Chapter 41: Fluid, Electrolytes, and Acid-Base Balance

Which of the following intravenous solutions is isotonic? A. 0.9% saline B. 5% dextrose in water (D5W) C. 0.45% NaCl D. 0.255% NaCl

D. 0.255% NaCl

Measurements related to fluid balance of clients that a nurse can initiate without a physician's order include: A. Daily weights, vital signs, and fluid intake and output B. Daily weights, diuretics, and waist measurement C. Monitoring temperature, fluid intake and output, and calorie count D. Auscultating lung sounds, monitoring color of urine, and placing a Foley catheter into the client

A. Daily weights, vital signs, and fluid intake and output Daily weights, checking vital signs, and monitoring fluid I&O all fall within the realm of nursing interventions. The remaining interventions either have the nurse perform a task requiring an MD order, such as giving diuretics or placing a Foley catheter, or have an action unrelated to this problem, such as the calorie count.

A patient informs the nurse that he has the type of diabetes that does not require insulin. The nurse advises the patient to make which dietary change? A. Drink plenty of fluids throughout the day to stay hydrated B. Avoid food high in acid to avoid metabolic acidosis C.Reduce the quantity of carbohydrates ingested to lower blood sugar D. Include a serving of dairy in each meal to elevate calcium levels

A. Drink plenty of fluids throughout the day to stay hydrated The patient is indicating that he has diabetes insipidus, which places him at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid should be avoided in a patient with GERD. A reduction in carbohydrates applies to type 2 diabetes mellitus patients. Calcium-rich dairy products would be recommended for a hypocalcemic patient.

Assessment findings consistent with intravenous (IV) fluid infiltration include: (Select all that apply.) A. Edema and pain B. Streak formation C. Pain and erythema D. Pallor and coolness E. Numbness and pain

A. Edema and pain D. Pallor and coolness Inadvertent fluid leakage into the interstitial compartment around an IV site can cause swelling, pain from the pressure, pale color, and coolness of the infiltrated area.

When caring for a patient with fluid excess, which of the following interventions will best help relieve respiratory distress? A. Elevate the head of the bed B. Encourage the patient to cough and deep breathe. C. Increase fluids to promote urine output. D. Perform percussion and postural drainage.

A. Elevate the head of the bed Elevating the head of the bed will provide more room for lung expansion and provide the quickest relief for shortness of breath.

A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

A. Metabolic acidosis The low pH indicates acidosis. The low PaCO2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO3- indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus metabolic acidosis is the correct interpretation.

While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action? A. Notify a health care provider B. Insert an indwelling catheter C. Alert the blood bank D. Stop the transfusion

D. Stop the transfusion Development of chills, tachycardia, and flushing during a blood transfusion is an indication of an acute hemolytic reaction. You stop the transfusion immediately so no more of the incompatible blood reaches the patient.

The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate do you program into the infusion pump? A. 125 mL/hr B. 167 mL/hr C. 200 mL/hr D. 1000 mL/hr

B. 167 mL/hr 1000 mL divided by 6 hours is 166.7 mL/hr, which rounds to 167 mL/hr (if infusion pump accepts decimals, program it to 166.7 mL/hr).

A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 20 mL/hr. At what time should the infusion be completed? A. 0645 Tuesday B. 0675 Tuesday C. 0715 Tuesday D. 0735 Tuesday

C. 0715 Tuesday 250 mL divided by 20 mL/hr = 12.5 hr 0.5 hr × 60 min = 30 min 1845 + 12 hr 30 min = 3115, which would be 0715 on Tuesday, the following day.

You assess four patients. Which patient is at greatest risk for the development of hypocalcemia? A. 56 year old with acute kidney renal failure B. 40 year old with appendicitis C. 28 year old who has acute pancreatitis D. 65 year old with hypertension and asthma

C. 28 year old who has acute pancreatitis People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This is called steatorrhea. This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids.

The nurse is caring for a patient with hyperkalemia. Which body system would be most important for the nurse plan to monitor closely? A. Gastrointestinal B. Neurological C. Cardiac D. Respiratory

C. Cardiac Potassium balance is necessary for cardiac function. Hyperkalemia places the patient at risk for potentially serious dysrhythmias. Monitoring of gastrointestinal, neurological, and respiratory systems would be indicated for other electrolyte imbalances.

Three major mechanisms the body employs to control acid-base balance are cellular buffers, the lungs and the _________.

Kidneys

A patient is being discharged following hospitalization for fluid imbalance. Which instruction by the nurse should take priority? A. "Weigh yourself at the same time every day and report changes." B. "Call your doctor immediately if you feel weak or fatigued." C. "Drink eight glasses of water a day." D. "Measure everything you drink, and measure how much you urinate each day."

A. "Weigh yourself at the same time every day and report changes." Daily or every other day weights are easy to keep track of at home.

Which fluid order should the nurse question for a patient with a traumatic brain injury? A. 0.45% sodium chloride B. 0.9% sodium chloride C. Lactated Ringer's D. Dextrose 5% in 0.9% sodium chloride

A. 0.45% sodium chloride 0.45% sodium chloride is a hypotonic solution, and hypotonic solutions cause cells to swell, which can cause increased intracranial pressure. This can be life threatening for a patient with a traumatic brain injury. The other solutions are physiologically isotonic sodium-containing solutions that will expand ECV but will not cause cell swelling. In the fluid container, dextrose 5% in 0.9% sodium chloride is hypertonic, but the dextrose enters cells rapidly, leaving isotonic 0.9% sodium chloride.

A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours. The nurse anticipates which fluid therapy initially? A. 0.9% sodium chloride B. Dextrose 10% in water C. Dextrose 5% in water D. 0.45% sodium chloride

A. 0.9% sodium chloride Patients with prolonged vomiting and diarrhea become hypovolemic. The best solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. Dextrose 10% in water, dextrose 5% in water, and 0.45% sodium chloride act as hypotonic solutions in the body. The first consideration is replacing extracellular volume to oxygenate tissues.

Which pH value represents acidosis? A. 7.26 B. 7.35 C. 7.4 D. 7.49

A. 7.26 A value below 7.35 is acidotic.

The nurse working on a medical unit recognizes that which of the following individuals are a risk for hyponatremia? (Select all that apply.) A. A 19 year old drowning victim rescued from a nearby lake B. A 52 year old with congestive heart failure taking diuretics who is NPO for a cardiac catheterization C. A 68 year old with bowel obstruction receiving nasogastric suction D. A 92 year old who is receiving total parenteral nutrition E. A 55 year old who takes calcium supplements for osteoporosis F. A 42 year old with chronic renal failure

A. A 19 year old drowning victim rescued from a nearby lake B. A 52 year old with CHF taking diuretics who is NPO for a cardiac catheterization C. A 98 year old with bowel obstruction receiving nasogastric suction D. A 92 year old who is receiving total parenteral nutrition

The nurse would select the dorsal venous plexus of the foot as an IV site for which patient? A. A 2 year old child B. A 22 year old adult C. A 50 year old patient D. An 80 year old patient

A. A 2 year old child Use of the foot as an IV site is common in children but is avoided in adults because of the risk for thrombophlebitis.

A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300 mL output. The patient has voided 400 mL of urine. After reporting these values to the physician, what orders does the nurse anticipate? A. Add a potassium supplement to replace loss from output B. Decrease the rate of intravenous fluids to 100 mL/hr C. Discontinue the nasogastric suctioning D. Administer a diuretic to prevent fluid volume excess

A. Add a potassium supplement to replace loss from output The total fluid intake and output equals 700 mL, which meets the provider goals. Record half the volume of ice chips when calculating intake. Patients with nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition. The other measures would be unnecessary because the net fluid volume is equal.

Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? A. Auscultate dependent portions of lungs B. Check color of urine C. Assess muscle strength D. Check skin turgor over sternum or shin

A. Auscultate dependent portions of lungs Excessive or too-rapid infusion of 0.9% NaCl (normal saline) causes extracellular fluid volume (ECV) excess with pulmonary vessel congestion and potential pulmonary edema, especially in older adults, who cannot adapt as rapidly to increased vascular volume. Overload of intravenous normal saline eventually increases urine volume if kidneys are functioning but may not change urine color. Assessment of muscle strength is appropriate for potassium imbalances, not ECV imbalances. Skin turgor is not a reliable assessment of ECV deficit in older adults.

The nurse would expect a patient with respiratory acidosis to have an excessive amount of: A. Carbon Dioxide B. Bicarbonate C. Oxygen D. Phosphate

A. Carbon Dioxide Respiratory acidosis occurs when the lungs are not able to excrete enough carbon dioxide. Carbon dioxide and water create carbonic acid. A build up of carbonic acid caused the ECF to become more acidic, decreasing the pH. Bicarbonate is normal with uncompensated respiratory acidosis or elevated with compensated respiratory acidosis. Excessive oxygen and phosphate are not characteristic of respiratory acidosis.

Which of the following assessments would indicate that a patient's IV has infiltrated? (Select all that apply.) A. Edema of the extremity near the insertion site B. Skin discolored or bruised in appearance C. Pain and warmth at the insertion site D. Skin cool to the touch E. Reddish streak proximal to the insertion site F. Numbness or loss of sensation G. Palpable venous cord

A. Edema of the extremity near the insertion site B. Skin discolored or bruised in appearance D. Skin cool to the touch F. Numbness or loss of sensation Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and may be bruised or discolored, and the patient may experience some numbness. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis.

Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period that blood: A. Hanging for a longer four hours creates an increased risk of sepsis B. May clot in the bag C. May evaporate D. May not clot in the recipient after this time period

A. Hanging for a longer four hours creates an increased risk of sepsis Hanging for a longer four hours creates an increased risk of sepsis, which is why the nurse wants to complete the unit transfusion in less than four hours. The remaining items are not likely to happen.

The nurse knows that an imbalance of which ion causes acid-base impairment? A. Hydrogen B. Calcium C. Magnesium D. Sodium

A. Hydrogen The concentration of hydrogen ions determines pH. Low pH designates an acidic environment. High pH designates an alkaline environment. Calcium, magnesium, and sodium are ions, but their imbalances are not direct acid-base impairments.

The nurse knows that edema in a patient who has venous congestion from right heart failure is facilitated by an imbalance regard to __________ pressure. A. Hydrostatic B. Osmotic C. Oncotic D. Concentration

A. Hydrostatic Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic pressure involve the concentrations of solutes and can contribute to edema in other situations. Concentration pressure is not a nursing term.

The nurse is caring for a patient who is very anxious and hyperventilating. Which of the following are signs and symptoms of respiratory alkalosis for which to observe? (Select all that apply.) A. Increased heart rate B. Increased PaCO2 level C. Slow deeps respirations D. Rapid shallow respirations E. Decreased heart rate F. Lightheadedness

A. Increased heart rate D. Rapid shallow respirations F. Lightheadedness

Approximately 2/3 of the body's total water volume exists in the __________ fluid. A. Intracellular B. Interstitial C. Intravascular D. Transcellular

A. Intracellular Intracellular fluid accounts for approximately 2/3 of the fluids in the body - about 42% of total body weight. Interstitial fluid, intravascular fluid, and transcellular fluid constitute extracellular fluid, which is the fluid outside a cell.

The nurse understands that administering a hypertonic solution to a patient will shift water from the _______ to the _______ space. A. Intracellular; extracellular B. Extracellular; intracellular C. Intravascular; intracellular D. Intravascular; interstitial

A. Intracellular; extracellular A hypertonic solution has a concentration greater than normal body fluids, so water will shift out of cells because of the osmotic pull of the extra particles. Movement of water into cells occurs when hypotonic fluids are administered. Distribution of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.

Which of the following are functions of sodium in the body? (Select all that apply.) A. Maintenance of serum osmolarity B. Formation of bones and teeth C. Control of bronchodilation D. Control of serum glucose E. Maintenance of cellular function

A. Maintenance of serum osmolarity E. Maintenance of cellular function Sodium is the major cation in the blood and helps maintain serum osmolarity. Sodium is also important for cell function, especially in the central nervous system.

Which of the following activities can you delegate to nursing assistive personnel (NAP)? (Select all that apply.) A. Measuring oral intake and urine output B. Preparing intravenous (IV) tubing for routine change C. Reporting an IV container that is low in fluid D. Changing an IV fluid container

A. Measuring oral intake and urine output C. Reporting an IV container that is low in fluid The registered nurse cannot delegate working with IV tubing or changing an IV infusion to NAP.

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most concerned about? A. Potassium imbalance B. Sodium imbalance C. Calcium imbalance D. Phosphate imbalance

A. Potassium imbalance Using a diuretic can cause excess excretion of potassium, unless it is a potassium-sparing diuretic. The other electrolytes are not excreted in the same with with diuretics.

Edema that forms in clients with kidney disease is due to: A. Reduced plasma oncotic pressure, so that fluid is not drawn into the capillaries from interstitial tissues B. Decreased capillary hydrostatic pressures pushing fluid into the interstitial tissues C. Capillaries becoming less permeable, allowing fluid to escape into interstitial tissues D. Obstructed lymph flow that assists the movement of fluid from the interstitial tissues back into the vascular compartment

A. Reduced plasma oncotic pressure, so that fluid is not drawn into the capillaries from interstitial tissues The edema is due to low levels of plasma proteins that exist with this disease, altering the oncotic pressure that helps regulate fluid movement in the vascular space moving into interstitial area. Increased capillary hydrostatic pressure is the cause. Capillaries have increased permeability when edema formation is possible. Obstructed lymph flow impairs the movement of fluid from interstitial tissues back into the vascular compartment, resulting in edema.

A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, elevated white blood cell count, and oral candidiasis. The nurse knows that the purpose of starting total parenteral nutrition (TPN) is to: A. Replace fluid, electrolytes, and nutrients in the patient B. Stimulate the patient's appetite to eat C. Provide medication to raise the patient's blood pressure D. Deliver antibiotics to fight off infection

A. Replace fluid, electrolytes, and nutrients in the patient Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace the ones the patient is not eating. TPN does not stimulate the appetite. TPN does not contain blood pressure medication or antibiotics.

A 2 year old child with brought into the emergency department after ingesting several morphine tablets from a bottle in his mother's purse. The nurse knows that the child is at greatest risk for which acid-base imbalance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis Morphine overdose can cause respiratory depression and hypoventilation. Hypoventilation results in retention of carbon dioxide and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, cause a decrease in carbon dioxide levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.

A client suffering from a narcotic overdose is seen in the Emergency Department. The client is confused, with warm, flushed skin, headache, and weakness. Vital signs of noted are T 102.6, HR 128, R 24, and BP 130/86. A blood gas analysis sample was drawn on room air, and the results are as follows: pH 7.33, PaCO2 53, PaO2 72, HCO3 24. This client is at risk for: A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

A. Respiratory acidosis Narcotic overdose causes more carbonic acid levels to rise because of hypoventilation and carbon dioxide retention.

The nurse knows that intravenous fluid therapy has been effective for a patient with hypernatremia when: A. Serum sodium concentration returns to normal B. Systolic and diastolic blood pressure decrease C. Large amounts of emesis and diarrhea decrease D. Urine output increases to 150 mL/hr

A. Serum sodium concentration returns to normal Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia.

The nurse knows that the most abundant cation in the blood is: A. Sodium B. Potassium C. Chloride D. Magnesium

A. Sodium Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation. Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium is found predominately inside cells and in bone.

The nurse is caring for a patient with suspected hypokalemia. Which of the following are signs and/or symptoms for which the nurse should be vigilant? (Select all that apply.) A. Weak thready pulse B. Shallow breathing C. Increased gastrointestinal motility D. Muscle weakness E. Nausea F. Pinpoint pupils

A. Weak thready pulse B. Shallow breathing D. Muscle weakness E. Nausea

The physician asks the nurse to monitor the fluid volume status of a congestive heart failure patient and a patient at risk for clinical dehydration. What is the most effective nursing intervention from monitoring both of these patients? A. Weigh the patients every morning before breakfast B. Ask the patients to record their intake and output C. Measure the patients' blood pressure every 4 hours D. Assess the patients for edema in extremeties

A. Weigh the patients every morning before breakfast An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with ECV deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration.

The nurse is caring for a diabetic patient in renal failure. Which laboratory findings would the nurse expect? A. pH 7.3, PaCO2 36 mmHg, HCO3 19 mEq/L B. pH 7.5, PaCO2 35 mmHg, HCO3 35 mEq/L C. pH 7.3, PaCO2 47 mmHg, HCO3 23 mEq/L D. pH 7.35, PaCO2 40 mmHg, HCO3 25 mEq/L

A. pH 7.3, PaCO2 36 mmHg, HCO3 19 mEq/L Patients in renal failure develop metabolic acidosis. The laboratory values that reflect this are pH 7.3, PaCO2 36 mmHg, HCO3 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mmHg, HCO3 35 mEq/L is metabolic alkalosis. pH 7.3, PaCO2 47 mmHg, HCO3 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mmHg, HCO3 25 mEq/L values are within normal range.

What percentage of an older adult's body weight is water? A. 30% B. 50% C. 60% D. 70%

B. 50%

In which patient would the nurse expect to see a positive Chvostek sign? A. A 7 year old child admitted for severe burns B. A 24 year old adult admitted for chronic alcohol abuse C. A 50 year old patient admitted for an acute exacerbation of hyperparathyroidism D. A 75 year old patient admitted for a broken hip related to osteoporosis

B. A 24 year old admitted for chronic alcohol abuse A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which can also be affected by alcohol consumption). Burn patients frequently experiences ECV deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia.

Which of these patients do you expect will need teaching regarding dietary sodium restriction? A. An 88 year old with a fractured femur scheduled for surgery B. A 65 year old recently diagnosed with heart failure C. A 50 year old recently diagnosed with asthma and diabetes D. A 20 year old with vomiting and diarrhea from gastroenteritis

B. A 65 year old recently diagnosed with heart failure Heart failure commonly causes extracellular fluid volume (ECV) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na+ and water. Dietary sodium restriction is important with heart failure because Na+ holds water in the extracellular fluid, making the ECV excess worse.

A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding would the nurse expect? A. Thready peripheral pulses B. Abdominal distention C. Dry mucous membranes D. Flushed skin

B. Abdominal distention Signs and symptoms of hypokalemia are muscle weakness and fatigue, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia.

Which individual would least likely suffer from a disturbance in fluid volume, electrolyte, or acid-base balance? A. An infant suffering from gastroenteritis for three days B. An elderly client suffering from a type I decubitus C. Adults with impaired cardiac function D. Clients who are confused

B. An elderly client suffering from a type I decubitus The proportion of body water decreases with aging. Tissue trauma, such as burns, causes fluids and electrolytes to be lost from the damaged cells, and the breakdown in the continuity of the tissue. In Type I Decubitus, the skin remains intact, and any shifting of fluids is due to the inflammatory process and internally maintained within the body. Vomiting and diarrhea can cause significant fluid loses. Age, sex, and body fat affect total body water. Infants have the delete spaces highest proportion of water; it accounts for 70-80% of their body weight. Decreased blood flow to the kidneys as caused by impaired cardiac function stimulates the renin-angiotensin-aldosterone system, causing sodium and water retention. Clients who are confused or unable to communicate are at risk for inadequate fluid intake. Age does not play a significant factor here.

The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? A. Sodium of 145 mEq/L B. Calcium of 17.5 mg/dL C. Potassium of 3.5 mEq/L D. Chloride of 100 mEq/L

B. Calcium of 17.5 mg/dL Calcium: 8.5 to 10.5 mg/dL Sodium: 135 to 145 mEq/L Potassium: 3.5 to 5.0 mEq/L Chloride: 98 to 106 mEq/L

The nurse is caring for an older adult patient who presents to the emergency room complaining of severe vomiting and diarrhea, sweating, and rapid heartbeat. The body temperature is normal. Which of the following assessments should the nurse complete next? A. Evaluate the presence of leg edema B. Check skin turgor C. Listen for crackles D. Assess capillary refill

B. Check skin turgor

When selecting a site to insert an intravenous catheter on an adult, the nurse should (Select all that apply.) A. Start proximally and move distally on the arm B. Choose a vein with minimal curvature C. Choose the patient's dominant arm D. Check for contraindications to the extremity E. Select a vein that is rigid F. Avoid areas of flexion

B. Choose a vein with minimal curvature D. Check for contraindications to the extremity F. Avoid areas of flexion The nurse should start distally and move proximally, choosing the nondominant arm if possible. The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such mastectomy, AV fistula, and central line in the extremity. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage.

The nurse would expect a patient with increased levels of serum calcium to also have ________ levels. A. Increased potassium B. Decreased phosphate C. Decreased sodium D. Increased magnesium

B. Decreased phosphate Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease. Increased serum calcium would not necessarily cause changes in levels of potassium, sodium, or magnesium.

A 93-year-old patient with diarrhea and dehydration is admitted to the hospital from an extended care facility. For which of the following symptoms of dehydration should the nurse assess? A. Pale-colored urine, bradycardia B. Disorientation, poor skin turgor C. Decreased hematocrit, hypothermia D. Lung congestion, abdominal discomfort

B. Disorientation, poor skin turgor Dehydration is associated with poor skin turgor because of loss of water in the tissues, and with disorientation because of loss of blood volume in the brain.

You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? A. Tap water or bottled water B. Fluid that has sodium in it C. Fluid that has K and HCO3 in it D. Coffee or tea, whichever they prefer

B. Fluid that has sodium in it Body fluid losses remove sodium-containing fluid from the body and can cause extracellular fluid volume deficit unless both the sodium and the water are replaced.

An elderly patient was hydrated with lactated Ringer's solution in the emergency room for the last hour. During the most recent evaluation of the patient by the nurse, a finding of a rapid bounding pulse and shortness of breath were noted. Reporting this episode to the physician, the nurse suspects that the patient now shows signs of: A. Hypovolemia, and needs more fluids B. Hypervolemia, and needs the fluids adjusted C. An acid-base disturbance D. Needing no adjustment in fluid administration

B. Hypervolemia, and needs the fluids adjusted Isotonic solutions has the same osmolality as body fluids. Isotonic solutions, such as Normal Saline and Ringer's Lactate, initially remain in the vascular compartment, expanding vascular volume. Isotonic imbalances occur when water and electrolytes are lost or gained in equal proportions, and serum osmolality remains constant.

What term is used to refer to the relationship between a 0.9% saline solution and the blood? A. Hypotonic B. Isotonic C. Hypertonic

B. Isotonic

When discontinuing a peripheral IV access, the nurse should (Select all that apply.) A. Use scissors to remove the IV site dressing and tape B. Keep the catheter parallel to the skin while removing it C. Apply firm pressure with sterile gauze during removal D. Stop the infusion before removing the IV catheter E. Wear sterile gloves and a mask F. Apply pressure to the site for 2 to 3 minutes after removal

B. Keep the catheter parallel to the skin while removing it D. Stop the infusion before removing the IV catheter F. Apply pressure to the site for 2 to 3 minutes after removal The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the patient's skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicated to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile.

The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as: A. Hydrolysis B. Osmosis C. Filtration D. Active Transport

B. Osmosis The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Hydrolysis is not a term related to fluid and electrolyte imbalance. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Active transport requires metabolic activity and it not passive.

A patient is being placed on a potassium-losing diuretic. Which foods are high in potassium and should be recommended to the patient by the nurse? (Select all that apply.) A. Bread B. Potato C. Tomato juice D. Banana E. Gelatin

B. Potato C. Tomato juice D. Banana

Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient's breathing? A. Notify her health care provider that she is hyperventilating B. Provide frequent oral care to keep her mucous membranes moist C. Ask her to breathe slower and help her to calm down and relax D. Assess her for pain

B. Provide frequent oral care to keep her mucous membranes moist Hyperventilation is a compensatory mechanism for metabolic acidosis and should be allowed to continue. Rapid breathing can make oral mucous membranes dry and cracked.

Which organ system is responsible for compensation of respiratory acidosis? A. Respiratory B. Renal C. Gastrointestinal D. Endocrine

B. Renal The kidneys are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing balance.

The nurse would not expect full compensation to occur for which acid-base balance? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis Usually the cause of respiratory alkalosis is a temporary event (asthma or anxiety attack). The kidneys take about 24 hours to compensate for an event, so it is unlikely to see much if any compensation for respiratory alkalosis. Respiratory acidosis usually results from longer-term conditions such as chronic lung disease, narcotic overdose, or another even that causes respiratory depression. The kidneys still do not respond for about 24 hours, but usually the event is still occurring. For both metabolic imbalances, the respiratory system is quick to attempt to compensate: however, it may have difficulty sustaining that compensation.

A patient had an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, what is the nurse's next action? A. Run normal saline through the existing tubing B. Start normal saline at TKO rate using new tubing C. Discontinue the IV catheter D. Return the blood to the blood bank

B. Start normal saline at TKO rate using new tubing The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any sorts of medications need to be delivered through that IV site. The existing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the patient has been assessed and stabilized, the blood can be returned to the blood bank.

A nurse is preparing to administer a blood transfusion. Which assessment finding would the nurse report immediately? A. Blood pressure 120/60 B. Temperature 101.3 C. Poor skin turgor and pallor D. Heart rate of 100 beats per minute

B. Temperature of 101.3 A fever should be reported immediately, and the blood transfusion may be postponed. All other assessment findings are acceptable before starting a blood transfusion.

Which patient is at risk for respiratory acidosis? A. The patient with uncontrolled diabetes mellitus B. The patient with chronic pulmonary disease C. The patient who is very anxious D. The patient who overuses antacids

B. The patient with chronic pulmonary disease

A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values? A. pH 7.78, PaCO2 40 mmHg, HCO3 30 mEq/L B. pH 7.52, PaCO2 48 mmHg, HCO3 28 mEq/L C. pH 7.35, PaCO2 35 mmHg, HCO3 26 mEq/L D. pH 7.25, PaCO2 47 mmHg, HCO3 29 mEq/L

B. pH 7.52, PaCO2 48 mmHg, HCO3 28 mEq/L Compensated metabolic alkalosis should show alkalosis pH and HCO3 (metabolic) values, with a slightly acidic CO2 (compensatory respiratory acidosis). In this case, pH 7.52 is alkaline (normal: 7.35 to 7.45), PaCO2 is acidic (normal: 35 to 45 mmHg), and HCO3 is elevated (normal: 22 to 26 mEq/L). A result of pH 7.78, PaCO2 40 mmHg, HCO3 30 mEq/L is uncompensated metabolic alkalosis. pH 7.35, PaCO2 35 mmHg, HCO3 26 mEq/L is within normal limits. pH 7.25, PaCO2 47 mmHg, HCO3 29 mEq/L is compensated respiratory acidosis.

Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record? A. 700 mL B. 900 mL C. 1000 mL D. 1100 mL

C. 1000 mL Add one half the volume of ice chips to other intake to calculate total intake.

A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. What is the minute flow rate (drops per minute)? A. 12 gtt/min B. 24 gtt/min C. 125 gtt/min D. 150 gtt/min

C. 125 gtt/min Microdrip tubing delivers 60 gtt/mL. Calculation for a rate of 125 mL/hr using microdrip tubing: (125 mL/1 hr)(60 gtt/1 mL)(1 hr/60 min) = 125 gtt/min.

The nurse is caring for a patient with sepsis. The plan of care for the patient is to administer antibiotics 3 times a day for 4 weeks. What device will be used to administer these antibiotics? A. A continuous infusion B. A heparin locked peripheral catheter C. A PICC line D. An implanted port catheter

C. A PICC line A PICC line is a type of central venous device that can be introduced into a peripheral vein for administration of IV antibiotics for an extended period, over the course of several weeks. A continuous infusion would not take place if the patient received antibiotics only 3 times daily. A peripheral catheter would not be necessary or heparin locked. An implanted port catheter is intended for long-term use of venous access over months, or even years.

Which of the following is the most reliable way to monitor a patient's fluid status? A. I&O B. Skin turgor C. Daily weights D. Lung sounds

C. Daily weights Daily weights are the best way to monitor fluid imbalances. They are easier to monitor more accurately than intake and output.

Which of the following defining characteristics is consistent with fluid volume deficit? A. A 1-lb (0.5 kg) weight loss, pale yellow urine B. Engorged neck veins when upright, bradycardia C. Dry mucous membranes, thready pulse, tachycardia D. Bounding radial pulse, fl at neck veins when supine

C. Dry mucous membranes, thready pulse, tachycardia The nursing diagnosis fluid volume deficit includes extracellular fluid volume (ECV) deficit, hypernatremia, and clinical dehydration. ECV deficit is characterized by dry mucous membranes, thready pulse, and tachycardia, among other indicators. Weight loss of 1 lb (0.5 kg) in 1 week could indicate fat loss instead of fluid loss. ECV deficit causes dark yellow urine rather than pale yellow, which is normal.

A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 55 mm Hg, and HCO3 of 20 mEq/L. The physician has been notified. Which is the priority nursing intervention for this patient? A. Check the color of the patient's urine output B. Place the patient in Trendelenburg position C. Encourage the patient to increase respirations D. Place the patient in high Fowler's position

C. Encourage the patient to increase respirations The patient has respiratory acidosis from CO2 retention. Increasing rate and depth of respiration will allow the patient to blow off excess carbon dioxide, and this will begin to correct the imbalance. Checking the urine color is not a necessary assessment. The Trendelenburg position likely would make it more difficult for the patient to breathe and should be avoided. Placing the patient in high Fowler's position may make the patient more comfortable, but it is not necessary.

A patient was admitted for hypovolemia and has intravenous fluid running at 250 mL/hr. The patient complains of burning at the IV insertion site. Upon assessment, the nurse does not find redness, swelling, heat, or coolness. The nurse suspects that the: A. IV has infiltrated B. IV has caused phlebitis C. Fluid is infusing too quickly D. Patient is allergic to the fluid

C. Fluid is infusing too quickly The infusion may be flowing faster than the vein can handle, causing discomfort. The nurse should slow down the infusion. Infiltration results in skin that is blanched, cool, and edematous around the IV insertion site. Pain, warmth, erythema, and a palpable venous cord are all symptoms of phlebitis. Allergic response to the fluid could involve a combination of itching, flushing, hypotension, and dyspnea, depending on the severity.

A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. The nurse recognizes that the patient is experiencing which transfusion complication? A. Anaphylactic shock B. Septicemia C. Fluid volume overload D. Hemolytic reaction

C. Fluid volume overload The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.

A positive Chvostek's sign and a positive Trousseau's sign are classic signs of hypocalcemia and of what other electrolyte imbalance? A. Hypermagnesemia B. Hyponatremia C. Hypomagnesemia D. Hypokalemia

C. Hypomagnesemia

Which laboratory value should the nurse examine when evaluating uncompensated respiratory alkalosis? A. PaO2 B. Anion gap C. PaCO2 D. HCO3

C. PaCO2 Uncompensated respiratory imbalances are seen in the PaCO2 levels. PaCO2 indicates oxygen status. Anion gap is used for metabolic acidosis. HCO3 is used to evaluate compensation for respiratory imbalances or uncompensated metabolic imbalances.

The nurse is admitting a new client, 80 years old, with congestive heart failure into your home health agency. The following assessment findings have been determined after meeting the client: overweight but no gain since the client left the hospital two days ago; VS: T 99.0, HR 100, R 22, BP 130/86. Foods eaten include canned soup at each meal, ham, and cheese. When completing the care plan for this client, the nurse should include which of the following nursing diagnosis: A. Improved Gas Exchange B. Risk for Fluid Volume Deficit C. Risk for Fluid Volume Imbalance D. Impaired Skin Integrity

C. Risk for Fluid Volume Imbalance Sodium is found in high quantities in the foods noted that the client has consumed. When sodium levels increase in the body, water is retained, adding to the volume of fluid in circulation, making it harder for the body to move fluids through the circulation. Therefore, the excess fluid may in time impair gas exchange if levels eventually act on the lungs; fluid volume is increasing, not decreasing, in this situation, and this problem has no involvement with platelets.

Which assessment finding would the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? A. Lightheadedness when standing up B. Weak quadriceps muscles C. Tingling of the extremities and tetany D. Decreased deep tendon reflexes

C. Tingling of the extremities and tetany This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Hypocalcemia causes muscle tetany, positive Trousseau's sign, and tingling of the extremities. Lightheadedness when standing up is a manifestation of ECV deficit or sometimes hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep tendon reflexes are related to hypercalcemia or hypermagnesemia.

A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? A. "Are you having difficulty sleeping at night?" B. "How many calories a day do you consume?" C. "Do you have dry mouth or feel thirsty?" D. "How many times a day do you urinate?"

D. "How many times a day do you urinate?" A rapid gain in weight usually indicates ECV excess if the person began with normal ECV. Asking the patient about urination habits will illuminate whether the body is trying to excrete the excess fluid, or if renal dysfunction is contributing to ECV excess. Difficulty sleeping at night can occur if the body builds up excessive fluid in the lungs; however, it could also mean that the patient is getting up frequently to urinate, so the question is not specific enough. Caloric intake does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.

A nurse has just received a bag of packed red blood cells. The nurse knows that the blood must not remain at room temperature for longer than: A. 30 minutes B. 1 hour C. 2 hours D. 4 hours

D. 4 hours Blood should be allowed to sit at room temperature for a maximum of 4 hours. After 4 hours, risk of bacterial contamination of the blood is increased.

The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has: A. Two-way valves to allow the patient's blood to mix and warm the blood transfusing B. An injection port to mix additional electrolytes into the blood C. An air vent to let bubbles in the blood escape D. A filter to ensure that clots do not enter the patient

D. A filter to ensure that clots do not enter the patient All blood transfusions must have a filter to prevent microemboli from being administered to the patient. The patient's blood should not be aspirated to mix with the infusion blood. The blood should not have air bubbles to vent; if a bag of blood does have bubbles, the nurse should promptly return the blood to the blood bank. The only substance compatible with blood is normal saline; no additives should be mixed with the infusing blood.

Which patient is most at risk for sensible water loss? A. A 7 year old child with asthma B. A 24 year old adult with constipation C. A 56 year old patient with gastroenteritis D. An 80 year old patient with pneumonia

D. An 80 year old patient with pneumonia Sensible water loss consists of fluids lost from the skin through visible perspiration, such as with a resolving fever related to pneumonia. Asthma would be insensible water loss through respiration. Gastroenteritis causes diarrhea with its large volume loss. Constipation does not affect fluid loss.

Which patient is most at risk for fluid excess? A. An infant with pneumonia B. A teen with multiple injuries following and automobile accident. C. A middle-aged man who has just had surgery D. An elderly patient receiving IV therapy

D. An elderly patient receiving IV therapy The elderly have reduced kidney function and may not be able to handle excess fluids.

The nurse has been invited to discuss "the importance of promoting a good fluid and electrolyte balance in children" for a group of parents at the local school parents club meeting. Of the following actions, which is not representative of this topic? A. Recognizing possible risk factors for fluid and electrolyte balance, such as prolonged or repeated vomiting, frequent watery stools, or inability to consume fluids B. Increasing fluid intake before, during, and after strenuous exercise, particularly when the environmental temperature is high, and replacing lost electrolytes from excessive perspiration as needed with commercial electrolyte solutions C. Consuming six to eight glasses of water daily D. Encouraging excessive amounts of foods or fluids high in salt or caffeine

D. Encouraging excessive amounts of foods or fluids high in salt or caffeine Salt causes the body to retain fluids due to an increase in the concentration of sodium and the release of ADH. Caffeine acts as a diuretic in individuals and may lead to loss of excess fluids in the body. The remaining identified measures are all appropriate.

Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.2 mEq/L? A. Lungs B. Kidneys C. Liver D. Heart

D. Heart

A patient is being treated for hypokalemia. When evaluating his response to potassium replacement therapy, which of the following changes in his assessment should the nurse observe for? A. Improving visual acuity B. Worsening constipation C. Decreasing serum glucose D. Increasing muscle strength

D. Increasing muscle strength Hypokalemia is associated with muscle weakness.

The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid? A. Flat neck veins B. Tachycardia C. Hypotension D. Oliguria

D. Oliguria Administration of KCl (increased K+ intake) to a person who has oliguria (decreased K+ output) can cause hyperkalemia.

Which assessment finding should cause a nurse to question administering a sodium-containing isotonic intravenous fluid? A. Blood pressure 102/58 B. Dry mucous membranes C. Poor skin turgor D. Pitting edema

D. Pitting edema Pitting edema indicates that the patient may be retaining excess extracellular fluid, and the nurse should question the type of solution meant to rehydrate the patient. All other options are consistent with ECV deficit, and the patient would benefit from a sodium-containing isotonic solution that expands extracellular volume.

A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first? A. Serum albumin B. Serum sodium C. Hematocrit D. Serum potassium

D. Serum potassium Potassium-wasting diuretics such as furosemide increase potassium urinary output and can cause hypokalemia unless potassium intake also increases. Hypokalemia causes muscle weakness.

A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patient's peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? A. Notify the physician B. Administer pain medication C. Discontinue the IV D. Start a new IV line

D. Start a new IV line The IV site has phlebitis. The nurse should start a new IV before discontinuing the old one because it is important to always have an IV access site in a patient who is in hypertensive crisis. Then the physician can be notified. Pain medication may or may not need to be administered.

The results of an arterial blood gas are as follows: pH: 7.5, PaCO2: 50, PaO2: 88, HCO3: 28; Base excess: +5. Evaluate the acid-base imbalance.

Metabolic alkalosis with a respiratory compensation Arterial blood gases are performed to evaluate the client's acid-base balance and oxygenation. pH is the measure of relative acidity or alkalinity. PaCO2: is the partial pressure of carbon dioxide in arterial plasma. PaO2 is the pressure exerted by oxygen dissolved in the plasma, HCO3: is the measure of the metabolic component of acid-base balance. Base excess is a calculated value of bicarbonate levels.

The most reliable indicator of fluid loss or gain is body __________.

Weight

A client taking lasix (furosemide) for congestive heart failure is seeing the physician for a potassium value of 3.0. An order for oral potassium taken daily is written and discussed with the client. In addition, potassium-rich foods should be eaten. The nurse educator meets with this client and has the client identify all of the following foods as potassium-rich except: A. Baked potato B. White bread C. Apricot D. Orange juice

White bread White bread is known to help meet fiber needs for the body. Potassium is found in many fruits, vegetables, meat, and fish.