Ch 41 Fluid, Electrolyte, & ABB

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I need to drink no more than 1,000 mL/day" "I should drink 1,500 mL/day of fluid." "I should drink 2,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid."

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

A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted? 30- to 35-degree angle 20- to 25-degree angle 10- to 15-degree angle 40- to 45-degree angle

10- to 15-degree angle Explanation: The IV catheter should be inserted at a 10- to 15-degree angle.

A health care provider 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? 30 drops/mL 60 drops/mL 90 drops/mL 120 drops/mL

60 drops/mL Explanation: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

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.

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.

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV? Change the site every three to four days. Clean the insertion site daily using sterile technique. Insert the largest gauge possible to maximize flow and minimize the risk of occlusion. Flush the catheter every six hours with hypertonic solution if the IV is not in constant use.

Change the site every three to four days. Explanation: Peripheral IV sites should be rotated every 72 to 96 hours, depending on the institutional protocol. IV insertion sites are not cleansed daily, but the site should be assessed per institutional protocol or every nursing shift. Flushes are not necessary every six hours. Hypertonic solution is not used for IV flushes. The smallest gauge that is practical should be inserted in order to minimize trauma.

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. Prescribing the kind of IV solution. Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution. Determining the amount of IV solution.

Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution. Explanation: The nurse is responsible for deciding the location and size of the IV catheter, as well as for administering the solution. The primary care provider is responsible for prescribing the kind and amount of solution.

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 the expected color and consistency. Use half-instilled IV solutions before infusing a new one. Avoid replacing IV solutions every 24 hours.

Ensure that the prescribed solution the expected color and consistency. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution's color and consistency matches that expected based on the prescription, 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.

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

Flush the IV with 3 mL of normal saline. Explanation: If fluid is slow to infuse, the nurse should reposition the client's arm and/or flush the IV. Changing to IV infusion will not resolve the problem and heparin is not used for clearing peripheral IVs. Deep vein thrombosis is unrelated to slow IV fluid infusion.

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? Transparent semipermeable membrane dressing Occlusive dressing Sealed IV dressing Gauze dressing

Gauze dressing Explanation: 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 nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect? Hypocalcemia Hypermagnesemia Hypokalemia Hypophosphatemia

Hypocalcemia Explanation: The parathyroid gland regulates calcium levels, and partial removal can cause hypocalcemia. Hypocalcemia is manifested by numbness and tingling as well as tetany. The signs and symptoms do not relate to altered magnesium or potassium levels. Calcium and phosphorus have an inverse relationship, so with low calcium, the nurse will expect a high, not a low, phosphorus level.

An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching? Include more canned vegetables in the diet. Include more cheese in the diet. Include more bread in the diet. Include more bananas in the diet.

Include more bananas in the diet. Explanation: Hypokalemia is a below-normal potassium level. Bananas are high in potassium. Adding bananas to the diet can help increase the serum potassium level. Canned vegetables, cheese, and bread do not have a high potassium content.

An adult client has developed gastric esophageal reflux disease and is treating it with frequent doses of antacids. The nurse will assess for what acid-base disorder? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Metabolic alkalosis Explanation: Ingestion of large amounts of antacids cause metabolic alkalosis due to the increase in stomach pH. This alkalosis is unrelated to respiratory function.

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? Metabolic acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic alkalosis Explanation: Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high.

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and fatigue and the nurse's assessment reveals an irregular heart rate. The nurse should assess the client's levels of 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, fatigue and arrythmias.

A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. Which nursing interventions would the nurse perform? Select all that apply. Stop the infusion immediately. Apply warm compresses as ordered by the primary care provider. Rub or massage the affected area. Monitor vital signs and pulse oximetry. Restart the IV at another site. Place client on left side in Trendelenburg position.

Stop the infusion immediately. Apply warm compresses as ordered by the primary care provider. Restart the IV at another site. Explanation: If a thrombus (blood clot) forms at the site of the IV, the infusion should be stopped immediately in order to prevent the thrombus from becoming dislodged. Application of a warm, moist compress will help to dissolve the thrombus, and the IV should be restarted in another site. The area should not be rubbed or massaged because this could cause the thrombus to become an embolus. Monitoring vital signs and pulse oximetry would not be necessary, nor would placing the client in the Trendelenburg position.

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.

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 arrythmias. 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.

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.

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.

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 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? albumin plasma granulocytes normal saline solution

plasma Explanation: The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells. Albumin pulls third-spaced fluid by increasing colloidal osmotic pressure but does not restore clotting factors. The infusion of granulocytes improves the ability of the body to overcome infection. Normal saline is an isotonic solution that replaces fluid loss but does not replace clotting factors.