Chap. 39: Fluid, Electrolyte, and Acid-Base Balance

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." Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be re-infused.

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

1 unit over 2 to 3 hours, no longer than 4 hours Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours. Answer A describes platelets, answer C represents cryoprecipitate, and answer D describes fresh-frozen plasma.

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 Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

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

Arterial blood gas 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.

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 elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. The elderly typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.

Which is a common anion?

Chloride

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

Fruit consumption Any water consumption must be recorded in order to closely monitor a patient who has congestive heart failure. Many of these patients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.

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

Which client has more extracellular fluid?

Newborn Newborns have more extracellular fluid than intracellular fluid.

Which of the following is not true regarding magnesium?

The liver regulates magnesium levels by breaking down the ion when serum levels are low. The kidneys regulate magnesium levels by reabsorbing the ion when serum levels are low and excreting it when serum levels are high.

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

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

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 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.

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. 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 non-electrolytes, colloid solution, or interstitial fluid restored. Non-electrolytes 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.

Edema happens when there is which fluid volume imbalance?

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

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 The nurse prepares the solution for administration, performs a venipuncture, regulates the rate of administration, monitors the infusion, and discontinues the administration when fluid balance is restored. The healthcare provider, not the nurse, specifies the type of solution, additional additives, the volume (in mL), and the duration of the infusion.

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. Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, 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 woman age 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires:

replacement of fluids for those lost from vomiting and diarrhea. The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. What is the most likely complication that has occurred?

thrombus Phlebitis and thrombus present as local acute tenderness, redness, warmth, and slight edema of the vein above the site. Sepsis manifests as a red and tender insertion site with fever, malaise, and other vital sign changes. Infiltration or the escape of fluid into the subcutaneous tissue manifests as swelling, pallor, coldness, or pain around the infusion site and significant decrease in the flow rate. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.

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.)

• drinking milk • urination • vomiting • infusion of intravenous solution The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output.

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

"Fluid in the tissue space between and around cells." 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 nursing student how to record strict I&O;for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate?

"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." Fluid output is the sum of liquid eliminated from the body, including urine, emesis (vomitus), blood loss, diarrhea, wound or tube drainage, and aspirated irrigations. In cases in which an accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, diapers, or dressings, and subtracts the weight of a similar dry item. An estimate of fluid loss is based on the equivalent: 1 lb (0.47 kg) = 1 pint (475 mL).

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

2,500 mL/day 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 nurse identifies a nursing diagnosis of Excess Fluid Volume related to heart failure as evidenced by edema and weight gain. The nurse reviews the client's laboratory test results. Which plasma osmolality value would support the nurse's nursing diagnosis?

260 mOsm/kg 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.

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

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 Agencies often specify the types of clients that are placed automatically on I&O;Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O;documented. The other clients do not require the nurse to document all I&O;.

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 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).

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) 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.

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 Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

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. 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.

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.

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative 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. B positive, A positive, and AB negative are not considered compatible in this scenario.

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 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.

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. Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so 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. 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.

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 phosphorus 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.

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 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.

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:

fluid overload. 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.

Which individual will take longer to sense thirst?

70-year-old When adults older than 65 years of age were compared with younger adults, the plasma osmolarity at which the older group experienced thirst was increased, indicating an increased risk for development of a water deficit.

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L Potassium: 3.2 mEq/L Calcium: 4.4 mEq/L Magnesium: 1.6 mEq/L Chloride: 100 mEq/L Phosphate: 1.8 mEq/L Based on these levels, the nurse would identify which imbalance?

Hypokalemia 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). Therefore the client has hypokalemia.

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. 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.