly used intravenous solution is hypotonic? A. 0.45% NaCl B. 0.9% NaCl C. lactated Ringer's D. 5% dextrose in 0.45% NaCl
A 0.45% NaCl is hypotonic. Normal saline and lactated Ringer's are isotonic. 5% dextrose in 0.45% NaCl is hypertonic.
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? A. Stop the transfusion and infuse normal saline using a new administration set. B. Check the client's vital signs. C. Stop the transfusion and infuse normal saline using the blood tubing. D. Notify the health care provider of the client's response.
A 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.
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? A. daily weights B. daily BUN and serum creatinine monitoring C. output measurements D. daily electrolyte monitoring
A Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client's daily weight may be the more accurate measurement of a client's fluid status. Laboratory tests are helpful in assessing kidney function and electrolyte values, but do not provide the precise information on fluid losses or gains as is provided by a daily weight (at the same time, using the same scale). Output measurements are not meaningful without intake measurements.
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? A. Infants B. Toddlers C. Adolescents D. School-age children
A 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.
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
A 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 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? A. 1+ B. 2+ C. 3+ D. 4+
A 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 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? A. maintenance of cell size B. maintenance of blood volume C. transportation of nutrients D. removal of waste
A 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 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? A. Apply pressure to insertion site for at least 3 minutes. B. Ask client to perform Valsalva maneuver. C. Instruct client to remain flat for 30 minutes. D. Apply petroleum-based ointment and sterile occlusive dressing.
A 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.
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? A. calcium and phosphorus B. potassium and sodium C. chloride and magnesium D. potassium and chloride
A The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance.
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? A. Tighten the roller clamp to stop the infusion. B. Twist the tubing around a pencil. C. Tap the tubing below the air bubbles. D. Milk the air in the direction of the drip chamber.
A 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.
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 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.
The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. A. Rate of the IV solution B. Manufacturer of the IV catheter C. Location of the IV catheter access D. Client's reaction to the procedure E. Type of IV solution F. Gauge and length of the IV catheter
A, C, D, E, F 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.
A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply. A. blood pressure 100/48 mmHg B. crackles in the lungs C. distended neck veins D. poor skin turgor E. heart rate 128/bpm
A, D, E Fluid volume deficit causes a low BP (100/48 mmHg), poor skin turgor, and an elevated heart rate (128/bpm). Fluid excess can cause crackles and distended neck veins.
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 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.
A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed? A. Isotonic B. Hypertonic C. Hypotonic D. Osmolar
B A hypertonic solution has a greater osmolarity than plasma, which causes water to move out of the cells and be drawn into the intravascular compartment. A hypotonic solution has a lower osmolarity than plasma; therefore, fluid would move out of the intravascular space rather than pulling fluids from the tissues into the vascular space. An isotonic fluid remains in the intravascular compartment without any net flow across the semipermeable membrane. The concentration of particles in a solution is referred to as the osmolarity of a solution.
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: 5.75 mg/dL (1.8 mEq/L)Based on these levels, the nurse would identify which imbalance? A. Hyponatremia B. Hypokalemia C. Hypercalcemia D. Hypermagnesemia
B 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.
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 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.
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? A. Notify the primary care provider immediately because these are signs of speed shock. B. Notify the primary care provider immediately for possible fluid overload. C. Check all clamps on the tubing and check tubing for any kinking. D. Place the client in the Trendelenburg position to keep the client's airway open.
B If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify the primary care provider immediately because the client may be exhibiting signs of fluid overload. The Trendelenburg position is not used to rectify this complication, but to help raise the blood pressure of a client with hypotension.
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 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.
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? A. Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). B. Sodium is regulated by the renin-angiotensin-aldosterone system. C. If sodium is low, it means that there is not enough water. D. Sodium is not regulated by natriuretic peptides.
B Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.
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 Normal total serum calcium levels range between 8.9 and 10.1 mg/dL (2.225 to 2.525 mmol/L).
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? A. Elevate the client's head. B. Apply a warm compress. C. Position the client on the left side. D. Apply antiseptic and a dressing.
B 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.
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? A. Face B. Sacral area C. Hands D. Abdomen
B The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. The edema cannot be assessed in the face, hands and abdomen, as these are not dependent areas.
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? A. hypervolemia B. hypovolemia C. edema D. circulatory overload
B 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.
When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which guideline should the nurse follow? A. Use veins of the lower extremities. B. Use distal veins before proximal veins. C. Use small veins before larger veins. D. Use the brachial plexus vein.
B Use larger veins and the distal portion of the vein, leaving the more proximal sites for later venipunctures.
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? A. The client has a decreased sensation of thirst. B. The renal system retains more water. C. Urine becomes more diluted. D. The frequency of voiding increases.
B When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.
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? A. Bowel motility will be restored within 24 hours after beginning supplemental K+. B. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. C. ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. D. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.
B f 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 caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply. A. clients who have not eaten for a day B. clients with major trauma or burns C. clients with liver and renal failure D. clients who are recovering from cataract surgery E. clients with inflammatory bowel disease
B, C, E The nurse knows that clients with major trauma or burns, clients with liver and renal failure, and clients with inflammatory bowel disease are likely candidates for TPN. Clients who have not eaten for a day or clients recovering from cataract surgery are not likely candidates for TPN. Clients who have not eaten for 5 days and are not likely to eat during the next week are considered for TPN.
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? A. isotonic B. hypotonic C. hypertonic D. plasma
C Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? A. Constipation related to immobility B. Pain related to surgical incision C. Acute Confusion related to cerebral edema D. Risk for Infection related to inadequate personal hygiene
C Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing: A. allergic reaction. B. pulmonary embolism. C. fluid overload. D. anaphylaxis.
C Fluid overload can occur when blood components are infused too quickly or too voluminously. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds.
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? A. interstitial B. extracellular C. intracellular D. intravascular
C 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.
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 Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
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 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.
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 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.
The client is being discharged and has a prescription to have the PICC (peripherally inserted central catheter) discontinued prior to discharge. The nurse has checked the chart. The PICC has been inserted in the client's arm to the 30 cm mark. What interventions would the nurse include when discontinuing the PICC? Select all that apply. A. Elevate the client's head of the bed to 45°. B. Instruct the client to breath normally during the catheter removal. C. Remove the catheter slowly, keeping the catheter parallel to the client's skin. D. Measure the catheter and ensure 30 cm of the catheter has been removed. E. Apply pressure to the site with a clean gauze until hemostasis occurs.
C, D When removing a PICC, the nurse would remove the catheter slowly and keep the catheter parallel to the client's skin. This is to prevent tearing of the catheter. The nurse would measure the catheter and ensure the catheter had been removed intact to the 30 cm mark. The nurse would lay the client flat or place the client in Trendelenburg position. This is to prevent the risk of an air embolism. The nurse would instruct the client to hold the breath and perform a Valsalva maneuver during the catheter removal. This action also reduces the risk for an air embolism. The nurse would apply sterile gauze, not clean gauze, to the insertion site. Sterile gauze is used to prevent an infection.
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 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.
The nurse is caring for a client who was in a motor vehicle accident and has internal bleeding from the trauma. Which solution does the nurse anticipate infusing? A. isotonic B. hypotonic C. hypertonic D. colloidal
D Colloidal solutions are used to replace circulating blood volume. Examples include blood, blood products like albumin, and plasma expanders. Because the client is freely bleeding internally, blood products would be used to combat the traumatic loss.
A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? A. hypotonic solution B. isotonic solution C. colloid solution D. hypertonic solution
D Hypertonic solutions are used in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. Hypotonic solutions are administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. However, these solutions are not related to clients with cerebral edema.
A mother of an infant calls the pediatric nurse and asks which fluids she should provide her baby since he is suffering from diarrhea. The nurse would inform the mother not to give: A. Pedialyte. B. formula. C. breast milk. D. bottled water.
D Hyponatremic seizures among infants fed with commercial bottled drinking water have been noted.
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? A. every 12 hours B. every 24 hours C. every 36 hours D. every 72 hours
D 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.
The student nurse asks, "What is intravascular 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."
D 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 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: A. increase in muscle mass. B. smaller stomach capacity. C. decreased skin area. D. increase in fat cells.
D The decreasing percentage of body fluid in older adults is related to an increase in fat cells. In addition, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults. Older adults do not have an increase muscle mass, smaller stomach capacity, or decrease skin area.
