Chapter 39 Prep-U Questions
What is the rate of administration for packed red blood cells?
1 unit over 2-3 hours, no longer than 4 hours
What equivalent is fluid loss based on?
1lb = 1 pint
How much fluid is lost through insensible loss?
300 to 400 mL/day.
What is the normal pressure of ECF?
4 to 11 cm H2O
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
How is control over the extracellular concentration of potassium within the human body is exerted?
Aldosterone
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
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
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.
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
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 most likely find?
Hypokalemia
What is phlebitis?
Infection
Where is most of the body fluid located?
Intracellular
What is a function of intracellular fluid?
Maintain cell size
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?
Metabolic alkalosis
What assessment findings would a nurse look for in someone with hypocalcemia?
Muscle cramping and tetany
A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order?
Packed cells
What do the passageways of the kidneys do?
Permit the urine to flow to the bladder and selectively reabsorb or secrete substance to maintain fluids and electrolytes
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
What is interstitial fluid?
The fluid in the tissue space between and around cells
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?
The pump will continue to infuse liquid even when the needle is displaced
What phenomenon takes place when antidiuretic hormone is present?
The renal system retains more water
What do the kidneys regulate?
pH of extracellular fluid by excreting and retaining hydrogen ions and extracellular fluid by retention and excretion of body fluids
What is considered a normal fluid intake for a healthy adults?
2500 mL/dayThe 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
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
What are normal total serum calcium levels?
8.9 - 10.1 mg/dL
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
An infant
What do the adrenal glands regulate?
Blood volume by secreting aldosterone
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
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 is taking a diuretic such as furosemide. When implementing client education, what information should be included?
Decreased potassium levels
Which veins should be used first when starting an IV, distal or proximal?
Distal
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
Place the steps in order once the CO2 in the blood has increased, resulting in increased respirations to eliminate CO2.
H2CO3 level in the blood decreases, pH becomes more alkaline,Blood level of CO2 decreases,Decreased respirations,Carbon dioxide retention,Carbonic acid formed
A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding?
Low back pain, facial flushing, fever, and hematuria
What manifestations should a nurse watch for in a patient with hypokalemia?
Muscle weakness, fatigue, and dysrhythmias
What is insensible water loss?
Occurs when water molecules move from an area of higher concentration, such as the body, to an area of lower concentration, like the atmosphere.
Why is an infant prone to have fluid volume deficits?
They have more ECF to begin with and it is more easily lost from the body
T/F Are apricots a rich source of potassium
True
The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?
Watery plasma, or serum, portion of blood
When accessing the scalp vein, the nurse should use what type of needle?
A winged infusion needle
Which client will have more adipose tissue and less fluid?
A woman
Where does filtration begin in the kidney?
Glomerulus
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?
Hypertonic soln
The client has a brain injury which is causing the pressure inside the skull to increase, which may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?
Hypertonic soln
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of what electrolyte imbalance?
Hypokalemia
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
Define 1+edema
Edema is just perceptible and of 2 mm dimension.
Can a patient donate blood and have it be reinfused later on during surgery if they need it?
Yes
Which client would have the most extracellular fluid?
A newborn
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 alkalosis
What does the nervous system regulate?
Oral intake by sensing intracellular dehydration, which in turn stimulates thirst
A nurse is teaching a client about the newly prescribed furosemide and how it affects fluid and electrolyte balance. In addition to water, the nurse would explain that the drug also affects which electrolyte(s)?
Potassium, magnesium, chloride, and sodium
What are the primary extracellular electrolytes?
Sodium, chloride and bicarbonate
During a blood transfusion, a client displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?
Hemolytic transfusion reaction: incompatibility of blood product
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 would the nurse most likely address?
Increased hydrostatic pressure