fluid PrepU

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? As fast as the client can tolerate 1 unit over 2 to 3 hours, no longer than 4 hours 75 mL/hr for the first 15 minutes, then 200 mL/hr 200 mL/hr

1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

A client with renal disease requires IV fluids. It is important for the nurse to: catch the rate up when it falls behind. place the fluids on an electronic device. check the intravenous rate once a shift. administer the fluids through the dialysis access.

place the fluids on an electronic device. Explanation: An IV electronic infusion device usefully and accurately regulates the infusion rate, especially if fluid administration must be watched very carefully, such as when infusing fluid to a renal client or when administering certain medications.

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? "Unfortunately, your own blood cannot be reinfused during surgery." "Let me refer you to the blood bank so they can provide you with information." "This surgery has a very low chance of hemorrhage, so you will not need blood." "We now have artificial blood products, so giving your own blood is not necessary."

"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 reinfused.

What signs of complications and their probable causes may occur when administering an IV solution to a client? Select all that apply. -Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. -Redness, swelling, heat, and pain at the site may indicate phlebitis. -Local or systemic manifestations may indicate an infection is present at the site. -A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when an air embolus is present. -Bleeding at the site when the IV is discontinued indicates an infection is present. -Engorged neck veins, increased blood pressure, and dyspnea occur when a thrombus is present.

-Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. -Redness, swelling, heat, and pain at the site may indicate phlebitis. -Local or systemic manifestations may indicate an infection is present at the site. Explanation: If the IV catheter has become dislodged and IV fluid is flowing into the tissues, then infiltration has occurred. Infiltration is indicated with swelling, pain, coolness, or pallor at the insertion site. Redness, swelling, heat, and pain at the site may indicate phlebitis of the vein. If the site has become infected, it may be contained as a localized infection, or it can spread throughout the bloodstream as a systemic infection. A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when fluids are administered too rapidly (speed shock). Bleeding at the IV site indicates the need for additional pressure to be applied to the site. This can occur if the client is taking anticoagulants or has a bleeding disorder. Engorged neck veins, increased blood pressure, and dyspnea occur when fluid overload has occurred.

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade?

1+ Explanation: The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)? -Changing the dressing on a client's peripheral IV site -Initiating a client's transfusion of packed red blood cells -Deaccessing a client's implanted port -Removing a client's PICC in anticipation of the client's discharge

Changing the dressing on a client's peripheral IV site Explanation: Changing a peripheral IV dressing poses a lower risk to the client's safety than the other listed nursing actions and this would be the safest task to delegate. It would be inappropriate to delegate a blood transfusion, deaccess an implanted port, or remove a PICC to an LPN.

A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances? Infants Toddlers Adolescents School-age children

Infants Explanation: Infants have a far greater volume of total fluid as a percentage of body weight than other children . However, this high percentage of fluid does not give infants a greater reserve against fluid deficit. Instead, it creates a vulnerability to fluid deficit due to the high percentage of fluid required for homeostasis. In addition, kidney immaturity and increased body surface area in relation to body size place infants at greater risk than older children or adults for fluid and electrolyte imbalances.

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Ask the client every hour to drink more fluid. Offer small amounts of preferred beverage frequently. Have a loved one tell the client to drink more. Leave water on the bedside table.

Offer small amounts of preferred beverage frequently. Explanation: Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

A nurse is presenting an in-service program to a group of graduate nurses about blood component therapy. The nurse determines that the education was successful when the group identifies which complication as the primary cause of transfusion-related client death in the United States? Transfusion-associated circulatory overload Septic reaction Hemolytic reaction Transfusion-related acute lung injury

Transfusion-related acute lung injury Explanation: Although transfusion-associated circulatory overload (TACO), septic reaction, and hemolytic reaction are possible complications of blood transfusion therapy, transfusion-related acute lung injury (TRALI) is the number one cause of client death related to blood transfusion in the United States.

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? platelets granulocytes albumin cryoprecipitate

platelets Explanation: Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third-spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia.

The primary extracellular electrolytes are: potassium, phosphate, and sulfate. magnesium, sulfate, and carbon. sodium, chloride, and bicarbonate. phosphorous, calcium, and phosphate.

sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.