Fluid & electrolytes

Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia?

0.9% NaCl (normal saline) • Lactated Ringer's solution • 5% dextrose in 0.9% 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 healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?

3,000 Rationale: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

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

What is the lab test commonly used in the assessment and treatment of acid-base balance?

ABG

The nurse working at the blood bank is speaking with a potential blood donor client. The client has been living in South America where there was a Zika outbreak. Which statement by the nurse is most appropriate?

Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions.\

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV?

Change the site every 3-4days

Which is a common anion?

Chloride a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions

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.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?

Ensure that the prescribed solution is clear and transparent.

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 2500 ml/day of fluid

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 client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

Start an IV of normal saline as prescribed

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply.

The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client (it will decrease what is given because it will increase fluid volume) A symptom of fluid overload is distended neck veins. Fluid overload is more likely in very young children. The infusion rate must be carefully monitored during the administration of blood.

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

Total parenteral nutrition

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 Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive acute kidney failure. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

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 Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration

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

fluid in the tissue space between and around cells

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 explanation: diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. signs of potassium defecit, or hypokalemia, include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias.

A decrease in arterial blood pressure will result in the release of:

renin. explanation: decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

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?

Apply a warm compress. Explanation: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

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

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:

Winged infusion needles are short, beveled needles with plastic flaps or wings. They may be used for short-term therapy or when therapy is given to a child or infant.

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.\\\" Explanation: Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be re-infused.

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 not a man age 50 years rationale: an infant has considerably more total-body fluid and extracellular fluid (ecf) than does an adult. because ecf is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits.

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

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

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

Decreased potassium levels Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell. *osmotic pressure of cell = 250-375 mOsm/L*

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the side rail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which is the appropriate action for the nurse?

Remove the IV catheter and reinsert another in a different location. Explanation: An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

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?

implanted central venous access device (cvad) explanation: implanted cvads are ideal for long-term uses such as chemotherapy. the short-term nature of peripheral ivs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy. because of the caustic nature of most chemotherapy agents, peripheral iv's are not appropriate

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?

maintenance of cell size The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.

The nurse is providing care for several clients on a busy floor. The nurse receives a prescription to administer a transfusion of packed red blood cells for a client with decreased hemoglobin. Which action should the nurse take before entering the client's room to begin the transfusion?

Arrange for another nurse to monitor the nurse's other assigned clients. :Before administering a blood transfusion, the nurse should arrange for another nurse to monitor the nurse's other assigned clients for at least 15 minutes, because the nurse will need to remain with the client receiving the transfusion during this time to monitor for transfusion reaction. Verifying the client's name and date of birth with another nurse is important to avoid error and should happen at the bedside in the presence of the client medical record, client identification band, and the label of the blood product, not prior to entering the room. It is important for the nurse to obtain the client's vital signs immediately prior to starting the transfusion to obtain a baseline. Reviewing a prior assessment is not adequate. Changes in vital signs may indicate a transfusion reaction. The nurse will prime the blood administration set with normal saline solution only to prevent clumping of red blood cells and hemolysis.

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

Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

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 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.

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 needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility.

A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply.

crackles in the lungs distended neck veins Right-sided heart failure leads to a back up of volume which is unable to effectively flow back to the left side of the heart. The result is fluid volume excess in the peripheral circulation which eventually leads to fluid overload. Fluid excess or hypervolemia will manifest in clinical symptoms that lead the nurse to hear crackles in the lungs upon chest auscultation. Fluid volume excess leads to translocation of large volumes of intravascular fluid to the interstitial compartment or to areas with only potential spaces such as the peritoneal cavity, pericardium, and pleural space such as in the lungs. Circulatory overload from fluid volume excess will lead to the client having distended neck veins. Fluid volume deficit causes a low blood pressure whereas a volume excess would result in the client becoming hypertensive. Poor skin turgor is often seen in clients with fluid volume deficits or in dehydration. A client with a fluid volume excess would more likely have edema. A client who is hypovolemic is retaining fluid in the intravascular space preventing urinary elimination from occurring. Urinary retention rather than excessive elimination would be seen in this case

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