Chapter 40: Fluid, Electrolyte, and Acid-Base Balance

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. 5% dextrose in 0.9% NaCl 0.9% NaCl (normal saline) Lactated Ringer's solution 0.33% NaCl (⅓-strength normal saline) 0.45% NaCl (½-strength normal saline) 5% dextrose in Lactated Ringer's solution

0.33% NaCl (⅓-strength normal saline) 0.45% NaCl (½-strength normal saline) 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? 1 2 3 4

2 Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema - 6-mm pit - pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? 1+ pitting edema 2+ pitting edema 3+ pitting edema 4+ pitting edema

3+ pitting edema 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

5. A nurse monitoring the intake and output of fluids for a patient with severe diarrhea knows that normally how many mL of body fluids is lost via the gastrointestinal tract? A) 300 mL B) 1,000 mL C) 1,300 mL D) 2,600 mL

A) 300 mL Fluid output averages 2,500 to 2,900 mL per day (average 2,600 mL), with approximately 1,500 mL as urine from the kidneys, 600 mL fluid loss from the skin, 300 mL from the lungs, and 200 mL in feces via the GI tract

8. Which of the following descriptions best summarizes fluid homeostasis? A) Almost every body organ and system helps maintain homeostasis. B) The cardiovascular and renal systems primarily maintain homeostasis. C) Homeostasis is maintained through intra- and extracellular exchange. D) Homeostasis is maintained by the arterioles, capillaries, and venules.

A) Almost every body organ and system helps maintain homeostasis.

29. Which of the following patients would be the most likely candidate for the administration of total parenteral nutrition? A) a patient with severe pancreatitis B) a patient with a myocardial infarction C) a patient with hepatitis B D) a patient with mild malnutrition

A) a patient with severe pancreatitis

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion. - Place your answer on the line provided below.

Ans: 50 gtts/min. When administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula:

27. A patient scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this? A) The patients family members have been donors. B) The patient donates his or her own blood. C) The patients blood has been rendered sterile. D) The patient will only need fluids, not blood.

B) The patient donates his or her own blood.

2. Which body fluid is the fluid within the cells, constituting about 70% of the total body water? A) extracellular fluid (ECF) B) intracellular fluid (ICF) C) intravascular fluid D) interstitial fluid

B) intracellular fluid (ICF)

Edema happens when there is which fluid volume imbalance? extracellular fluid volume deficit water deficit water excess extracellular fluid volume excess

extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

A decrease in arterial blood pressure will result in the release of: protein. thrombus. renin. insulin.

renin. Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release. Think of the RAAS, when BP goes falls this process begins Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1559

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. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1556

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. "Try to drink at least six to eight glasses of water each day." "Try to limit your fluid intake to 1 quart of water daily." "Limit sugar, salt, and alcohol in your diet." "Report side effects of medications you are taking, especially diarrhea." "Temporarily increase foods containing caffeine for their diuretic effect." "Weigh yourself daily and report any changes in your weight."

"Try to drink at least six to eight glasses of water each day." "Limit sugar, salt, and alcohol in your diet." "Report side effects of medications you are taking, especially diarrhea." "Weigh yourself daily and report any changes in your weight." In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

13. Which of the following questions about fluid balance would be appropriate when conducting a health history for a patient? A) Describe your usual urination habits. B) Describe your problems with constipation. C) How did you feel when your calcium was low? D) Do you eat fruits and vegetables each day?

A) Describe your usual urination habits.

18. A physician writes an order to force fluids. What will be the first action the nurse will take in implementing this order? A) Explain to the patient why this is needed. B) Tell the patient and family to increase oral intake. C) Decide how much fluid to increase each 8 hours. D) Divide the intake so the largest amount is at night.

A) Explain to the patient why this is needed.

6. A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which of the following statements accurately describe this process? Select all that apply. A) The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the bodys needs. B) The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. C) The thyroid gland secretes aldosterone, a mineralocorticoid hormone that helps the body conserve sodium, helps save chloride and water, and causes potassium to be excreted. D) The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acidbase balance. E) Thyroxine, released by the adrenal glands, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output. F) The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.

A) The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the bodys needs. B) The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. D) The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acidbase balance. F) The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.

25. Cross-matching of blood is ordered for a patient before major surgery. What does this process do? A) determines compatibility between blood specimens B) determines a persons blood type C) predicts the amount of needed blood replacement D) specifies the donor and the recipient of the blood

A) determines compatibility between blood specimens

20. A nurse is administering a potassium supplement to a patient. What will the nurse do to disguise the taste and decrease gastric irritation? A) dilute it B) give it after meals C) mix it with food D) freeze it

A) dilute it

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? Encourage foods and fluids with high sodium content. Administer oral K supplements as ordered. Caution the patient about eating foods high in potassium content. Discuss calcium-losing aspects of nicotine and alcohol use.

Administer oral K supplements as ordered. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

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. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1583

Which nursing actions would be performed when preparing an IV solution and tubing to initiate intravenous therapy? Select all that apply. Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Squeeze drip chamber and allow it to fill one-quarter full. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. Allow fluid to flow and cap at end of tubing before all air bubbles have disappeared. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.

Apply label to tubing reflecting the day/ date for next set change, per facility guidelines. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Maintain aseptic technique when opening sterile packages and IV solution. Aseptic technique must be maintained when handling any of the IV solutions or containers to decrease the chance of infection. The nurse then clamps the tubing to allow for filling of the drip chamber to the halfway mark, uncaps the spike, and inserts the spike into entry site. The tubing is then primed to eliminate all air by removing the cap at the end of the tubing, releasing the clamp, and allowing fluid to move through tubing prior to initiating fluid flow into the client's IV cannula. A label is then applied to identify when the next change of tubing is required. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1594Remove cap at end of tubing, release clamp, and allow fluid to move through tubing.

What is the lab test commonly used in the assessment and treatment of acid-base balance? Complete blood count Basic metabolic panel Arterial blood gas Urinalysis

Arterial blood gas Explanation: 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. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level.

What is the lab test commonly used in the assessment and treatment of acid-base balance? Complete blood count Basic metabolic panel Arterial blood gas Urinalysis

Arterial blood gas Explanation: 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. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1572

3. Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this? A) Infants have less total body fluid and ECF than adults. B) Infants have more total body fluid and ECF than adults. C) Infants drink less fluid than adults. D) Infants lose more fluids through output than adults.

B) Infants have more total body fluid and ECF than adults.

14. A patient is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base a teaching plan? A) Impaired Skin Integrity B) Risk for Deficient Fluid Volume C) Impaired Urinary Elimination D) Urinary Retention

B) Risk for Deficient Fluid Volume

10. A home care patient is complaining of weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request? A) The nurse is concerned that the patients diet has caused sodium loss. B) The nurse recognizes these symptoms of hypokalemia. C) The patient is actively seeking increased attention. D) The patient had bananas and orange juice for breakfast.

B) The nurse recognizes these symptoms of hypokalemia. Skeletal muscles are generally the first to demonstrate a potassium deficiency. Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias (pins and needles), and dysrhythmias.

30. A nurse is initiating a peripheral venous access IV infusion ordered for a patient presurgically. In what position would the nurse place the patient to perform this skill? A) high Fowlers B) low Fowlers C) Sims D) dorsal recumbent

B) low Fowlers

The student nurse studying fluid and electrolyte balance learns that which of the following is a function of water? Select all that apply. A) provide a medium for transporting wastes to cells and nutrients from cells B) provide a medium for transporting substances throughout the body C) facilitate cellular metabolism and proper cellular chemical functioning D) act as a buffer for electrolytes and nonelectrolytes E) help maintain normal body temperature F) facilitate digestion and promote elimination

B) provide a medium for transporting substances throughout the body C) facilitate cellular metabolism and proper cellular chemical functioning E) help maintain normal body temperature F) facilitate digestion and promote elimination

15. A nurse measures a patients 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? A) Compare the patients intake with the normal range of adult fluid intake. B) Report the exact milliliter of intake to the physicians office nurse. C) Compare the total intake and output of fluids for the 24 hours. D) Ensure that the information is included in the verbal end-of-shift report.

C) Compare the total intake and output of fluids for the 24 hours.

24. A woman has had her left breast removed for cancer. She also had an axillary node dissection on the left during surgery. How would this affect placement of an intravenous line? A) Either arm may be used. B) Neither arm should be used. C) The left arm should not be used. D) The right arm should not be used.

C) The left arm should not be used.

11. A patients PaCO2 is abnormal on an ABG report. Which of the following illnesses would most likely be the medical diagnosis? A) rheumatoid arthritis B) sexually transmitted infection C) chronic obstructive pulmonary disease D) infection of the bladder and ureters

C) chronic obstructive pulmonary disease

16. A nurse reads a complete blood count report for a patient who has been admitted to the hospital with fluid overload from late-stage kidney disease. What abnormal result would the nurse expect to find? A) increased white blood cells B) increased platelets C) decreased hematocrit D) increased hematocrit

C) decreased hematocrit

7. By what route do oxygen and carbon dioxide exchange in the lung? A) osmosis B) filtration C) diffusion D) active transport

C) diffusion

12. A patient has metabolic (nonrespiratory) acidosis. What type of respirations would be assessed? A) periods of apnea B) decreased depth and rate C) increased depth and rate D) alternating fast and slow

C) increased depth and rate

22. Which of the following locations might the nurse use to assess the condition of an insertion site for a central venous access device? A) below the sternum B) over the fourth intercostal space C) over the jugular vein D) the back of the hand

C) over the jugular vein

Which is a common anion? magnesium potassium chloride calcium

Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1557

4. What is the average adult fluid intake and loss in each 24 hours? A) 500 to 1,000 mL B) 1,000 to 1,500 mL C) 1,500 to 2,000 mL D) 1,500 to 3500 mL

D) 1,500 to 3500 mL

28. A patient is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than 4 hours. What should the nurse do next? A) Continue with the transfusion and document the drip rate. B) Report to the next shift the amount of blood left to infuse. C) Take and record vital signs more often. D) Discontinue the blood transfusion.

D) Discontinue the blood transfusion.

9. A nurse reads the laboratory report for a patient and notes that the patient has hyponatremia. What physical assessment would be made? A) Observe skin color and texture. B) Auscultate bowel sounds. C) Percuss lung density. D) Palpate skin of sternum.

D) Palpate skin of sternum.

23. A specially trained nurse has inserted a PICC line. What would be done next? A) Start administration of prescribed fluids. B) Explain the procedure to the patient and family. C) Place the patient on restricted oral fluids. D) Send the patient to the radiology department.

D) Send the patient to the radiology department.

26. A patient asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond? A) There is only a very small chance - I know you will be safe. B) Although hepatitis is possible, AIDS is not. C) If I were you, I would request special handling of my blood. D) There is no way you can contract a disease by giving blood.

D) There is no way you can contract a disease by giving blood.

21. A student is learning how to administer intravenous fluids, including accessing a vein. Although all of the following may occur, which is the most potentially harmful risk posed for the patient when accessing the vein? A) discomfort B) pain C) minor bleeding D) infection

D) infection

19. A patient has an order to restrict fluids. What is one comfort measure nurses can implement for this patient to alleviate a common problem? A) back rubs B) chewing gum C) hair care D) oral hygiene

D) oral hygiene

17. A patient has a decreased potassium level. What high-potassium foods would the nurse teach the patient to eat? A) lunch meat, salted nuts, whole milk B) buttermilk, hard candy, spinach C) carbonated beverages, beer, olives D) oranges, bananas, broccoli

D) oranges, bananas, broccoli

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. 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. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1602-1610

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? Discontinue the IV and relocate it to another site. Call the primary care provider to see whether anti-inflammatory drugs should be administered. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.

Discontinue the IV and relocate it to another site. Explanation: The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1613-1617

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

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? muscle twitching distended neck veins fingerprinting over sternum nausea and vomiting

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 patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. Keeping fluids readily available for the patient. Emphasizing the long-term outcome of increasing fluids when the patient returns home. Planning to offer most daily fluids in the evening.

Keeping fluids readily available for the patient. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: Kidneys Lungs Adrenal glands Blood vessels

Lungs The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? Recording intake and output. Testing skin turgor. Reviewing the complete blood count. Measuring weight daily.

Measuring weight daily. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30 - PaCO2, 36 mm Hg -HCO3−, 14 mEq/L? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Metabolic acidosis A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

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? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Metabolic alkalosis Explanation: Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1574

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? A pinched and drawn facial expression Deep, rapid respirations. Moist crackles may indicate fluid volume excess. Tachycardia

Moist crackles may indicate fluid volume excess. Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? Reposition the extremity and raise the height of the IV pole. Apply pressure to the dressing on the IV. Pull the catheter out slightly and reinsert it. Put on gloves then remove the catheter

Put on gloves then remove the catheter This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? Remove the IV from the site and start at another location. Immediately notify the primary care provider. Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. Aspirate the catheter and attempt to flush again.

Remove the IV from the site and start at another location. If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

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? Slow the rate of IV fluids. Remove the IV. Apply a warm compress. Elevate the arm.

Remove the IV. Explanation: The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1578-1579

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? Slow or stop the infusion - monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

Slow or stop the infusion - monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Allow nothing by mouth. Give the client a glass of orange juice with added sugar. Encourage fluid intake. Start an IV of normal saline as prescribed.

Start an IV of normal saline as prescribed. Explanation: To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1605

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? Stop the transfusion immediately. Infuse saline at a rapid rate. Prepare to give an antihistamine. Administer oxygen.

Stop the transfusion immediately. Explanation: The nurse needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1622

Which hormone regulates the extracellular concentration of potassium within the human body? aldosterone androgen progesterone testosterone

aldosterone Explanation: Aldosterone regulates the extracellular concentration of potassium. It also enhances renal secretion of potassium. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1560

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. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1556

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? every 12 hours every 24 hours every 36 hours every 72 hours

every 72 hours Explanation: 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. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1582

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. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1576

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 likely to find? hyperphosphatemia hyperchloremia hypokalemia hypomagnesemia

hypokalemia Explanation: Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1565

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? hypervolemia hypovolemia edema circulatory overload

hypovolemia 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. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

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 will nurse likely address? decreased colloid oncotic pressure increased capillary permeability blockage of the lymph nodes increased hydrostatic pressure

increased hydrostatic pressure

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? hypertonic colloid isotonic hypotonic

isotonic Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

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. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1572

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 are indicative of: phlebitis. an infiltration. a systemic blood infection. rapid fluid administration.

phlebitis. Explanation: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, 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 Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1589-1590