fluid and electrolyte balance Q&A
the nurse cares for a client taking spirononlactone (Aldactone) for treatment of hypertension. the nurse instructs the client about the medication. the nurse determines that further teaching is necessary if the client states which of the following?
"I will use a salt substitute instead of iodized salt."
The nurse cares for the client with chronic kidney disease. during review of laboratory results, the nurse notes the client's serum magnesium is increased. Which is the priority question for the nurse to ask the client?
"what over-the-counter medications do you take?"-> magnesium excretion reduced in clients with chronic kidney disease; antacids and laxatives may contain high levels of magnesium and should be avoided by clients with chronic kidney disease
the client will receive a unit of whole blood within the next hour. which intravenous solution should the nurse obtain for infusion with the blood?
0.9% NaCl-> blood should always be administered with normal saline solution to prevent clumping of blood and other physiologic alterations in the blood
the nurse is to administer 1000 mL of D5W with 40 mEq of KCl at 100 mL./hour. the administer set delivers 60 drops/mL. the nurse adjust the flow rate to deliver how many drops/minutes?
100 drops/min -> in order to calculate the flow rate, multiply the mL/hour by the drop factor, and divide the results by 60 min; if the mL/hr is 100 and the drop facotr is 60, then (100 x 60)/60=100
The nurse administers D5W at 100 mL/hr. The administrations set administers 10 drops/mL. the nurse adjusts the flow rate to delieve how man drops/min?
100 mL x 10 drop divided by 60 minutes= 17 drops/minute
the health care provider orders IV total parental nutrition 1000 mL over eight hours. The drop factor is 60 drops/mL. which is the correct drip rate calculated by the nurse?
125 drops (gtts)/minute 1000mL/8 hours= 125mL 125mL/60 minutes x 60gtts/minutes / 60 minutes= 125 gtts/minutes
The nurse identifies which central venous pressure (CVP) reading indicates fluid overload?
15 mm Hg -> normal CVP reading ranges from 2-8 mmHg; CVP reading of greater than 9 indicates fluid volume overload
the nurse identifies which central venous pressure (CVP) reading indicates fluid overload?
15 mm Hg -> normal CVP reading ranges from 2-8 mmHg; CVP reading of greater than 9 indicates fluid volume overload
the client is receiving 40 drops/min of dextrose 5% in water. the IV set delivers 10 drops/mL. if the nurse starts the IV infusion at 1200 with 1000mL, how many mL will remain at 1350?
160 mL 40 gtts/min / 10 gtts/mL= xmL/min x=4 mL/min 4mL/min x 60 min= 240 mL/min 240mL/hr x 3.5 hours= 840 mL 1000mL- 840mL= 160 mL
The health care provider order furosemide 4mg/kg/day in 4 divided doses. The child weighs 45 lbs. How many milligrams will the nurse administer in one dose?
20.45 mg -> 45/2.2= 20.4545 kg 4 mg x 20.4545 kg= 81.8181 mg/day 81.8181/4 dose= 20.4545 20.45 mg/single dose
the nurse is to deliver 3,000 mL of D5W to client in 24 hours. the administration set delivers 15 drops/mL. the nurse regulates the flow rate to deliver how many drops/minute?
31 drops/minute-> to calculate drops per minute; first calculate the number of mL per hour by dividing 3,000 by 24, which gives 125 mL per hour; then multiply mL per hour by drop factor, which is 125 times 15, or 1.875; divide this by 60 minutes, for a flow rate of 31.25 or 31 drops/min
the toddler experiences burns on the back, right arm and right leg. Using the Rule of Nines, what percentage does the nurse correctly estimate the extent of the burns to be?
42.5% -> R. arm= 9%, R leg= 15.5% back= 18%
the client to receive 2000 mL of 5% dextrose in Lactated Ringer's in 24 hours. the infusion started at 0700. At 1900, 1300 mL has infused. At this time, to which IV drip rate should the nurse adjust the client's IV pump to deliver the ordered amount of fluid?
58 mL/hr -> 2000 mL- 1300 mL= 700 mL of IV fluid to be infused in 12 hours 700 mL divided by 12 hours= 58.33 mL/hr
the client spilled boiling water on the chest and arms. The nurse in the ED assesses the client. The client skin appears red. moist, and very painful to touch. Fluid filled vesicles are present. which statement best describes the depth of the burn injury?
A deep partial thickness burn is present-> deep partial thickness burns involve both the dermis and the epidermis; they are very painful due to injury or exposure of the nerve endings; mild to moderate edema is present; vesicles are present if not previously ruptured, flame, flash, scald, or contact burns often cause this depth of injury
the nurse cares for the client burned over 45% of the body. Which of the following is MOST concerning to the nurse?
A weight loss of 10% of baseline.
Two days after a sub-total thyroidectomy, the client tells the nurse, "my lips feel funny." Which assessment of the client should the nurse immediately make?
Check for Chvostek's sign -> positive Chvostek's sign indicates HYPOCALCEMIA; nurse should evaluate the client for signs of hypocalcemia because the parathyroid glands are often imbedded in the thyroid gland, and can be accidently removed or damaged during thyroid surgery; parathyroid gland is responsible for calcium metabolism; symptoms of hypocalcemia are often described as a tingling sensation or funny feeling; range for ionized calcium is 4.5- 5.4 mg/dL; calcium is required for blood clotting; skeletal muscle contraction's indications include: tetany, positive Trousseau's sign, positive Chvostek's sign, seizures, confusion, paresthesia, and irritability; causes include: hypoalbminemia, large volume IV infusions, administration of banked blood, kidney damage, pancreatitis, and fat embolism. Nursing considerations include administering oral calcium gluconate or calcium chloride with OJ to maximize absorption; if adminsitering via a parenteral route, gluconate may cause vessel irritation, so the nurse should avoid infiltration since tissue can become necrotic and slough; nurse should also take seizure precautions, maintain the airway larygneal stridor can occur, maintain safety since the client if often confused, and increase the protein intake or administration of hyperallmentation
Which is the correct nursing procedure for administering a blood transfusion?
Comparing the laboratory blood type record with the ABO group and RH type on the blood bag label.
the nurse cares for the client receiving IV therapy. Which sign and/or symptoms correctly indicate to the nurse that the client may be experiencing fluid overload?
Crackles in bases of lungs and cough
An adult male client has a hx of diabetes insipidus. the nurse identifies which imbalance is most likely to development if this medical problem recurs?
Hypernatremia -> diabetes insipidus is a disorder of water metabolism caused by a deficiency of antidiuretic hormone, or ADH; large amounts of water are lost from the body causing sodium in the body, leading to hypernatremia; sodium greater than 145 mEq/L; symptoms include excessive urine output, chronic, severe dehydration, excessive thirst, weakness; record intake and output, monitor urine specific gravity, condition of skin, vital signs, administer Pitressin
the nurse understands fatigue, weakness, and nausea and vomiting are signs of which?
Hypokalemia-> less than 3.5 mEq/L; muscle weakness, paresthesias, fatigue, and it increases sensitivity to digitalis
The nurse identifies nagoastric drainage, vomiting, diarrhea, and the nurse of diuretics likely cause which electrolyte imbalance?
Hypokalemia-> nasogastric drainage, vomiting, diarrhea, and the use of diuretics all involve the loss of extracellular fluid, which contains potassium
The nurse notices flattened T waves on the ECG of the client diagnosed with acute kidney injury. Based on this finding, the nurse should check the laboratory values for which electrolyte imbalance
Hypokalemia-> potassium levels are 3.5 to 5.0
the nurse cares for a client receiving a blood transfusion. the nurse observes which symptoms if fluid overload occurs during the transfusion?
Increased pulse rate, increased BP, increased respirations-> if blood transfusion is run rapidly and fluid overload occurs, signs of heart failure will be seen, including increased respirations, increased pulse rate, and increased blood pressure
the nurse knows that medication is best absorbed by a client with a major burn injury via which route?
Intravenously-> fluid shift during emergent post-burn phase causes limited absorption from subcutaneous and intramuscular spaces; administer medication prior to painful procedures; keep environment warm to prevent shivering
the nurse prepares to administer a RBC transfusion to the client with blood type B neg. The nurse verifies the blood type on the transfusion bag. which blood type is compatible for this client?
O negative.
which implementation is the best way for the nurse to maintain an adequate fluid intake for a toddler with nausea, vomiting, and diarrhea?
Offer oral rehydration solutions (ORS) to rehydrate.
the nurse cares for the client diagnosed with diarrhea. Which assessment would alert the nurse to dehydration?
One voiding eight hours ago.-> decrease in urine output stems from a decreased extracellular fluid volume available to the kidneys
the nurse evaluates a client's fluid balance. which finding most likely requires an intervention?
Output is 800 mL less than intake -> intake and output should be within 200 to 300 mL of each other. if client's output is 800 mL less than intake, indicates client retaining fluid, which requires intervention
a central venous pressure line is inserted in a client. following the catheter, the client reports dyspnea, shortness of breathe, and chest pain. the nurse understands the most probable cause of these symptoms if which?
Pneumothorax-> pneumothorax is a potential complication of the of the insertion of any central venous pressure line, especially a subclavian line; because of the proximity of the central veins and the lung cavity, pneumothorax can occur due to perforations of the pleura by the catheter; pneumothorax is collapse of a lung due to air in pleural space; symptoms include pain and respiratory distress
the client has a NG tube connected to intermittent suction. Which blood test results are of most concern to the nurse?
Potassium 2.9 mEq/L-> serum level is 3.5- 5.0 mEq/L; it is likely low due to removal of gastric secretions by the NG tube
the nurse is assigned to transfuse one unit of packed RBC to a client. prior to beginning the transfusion, the nurse has to leave the unit to attend an important administrative meeting. Which staff person is most appropriate for the nurse to delegate this assignment?
RN
a client receives magnesium sulfate IV for treatment of preeclampsia. the nurse knows that it is most important to have what at the bedside?
Reflex hammer and calcium gluconate. -> magnesium has central nervous system depressant effects; reflex hammer needed for monitoring deep tendon reflexes, the lessening or loss of which hypermangesemia; IV calcium gluconate can block the effects of hypermagnesemia; also, kidney excretion of magnesium can be increased with saline infusions having a diuretic effect, by calcium loss is a side effect and hypocalcemia can intensity hypermagnesemia; coagulation is not generally an issue with hypermanesemia
The nurse cares for the client diagnosed with heart failure. The client has an IV fusion ordered at 125 mL/hr. The nurse assesses that the client has dyspnea, coughs more frequently, and has rhonchi in both lungs. Which is the most initial action for the nurse to take?
Slow the IV to a keep open rate. -> client has signs of fluid overload; IV drip rate is appropriate for a healthy adult, but is high for someone with congestive heart failure; nurse should first slow down IV, then notify the health care provider; congestive heart failure is the failure of the heart to pump enough blood to meet metabolic (oxygen and nutrient) demands of tissues; left and right ventricles can fail separately; left-sided failure indications are: dyspnea, orthopnea, cough, crackles, tachycardia, fatigue, anxiety, restlessness, confusion; treatment includes: O2, digoxin, diuretics, vasodilators, potassium supplements, low sodium diet, and bedrest; nursing responsibilities include: promoting physical and emotional rest, high Fowler's position, assessing vitals, lung sounds, intake and outtake, good sin care, and client education.
The nurse cares for the client diagnosed with hypotonic dehydration. Which laboratory study should the nurse monitor in the client?
Sodium level-> hypotonic dehydration results in loss of electrolytes in excess of body fluid and results in hyponatremia
The 3 year-old child is brought to the emergency room with a hx of vomiting and diarrhea for the past 3 days. Which finding is the nurse most likely see?
Sunken eyes
which information is essential for the nurse to gather before administering IV potassium supplement to an elderly client?
The client's urine output. -> usually, potassium supplementation is contraindicated in clients with impaired kidney function; electrolyte solution used for replacement in treatment of hypokalemia is secondary to diuretic or steroid therapy or when there has been severe vomiting, diarrhea, other fluid drainage, or malabsorption; side effects: N/V, diarrhea, abdominal pain, confusion, paresthesias, muscle weakness, flaccid paralysis, oliguria, respiratory distress, dyshythmias, cardiac arrest; nursing considerations: monitor intake and output ECG, and serum electrolytes; teach about avoiding potassium sources in foods, including salt substitutes, llcorice, and in OTC drugs
the nurse knows which client is most likely to manifest likely to manifest symptoms of fluid volume deficit?
a client diagnosed with addison's disease-> addison's disease is an adrenal disorder stemming from hyposecretion of hormones from the adrenal gland; symptoms include fatigue, weakness, dehydration, emaciation, weight loss, fluid and electrolyte imbalance, hypotension; while not caused by fluid volume deficit, these symptoms are reflective of it; volume depletion issues are of concern in Addisonian crisis; overall treatment for Addison's includes hormone replacement
the client asks the nurse, "What does it mean if someone is a universal blood donor?" which is the best explanation the nurse can give the client?
a universal blood donor has type O blood, which is compatible with all blood types. this means the person can give blood to anyone.
the nurse instructs the nursing assistive personnel to distribute water pitchers to the client. The unit is very busy and the NAP asks for assistance in deciding which clients should have water pitchers first. what should be considered as a priority to determine the need for water pitches?
age of the client-> to avoid dehydration
which OTC medication decreases hyperphosphatemia in clients diagnosed with chronic kidney disease?
amphogel
the nurse cares for a client diagnosed with a fractured right hip. the client's lab values are: Hgb 15, Hct 46%, sodium 140 mEq/L, potassium 6.2 mEq/L, and chloride 100 mEq/L. the nurse is most concerned if which is observed?
an episode of ventricular fibrillation-> normal potassium is 3.5-5.0; severe hyperkalemia may cause ventricular fibrillation, which is life-threatening and must be treated immediately; think ABCs
the nurse cares for the client diagnosed with dehydration. the client has a past medical history of a stroke. the nurse needs to evaluate the therapeutic effect of fluid replacement. which action by the nurse is priority?
assess for increased mental alertness.
the nurse cares for several client on a busy unit. Which is the appropriate action for the nurse to take first?
begin a blood transfusion for the client diagnosed with anemia.
the nurse cares for the client who has severe decrease in serum albumin levels. which finding would the nurse expect to observe during assessment of the client?
bilateral pretibial edema-> albumin is protein that has strong osmotic effect; prevents plasma from leaking into interstitial fluid; interstitial edema and movement of fluids into "third space" will occur, hypoalbuminemia seen with kidney disease and cirrhosis
the nurse notices that an intravenous infusion is not running. which acton should the nurse take initially?
check the site-> when an intravenous infusion stops running, infiltration is common cause; by checking the site, the nurse can ascertain whether the infusion has inflitrated; if no infiltration present, then the nurse can reposition arm or raise solution; symptoms of infiltration include edema, pain, coolness of site, decrease in flow rate; if IV infiltrated, discontinue and start a new IV, apply warm compress to infiltrated site, apply sterile dressing, and elevate arm
following the transfusion of one unit of packed red blood cells, the nurse prepares to administer another unit. which action is most appropriate for the nurse to take initially?
check the type and cross-match with another nurse. -> prior to giving blood, two RNs must check the health care provider's order, client's identity, hospital ID band name and number, blood component tag and number, blood type and Rh, and the expiration date
which s/s does the nurse correctly identify as pyrogenic reaction to IV therapy?
chills, fever, and general malaise
which client has the highest risk for sudden changes in homeostasis?
client with vital signs taken every hour admitted after a motor vehicle accident earlier today-> high risk for sudden changes is indicated by vital signs being ordered on an hourly basis; establishing priorities enables the nurse to attend to the client's most important needs and helps the nurse organize care; situations that could cause physical harm to the client if left untreated have the highest priority; using Maslow's hierarchy of needs enables the nurse to establist priorities
the nurse cares for a client during the shock phase after suffering a full thickness burn injury. the nurse understands which finding is expected during this phase?
decreased urine output. -> due to fluid shift emergent phases, urine output is decreased and urine is concentrated and has a high specific gravity; accurate intake and output is measured and is one of the parameters used to determine the amount of IV fluids; output should be maintained at 30-50mL/hour
a nurse assesses a client who has sustained a burn injury. the burn area is blistered and painful. which classification best describes the burned area?
deep partial thickness. -> red in color, moderate edema present, painful, blisters present, no eschar
the nurse cares for an elderly client diagnosed with a fractured right wrist and confusion. the client fell in the home and was not found for 2 days. which is the most likely cause of the client's confusion?
dehydration
the nurse notes the client is confused, has poor skin turgor, dry mucus membranes, sunken eyeballs, and scanty amber urine. which condition do these signs and/or symptoms suggest the client has?
dehydration-> indications of dehydration include: rapid weak pulse, rapid respiration, hypotension, weight loss, emaciation, dry mucous membranes, increased hematocrit, increased urine specific gravity; nursing care includes: force fluids, provide isotonic IV fluids; monitor intake and output hourly, monitor daily weights, vitals, assess skin turgor and urine specifc gravity.
the nurse performs the morning assessment of the client, and determines that the IV in the client's right arm is infiltrated. which intervention should the nurse perform first?
discontinue the infusion and elevate the affected extremity.
The instructor teaches nursing students about burns. Which explanation best describes the Rule of Nines as applied to burns?
each arm constitutes 9% of body surface area
the instructor teaches nursing students about burns. which explanation best describes the rule of nines as applied to burns?
each arm constitutes 9% of body surface area
the nurse identifies which sign or symptom as an early indication of fluid volume excess?
edema-> edema, the collection of fluid in tissues, is often seen as an early sign of fluid volume overload; other symptoms include increased bounding pulse, elevated BP, dyspnea, crackles
The client diagnosed with ulcerative colitis has 20 liquid stools per day. the stools contain blood and mucous. Due to the characteristics of the stool, which diagnostic study should the nurse frequently monitor to prevent complications?
electrolytes-> client will need electrolyte replacement, IV fluids, and will be kept NPO
the nurse cares for the client that expresses apprehension about the diagnosis of terminal lung cancer. Then nurse notes the client's blood pressure is 140/88, pulse 92 bpm, and respirations 36. the client's blood gas values are pH 7.52, PaCO2 30, and HCO3 24. which action should the nurse take first?
encourage the client to breathe into a paper bag.
the client diagnosed with burns on the face and upper arms prepares for discharge. the nurse wants to help ease the client's adjustment back into the community. which of the nurse's actions would be most helpful?
encourage the client to walk in the hall with family members.
a family member brings a client to the ED. the client has third degree burns to the head, neck, chest and right upper extremity. which nursing intervention is the priority?
establish and maintain a patent airway
The instructor teaches nursing students about fluid balance. Which explanation best describes the phenomena known as "third spacing"?
fluid moves from the vasculature to interstitial spaces.
The nurse cares for a client who was critically burned 12 hours ago. the client has edema, hypotension, tachycardia, and an increased hematocrit. to which reason does the nurse attribute these symptoms?
fluid shifts
the client has burns over approximately 40% total body surface area (TBSA). which clinical findings suggest that the client is in the shock phase?
generalized body edema, tachycardia, dehydration
the nurse determines a client has a deep partial thickness burn injury of the back. Which is the best initial nursing action?
gently clean and then leave the area alone. -> for a deep partial thickness burn, gently clean away debris and dirt; blisters form a protective cover, so leave intact, without applying a sterile gauze
the nurse cares for a client receiving a blood transfusion. the nurse is most concerned if which is observed?
hematuria occurs-> hematuria indicates hemolytic reaction due to ABO incompatibility; other symptoms include nausea, vomiting, hypotension, increase in pulse rate, decreased urinary output; stop transfusion; supportive, oxygen, diphenhydramine, airway management
after having a total knee replacement, the client is anemic and receives a blood transfusion. Ten minutes after the transfusion starts, the client reports chills, chest tightness, low back pain, and nausea. Which condition do these symptoms suggest to the nurse the client is experiencing?
hemolytic transfusion reaction
an adult male client has a history of diabetes insipidus. the nurse identifies which imbalance is most likely to develop if this medical problem occurs?
hypernatremia.
2 days after a total thyroidectomy, the client reports painful spasms of the hands. the client says, "my muscles tingle and twitch." the nurse identifies that the client has developed which electrolyte imbalance?
hypocalcemia
the emergency department nurse knows that which is the most frequent underlying cause of tetany?
hypocalcemia. -> hypocalcemia is the most common underlying cause of tetany, which is a condition with convulsions, cramps, muscle twitching, sharp flexion of the ankle and wrist joints; possible respiratory stridor, calcium-related tetany is treated with IV calcium or calcium gluconate; if need to dilute calcium, use D5W, not saline, because saline promotes calcium loss, basic hypocalcemia is treated with calcium supplementation (with vitamine D to increase absorption) and dietary measures
the nurse identifies NG drainage, vomiting, diarrhea, and the use of diuretics likely cause which electrolyte imbalance?
hypokalemia
the nurse identifies NG drainage, vomiting, diarrhea, and the use of diuretics liekly cause with electrolyte imbalance?
hypokalemia-> NG drainage, vomiting, diarrhea, and the use of diuretics all in involve the loss of extracellular fluid, which contains potassium
48 hours after the client's burn injury, the nurse notes large amounts of edema in all burned areas. The nurse monitors the client for signs and symptoms of hypovolemic shock. which is a factor that contributes to the development of hypovolemic shock in the burn client?
increased capillary permeability.
the nurse admits a client diagnosed with hypoparathyroidism. which action should the nurse take to ensure the safety of the client?
instituting seizure precautions
which IV solution does the nurse use before and after administration of a blood transfusion?
isotonic saline
the nurse identifies which group of symptoms is indicative of a hemolytic transfusion reaction?
kidney pain, hematuria, cyanosis-> characteristic of a hemolytic reaction in which hemolysis or destruction or destruction of blood cells occurs; leads to hematuria, cyanosis, and kidney pain
the nurse instructs a client with a full thickness burn injury of the legs about an appropriate diet. the nurse determines teaching is successful is the client selects which menu?
meat and orange juice-> includes both meat, which is an excellent source of protein and orange juice, which is an excellent source of vitamin C; protein is necessary to offset the catabolism caused by the burn and to promote healing; vitamin C also promotes wound healing
Which assessment is necessary for the nurse to make prior to administering an IV medication?
observe for redness or swelling at the IV insertion site-> redness indicates phlebitis; swelling indicates an infiltration, either of which would mean the nurse should not administer the medication; presence of absence of a blood return in the catheter is not necessarily a part of site assessment, nor does it always mean an infiltrate is present; infiltration occurs when the needle moves out of the vein or leaks into the adjoining tissue
the client diagnosed with fluid volume deficit related to nausea and vomiting resumes oral intake. which nursing action has the highest priority?
offering 20-30 mL of ginger ale or water every 30 minutes-> when oral intake resumes, clear liquids such as ginger ale or water should be given in small amounts; if the client tolerates this, the amounts can be increased by progressing to a clear liquid diet of jello, tea, and broth
when measuring the central venous pressure, it is most important for the nurse to take which action?
place the manometer at level of the right atrium. -> by placing the level of the manometer at the right atrium, the pressure in the right atrium; if the manometer is higher or lower, the reading will be inaccurate; client should lie flat and breathe normally; reading should be taken at the highest level of fluctuation seen during respiration
the nurse assesses an elderly client diagnosed with dehydration. a liter of D5NS infusions IV at 100 ml/hour. the nurse notes that the client is having difficulty breathing. the blood pressure is 140/92. earlier it was 132/96. based on the analysis and plan, which action by the nurse should be taken initially?
reduce the IV fluids to 75 mL/hour
the nurse cares for an older client admitted to the hospital for persistent vomiting and abdominal pain. a nasograstic (NG) tube is inserted and connected to suction, and an intravenous infusion of 1,000 mL of D5W with 20 mEq of potassium chloride is started to infuse at 100 mL per hour. the nurse understands potassium chloride has been added to the infusion for which reason?
replaces the potassium lost in the gastric fluid. -> clients with NG tubes connected to NG suction lose a large amount of fluids are electrolytes; replacing potassium via an IV will prevent hypokalemia from occurring; symptoms of hypokalemia (less than 3.5 mEq/L) include muscle weakness, paresthesias, and dysrhythmias, and it increases sensitivity to digitalis; IV potassium irritates and can cause phlebitis; assess IV site q 2 hrs.
the nurse cares for a client with an IV infusion running at 60 mL/hr. the nurse notes that the IV is not running at the correct rate. The nurse assess the IV set-up and discovers no abnormalities or infiltration. which is the most appropriate action for the nurse to take?
reposition the client's arm
which laboratory finding should the nurse expect if a client is diagnosed with a fluid volume deficit?
specific gravity 1.034 -> specific gravity greater than 1.030 indicates fluid volume deficit; other symptoms include increased temp, rapid, weak, pulse, poor skin turgor, hypotension, dry eye sockets, dry mouth and mucous membranes; nursing considerations: force fluids, provide isotonic IV fluids, daily weights
the client with a central venous access receives parental nutrition (PN). The nurse notes the PN is infusing at a very sluggish rate despite attempts to increase the rate. WHich is the best action for the nurse to take?
stop he influsion and dlush the IV catherters
when any type of transfusion reaction occurs, which will be the nurse's first action?
stop the transfusion.-> any type of transfusion reaction can be life-threatening; the blood should be stopped immediately if a change in the client's status is noted; keep IV line open by piggybacking normal saline directly into IV line, notify health care provider, observe signs and symptoms, obtain vital signs frequently, administer emergency medications as ordered, obtain urine specimen
which of the following assessment findings in a young adult patient indicates to the nurse that there is a problem with fluid volume deficit?
tenting of the skin-> tenting of skin indicates fluid volume deficit except in the elderly; when assessing skin turgor, the nurse uses thumb and index finger to gently pinch and then lift skin on the forearm of the patient (sternum of area under clavicle may also be used); normal skin will flatten back to its original position in 1-3 seconds; skin that takes longer than that to flatten is referred to as tenting.
The nurse cares for the client diagnosed with hypokalemia. which findings does the nurse expect when assessing the client?
the EKG has a depressed ST segment and inverted T wave.
the nurse monitors a client receiving a blood transfusion. the nurse should intervene if which is observed?
the blood infuses at 10 mL/min for the first 15 minutes-> blood should run slowly at first (no faster than 5 mL/min for the first 15 min); if no reaction, regulate blood to the prescribed rate
the client receives fluid replacement because of dehydration. the nurse evaluates the effectiveness of the treatment. which signs and/or symptoms would cause the most alarm?
the client develops dyspnea, crackles, and jugular vein engorgement
the nurse assesses a client who sustained a burn injury in an apartment fire. the nurse is most concerned if which is observed?
the client has singed nasal hair-> intraoral burns are singed nasal hairs indicates potentially serious injuries; observe client for progressive hoarseness, brassy cough, drooling or exhibiting swallowing, crowing, wheezing, or stridor
the client reports dyspnea the third day after a major burn episode. The nurse notes the client has rhonchi in both lower lung fields, urine output is 125 mL, hr, and the CVp is 20 cm of water pressure. The nurse identifies which statement is the most appropriate interpretation of these data?
the client is in the remobilization phase.
the nurse cares for an adolescent diagnosed with a superficial, partial-thickness burn. which finding does the nure expect?
the client's skin is red and tender with no blisters
the nurse cares for the client diagnosed with dehydration. which finding should the nurse anticipate when assessing the client's hemoglobin and hematocrit?
the hemoglobin and hematocrit are increased.
the nurse observes a student nurse begin an IV on an elderly client. the nurse should intervene if which action is observed?
the student nurse marks the time on the IV bag with a permanent marker-> can contaminate the solution; use time taping
The client whose blood type is AB negative receives a blood transfusion of A positive. which reaction should the nurse anticipate the client will have?
there will be a severe reaction if the client receives another Rh positive transfusion.
the client diagnosed with leukemia asks, "why do I get blood transfusions of packed red blood cells, rather than whole blood?" which rational should the nurse provide?
this client requires the blood cells.
the client has a unit of blood infusing. which effect does the nurse expect when the transfusion is complete?
this client's hemoglobin and hematocrit levels will improve.
the nurse administers peripheral intravenous fluids to a child. for which purpose does the nurse utilize a volume control set?
to decrease the risk for fluid overload-> volume control sets are added to the IV tubing for infants and small children to limit the amount of fluid that could infuse in a free-flow situation; fluid volume overload is created by: an isotonic gain, an increase in the interstitial compartment, the IC compartment (such as in shock), heart failure, acute kidney injury, cirrhosis of the liver, excessive ingestion of sodium, or an IV fluid which has been infused too rapidly.
Which part(s) of the client's body should the nurse examine to assess for anasarca?
total body surface-> anasarca is massive generalized edema that develops when there is decreased kidney function and fluid lost to interstitial spaces; edema is evident throughout body surfaces; causes of accumulation of fluid in interstitial space
the nurse teaches a class on first aid at a community center. which instruction is the most appropriate initial community care for a person experiencing an electrical burn?
turn off the electrical current.
