Chapter 41 Fluid, Electrolyte, and Acid-Base Balance

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

"Fluid in the tissue space between and around cells."

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

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

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?

"I've been taking antacids almost every 2 hours over the past several days."

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."

The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply.

- 100 ml from melted ice chips - serving of jello infusion of intravenous solution cup of ice cream

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.

- Carbonic acid-sodium bicarbonate buffer system - Phosphate buffer system - Protein buffer system

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.

- Deciding the location of the IV catheter. - Deciding the size of the IV catheter. - Administering the IV solution.

The nursing instructor is explaining how the respiratory system is involved in hydrogen ion regulation to maintain normal pH. 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

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. - Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. - Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.

A client is preparing for discharge to home following a diagnosis of hypoparathyroidism with associated low parathyroid hormone. Which food(s) will the nurse include when creating a diet-based teaching plan for the client?

- yogurt - broccoli - tofu

What commonly used intravenous solution is hypotonic?

0.45% NaCl

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

A health care provider 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

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?

60 drops/mL

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?

83 gtt/min

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

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 hypotonic solution

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)

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?

Apply pressure to insertion site for at least 3 minutes.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels

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.

A nurse is inspecting the IV site of a client and notices that the site is swollen, red, warm to the touch, and painful. Which action by the nurse is appropriate?

Discontinue the IV and relocate it to another spot.

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 arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.

A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status?

HCO3: 25 mEq/L (25 mmol/L)

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?

Hypertonic

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?

Infants

Because metabolism continually produces acids, maintenance of pH within these incredibly narrow limits depends on two processes: buffering and compensation. Which statement describes a function of buffering?

It helps to prevent large changes in pH by absorbing or releasing H+ ions.

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

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

The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition?

Metabolic alkalosis

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?

Not wearing gloves when performing the intervention

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

O negative

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

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?

Phlebitis

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

The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next?

Remove the peripheral intravenous catheter.

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?

Restart infusion in another vein and apply a warm compress.

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.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?

The client has anti-A antibodies.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?

The renal system retains more water.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?

To assure the IV solution is appropriate for this administration

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?

Verify the prescription for type of solution and amount of infusion.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:

a winged infusion needle.

The nurse writes a a problem-based care plan, citing the client's excess fluid volume. What risk factor does the nurse expect to assess in this client?

acute kidney injury

Which hormone regulates the extracellular concentration of potassium within the human body?

aldosterone

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they 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

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 nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching?

cardiac function

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

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

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

The process of filtration begins at the:

glomerulus.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?

hemolytic transfusion reaction: incompatibility of blood product

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

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: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance?

hypokalemia

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?

hypovolemia

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?

increased hydrostatic pressure

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 health care provider of the client's:

low calcium.

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?

muscle cramping and tetany

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: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

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.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes

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?

plasma

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parenteral nutrition.