Foundations Exam 3 Review
The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?
"Watery plasma, or serum, portion of blood."
The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply.
-100 ml from melted ice chips -serving of Jell-O -infusion of intravenous solution -cup of ice cream
Laboratory Studies for Fluid and Electrolyte Imbalances
-CBCs -Serum electrolytes -Blood Urea Nitrogen (BUN) -Creatinine levels
5% dextrose in lactated Ringer's solution?
-Supplies fluid and calories to the body. -Replaces electrolytes; shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.
What commonly used intravenous solution is hypotonic?
0.45% NaCl
A rapid gain or loss of 1 kg (2.2 lb) of body weight is about equal to the gain or loss of?
1L of fluid.
The health care provider writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?
25 150 mL x 60 minutes / 10 drop factor = 25 drops per minute
How many mL are in 1 oz?
30 mL = 1 oz
While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority?
Apply a tourniquet to the client's upper arm.
Hypocalcemia
Calcium deficit in the ECF. (Serum calcium <8.9 mg/dL) Causes: -Inadequate calcium intake -Impaired calcium absorption -Excessive calcium loss Signs and Symptoms: -Tetany -Muscle cramps -Seizures Numbness and tingling of: -Fingers -Mouth -Feet
Nursing Physical assessment for Fluid and Electrolyte Imbalances?
Check patients: -Skin -Mucous membranes -Vital signs -Neurologic assessment -Excessive thirst -Nausea -Vomiting -Diarrhea -Draining wounds
A client suffers from a genetic bleeding deficiency involving a deficit in factor VIII. Which blood product will the nurse most likely administer?
Cryoprecipitate -Cryoprecipitate may be pooled from several units of blood and administered to clients with fibrinogen deficiencies who are predisposed to bleeding problems; genetically, these clients lack Factor VIII. Platelets, albumin and whole blood do not include sufficient quantities of this clotting factor.
The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?
Discontinue the infusion and record the volume left in the blood bag.
Nursing history for Fluid and Electrolyte Imbalances?
Does the patient have: -Diabetes -CHF -Renal failure -Vomiting -Diarrhea -Draining wounds -Fistulas -Burns -Trauma -Surgery -Diuretics -Steroids -IV therapy -Parenteral nutrition
Hypercalcemia
Excess of calcium in the ECF. ( Serum calcium <8.9 mg/dL) Causes: -Cancer -Hyperparathyroidism Signs and Symptoms: -Nausea -Vomiting -Constipation -Bone pain -Excessive urination -Thirst -Confusion -Lethargy -Slurred speech
Hyperkalemia
Excessive potassium in the ECF. (Serum potassium >5 mEq/L) Results from: -Renal failure -Hypoaldosteronism Use of medications: -Potassium chloride -Heparin -Angiotensis converting enzyme inhibitors -NSAIDs -Potassium-sparing diuretics Signs and symptoms: -Skeletal muscle weakness -Paraesthesias -Paralysis -Cardiac arrest
A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?
Flush the IV with 3 mL of normal saline.
For hypernatremia, avoid foods that are?
High in sodium content: (processed cheese, lunch meats, canned soups and vegetables, salted snack foods) -Eliminate use of table salt.
For hypokalemia, increase foods with?
High potassium content: (bananas, citrus fruits, apricots, melons, broccoli, potatoes, raisins, lima beans)
0.45% NaCl?
Hypotonic Solution (½-strength normal saline) -Solution that provides Na+, Cl-, and free water. -Used as a basic fluid for maintenance needs. -Often used to treat hypernatremia (because this solution contains a small amount of Na+, it dilutes the plasma sodium while not allowing it to drop too rapidly).
Fluid imbalance etiology?
Inability to obtain or swallow fluids (debilitation, oral pain), extremes of age, vomiting, diarrhea, burns, excessive use of laxative, excessive diaphoresis, fever.
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
Lactated Ringer's solution?
Isotonic Solution Contains multiple electrolytes in about the same concentrations as found in plasma. Used in the treatment of hypovolemia, burns, and fluid lost from GI sources.
0.9% NaCl (normal saline)?
Isotonic Solution Used to treat hypovolemia, metabolic alkalosis, mild hyponatremia, hypercalcemia. Used with administration of blood transfusions.
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?
It is regulated by the renin-angiotensin-aldosterone system.
A nurse is caring for a client who has recently suffered burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this client?
Lactated Ringer's
Which finding best indicates to the nurse that the client has a therapeutic outcome from a recent blood transfusion?
No signs of chills, fever, or shortness of breath
A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?
Offer the client sugar-free candy to help combat thirst.
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
Nursing Daily Weights for Fluids and Electrolyte Imbalances
Record daily, its an important gauge of fluid balance. -Acute weight loss or gain represents fluid gain or loss. -Weigh at the same time every day.
A low urine volume and low specific gravity indicates?
Renal disease/failure.
Fluid overload etiology?
Renal failure, decreased cardiac output, excessive IV infusion/fluid intake, excessive sodium intake.
Hypertonic Solutions?
Solutions that cause cells to shrink or shrivel due to loss of water. -Hypertonic to plasma. Types: -5% dextrose in lactated Ringer's solution. -5% dextrose in 0.9% NaCl
Hypernatremia
Surplus of sodium in the ECF. (Serum sodium >235 mEq/L) caused by excess water loss or an overall excess of sodium. Causes leading to excess sodium: -Fluid deprivation -Lack of fluid consumption (such as patients who cannot perceive, respond to, or communicate thirst) -Diarrhea -Excessive insensible water loss (hyperventilation, burns) Rapid or excessive administration of sodium-containing IV solutions can lead to hypernatremia. Signs and symptoms affecting the CNS Brain: -Neurologic impairment -Restlessness -Agitation -weakness -Disorientation -Delusions -Hallucinations -Seizures -Brain damage
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?
The renal system retains more water.
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?
Tighten the roller clamp to stop the infusion.
Isotonic Solutions?
Total osmolality close to that of the ECF; replace the ECF. -0.9% NaCl (normal saline) -Lactated Ringer's solution
What accurately describes the process of osmosis?
Water moves from an area of lower solute concentration to an area of higher solute
Hypotonic Solutions?
Water moves into the cell. Hypotonic to plasma; replace ICF. -0.45% NaCl (½-strength normal saline)
Nursing Fluid Intake and Output
When monitoring alert: -Patient -Family -All caregivers They must: Measure all fluids entering and leaving the body. Measurable Intake: -Ice cream -Gelatin -Juices -Parenteral fluids -GI tube feedings & flushes -IV flushes Measurable output: -Urine -Vomit -Diarrhea -Drainage from fistulas -Wound drainage -Ulcer drainage -Suctioning device drainage -Soaked clothing or bed linens from perspiration -Hyperventilation water vapor loss as rate and depth
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
Rapid variations in weight closely reflect?
changes in body fluid volume.
Hypovolemia causes?
decreased renal perfusion and oliguria.
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?
every 72 hours
A low urine volume and high specific gravity indicates?
fluid volume deficit.
A sustained decrease in systolic blood pressure or a decrease in diastolic blood pressure (hypotension) may indicate?
fluid volume deficit.
The absence of tearing and salivation in a child is a sign of
fluid volume deficit.
When the total intake is less than the total output, the patient is in danger of?
fluid volume deficit.
A high urine volume suggests?
fluid volume excess.
Moist crackles may indicate?
fluid volume excess.
When the total intake is more than the total output, the patient is in danger of?
fluid volume excess.
The process of filtration begins at the?
glomerulus
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?
hemolytic transfusion reaction: incompatibility of blood product
A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed?
hypertonic
The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing?
hypertonic
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?
hypertonic
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect?
hypocalcemia
A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance?
hypokalemia
During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?
hypovolemia
The nurse is caring for an 86-year-old client who fell at home and was not found for 2 days. The client is severely dehydrated. The client is at increased risk for fluid imbalance due to?
increase in fat cells.
Hypervolemia causes?
increased urinary volume if the kidneys are functioning normally.
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?
muscle cramping and tetany
Sodium excess causes the tongue to look?
red and swollen.
Dry sticky mucous membranes are noted in?
sodium excess.
The primary extracellular electrolytes are?
sodium, chloride, and bicarbonate.
Age-related changes affecting fluid balance?
-Decreased sense of thirst. -Medical conditions ( heart failure or hypertension, requiring medications such as diuretics). -Loss of nephrons. -Decreased renal blood flow.
A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding?
-Fever -Facial flushing -Low back pain -Hematuria
5% dextrose in 0.9% NaCl?
-Used to treat Syndrome of inappropriate antidiuretic hormone secretion (SIADH). -Can temporarily be used to treat hypovolemia if plasma expander is not available.
A home care nurse is visiting a client with acute kidney injury who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids.
Hyponatremia
Deficient sodium in the blood. (Serum sodium <135 mEq/L) caused by a loss of sodium or gain of water. May be lost through: -Vomiting -Diarrhea -Fistulas -Sweating -Diuretic use Decrease causes fluid to move by osmosis from the less concentrated ECF compartment to the ICF space. This leads to: -Edema -Cramps -Weakness -Dry skin -Increasing intracranial pressure -Lethargy -Muscle twitching -Hyperreflexia -Coma -Seizures -Death
A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the health care provider to order?
Packed 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
Hypokalemia
Potassium deficit in the ECF. (Serum potassium <3.5 mEq/L) Lost via: -Vomiting -Gastric suction -Alkalosis -Diarrhea -Use of diuretics When extracellular K falls, K moves from the cell, creating an intracellular K deficiency. Signs and symptoms: -Affects the cardiovascular system -Muscle weakness -Leg cramps -Fatigue -Paresthesias -Dysrhythmias
