Module 8 TTC (Fluids & Electrolytes and Acid-Base Balance)

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Fluid outside cells." "Watery plasma, or serum, portion of blood." "Fluid inside cells." "Fluid in the tissue space between and around cells."

"Fluid in the tissue space between and around cells."

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate? "Granulocytes help third spacing of fluid that occurs with infection." "Granulocytes are a type of white blood cell that can help fight infection." "Granulocytes help to control bleeding associated with infection." "Granulocytes replace clotting factors that are altered from infection."

"Granulocytes are a type of white blood cell that can help fight infection."

While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance? "How much do you typically urinate during the day?" "How often do you experience leg cramps? "How much coffee do you drink during a typical day?" "How often do you usually have a bowel movement?"

"How much do you typically urinate during the day?"

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? "I received a blood transfusion in the United Kingdom." "My blood type is B positive." "I have never given blood before." "My spouse would also like to donate blood."

"I received a blood transfusion in the United Kingdom."

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? "Infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed." "Infiltration is the inflammation of the vein, while phlebitis is a localized irritation." "Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." "Infiltration occurs when an IV is improperly placed, and phlebitis indicates circulatory overload."

"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

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

A client who is receiving total parenteral nutrition and lipids asks the nurse why the solution looks like milk. What is the most appropriate nursing response? "The white milky solution should be discarded and replaced with a clear solution." "The white milky solution is the total parenteral nutrition." "The white milky solution contains lipids, or fat, to provide extra calories." "The white milky solution is medication that is mixed into the total parenteral nutrition."

"The white milky solution contains lipids, or fat, to provide extra calories."

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? 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 As fast as the client can tolerate

1 unit over 2 to 3 hours, no longer than 4 hours

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? 3+ 2+ 1+ 4+

1+

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr 600 gtt/min 60 gtt/min 160 gtt/min 100 gtt/min

100 gtt/min

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? 1,500 mL/day 3,500 mL/day 1,000 mL/day 2,500 mL/day

2,500 mL/day

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? 3,750 3,000 1,000 500

3,000

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? 9.5 cm H2O 12 cm H2O 5 cm H2O 3.5 cm H2O

3.5 cm H2O

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? 20 gtt/min 40 gtt/min 50 gtt/min 30 gtt/min

50 gtt/min

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O? 48-year-old who has had a bowel movement after surgery 55-year-old with congestive heart failure on furosemide 23-year-old with ulnar and radial fracture 34-year-old whose urinary catheter was discontinued yesterday

55-year-old with congestive heart failure on furosemide

A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? 30 drops/mL 60 drops/mL 120 drops/mL 90 drops/mL

60 drops/mL

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? 5,000 gtt/min 42 gtt/min 167 gtt/min 83 gtt/min

83 gtt/min

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? 103 gtts/hr 83 mL/hr 100 mL/hr 13 mL/hr

83 mL/hr

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? A peripheral venous catheter inserted to the antecubital fossa A midline peripheral catheter An implanted central venous access device (CVAD) A peripheral venous catheter inserted to the cephalic vein

An implanted central venous access device (CVAD)

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. hypoglycemia. hypothyroidism. hypocalcemia.

Answer: hypokalemia

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Apply pressure to insertion site for at least 3 minutes. Instruct client to remain flat for 30 minutes. Apply petroleum-based ointment and sterile occlusive dressing. Ask client to perform Valsalva maneuver.

Apply pressure to insertion site for at least 3 minutes.

A client has been prescribed 2 units of packed red blood cells. A type and cross-match has been performed and the first unit has arrived on the floor from the blood bank. When administering this client's blood transfusion, the nurse should perform which actions? Select all that apply. Ask another nurse to assist with confirming the order, blood group, and other vital information. Collect the last 5 mL of the packed cells and send to the laboratory for culturing. Obtain appropriate tubing and prime it with normal saline or lactated Ringer's. Start the administration slowly for the first 15 minutes of the transfusion. Take baseline vital signs and expect slight increases in blood pressure and heart rate after the infusion begins.

Ask another nurse to assist with confirming the order, blood group, and other vital information. Start the administration slowly for the first 15 minutes of the transfusion.

A home care nurse is visiting a client with renal failure 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. Eat crackers and bread. Use an alcohol-based mouthwash to moisten your mouth. Use regular gum and hard candy.

Avoid salty or excessively sweet fluids.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? Tetany Fluid volume excess Cardiac dysrhythmias Pulmonary embolus

Cardiac dysrhythmias

The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients? Cardiac volume intolerance Increased renal blood flow An increased sense of thirst Increase in nephrons in the kidneys

Cardiac volume intolerance

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 size of the IV catheter. Determining the amount of IV solution. Deciding the location of the IV catheter. Administering the IV solution. Prescribing the kind of IV solution.

Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation? Discontinue the IV and relocate it to another spot. Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV. Call the physician and ask if anti-inflammatory drugs should be administered.

Discontinue the IV and relocate it to another spot.

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action? Flush with 3-mL normal saline. Slow the rate of infusion by 50%. Attempt to aspirate. Discontinue the IV.

Discontinue the IV.

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? Fully open the roller clamp on the infusion set and infuse the remaining PRBCs as rapidly as possible. Insert a larger gauge IV catheter and transfer the infusion to the new insertion site. Continue to infuse the PRBCs until they are completely infused. Discontinue the infusion and record the volume left in the blood bag.

Discontinue the infusion and record the volume left in the blood bag.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema? Request additional salt be added to the diet Elevate the legs Deeply massage the legs Direct the client to remain on bed rest

Elevate the legs

Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea Congestive Heart Failure related to edema Fluid Volume Deficit related to congestive heart failure, as evidenced by shortness of breath Fluid Volume Excess related to loss of sodium and potassium

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea

A nurse is measuring intake and output for a client who has congestive heart failure. What does not need to be recorded? Frozen fluids Fruit consumption Sips of water Parenteral fluids

Fruit consumption

Which individual with diarrhea for three days is most likely to suffer from fluid and electrolyte imbalance? Infant Young adult School-age child Adolescent

Infant

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? Muscle weakness, fatigue, and constipation Nausea, vomiting, and constipation Diminished cognitive ability and hypertension Muscle weakness, fatigue, and dysrhythmias

Muscle weakness, fatigue, and dysrhythmias

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action? Not wearing gloves when performing the intervention By pulling the dressing toward the insertion site Not performing the intervention under sterile conditions By applying stabilizing pressure to the catheter

Not wearing gloves when performing the intervention

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? O negative A positive B positive AB negative

O negative

The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client? AB negative O negative A positive B positive

O negative

A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take? Continue to use the current intravenous tubing Tell the client the infusion will be administered later in the shift Notify the health care provider to request a new prescription for an intravenous infusion Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing

Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing

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 Sepsis Air embolism Infiltration

Phlebitis

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 siderail. 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 action is most appropriate? Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. Apply a new dressing and observe for signs of infection over the next several hours. Remove the IV catheter and reinsert another in a different location. Decontaminate the visible portion of the catheter, and then gently reinsert.

Remove the IV catheter and reinsert another in a different location.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? Elevate the arm. Remove the IV. Apply a warm compress. Slow the rate of IV fluids.

Remove the IV.

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? Face Hands Abdomen Sacral area

Sacral area

The nurse is educating a client about the function of sodium in the body. What education points would the nurse make? Select all that apply. Sodium is the primary regulator of ECF volume The daily value of sodium cited on nutrition facts labels is 1,200 mg. The normal extracellular concentration of sodium is 85 to 95 mEq/L (85 to 95 mmol/L). Sodium participates in the generation and transmission of nerve impulses. Sodium does not influence ICF volume. Sodium is normally maintained in the body within a relatively narrow range, and deviations quickly result in serious health problems.

Sodium participates in the generation and transmission of nerve impulses. Sodium is normally maintained in the body within a relatively narrow range, and deviations quickly result in serious health problems. Sodium is the primary regulator of ECF volume

A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse? Apples Spinach Eggs Chicken

Spinach

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Allow nothing by mouth. Encourage fluid intake. Start an IV of normal saline as prescribed. Give the client a glass of orange juice with added sugar.

Start an IV of normal saline as prescribed.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action? Assess for visible rash. Call for assistance. Stop the transfusion. Assess oxygen levels.

Stop the transfusion.

When educating a client about foods that affect fluid balance, which methods should the nurse share to help the client reduce sodium and potassium intake? Teach the client to read food labels and identify foods high in sodium and potassium. Direct the client to eat a banana a day. Recommend the use of salt substitutes. Encourage the client to use spices mixtures liberally.

Teach the client to read food labels and identify foods high in sodium and potassium.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? Twist the tubing around a pencil. Tap the tubing below the air bubbles. Tighten the roller clamp to stop the infusion. Milk the air in the direction of the drip chamber.

Tighten the roller clamp to stop the infusion.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a 60-year-old who is 3 days post-myocardial infarction and has been stable. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today a newly admitted 88-year-old with a 2-day history of vomiting and loose stools a 47-year-old who had a colon resection yesterday and is reporting pain

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

A client with dehydration will have an increase in: aldosterone albumin glucose potassium

aldosterone

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? potassium and sodium calcium and phosphorus chloride and magnesium potassium and chloride

calcium and phosphorus

Potassium is needed for neural, muscle, and: auditory function. skeletal function. optic function. cardiac function.

cardiac function.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? cardiac irregularities increased intracranial pressure (ICP) metabolic acidosis muscle weakness

cardiac irregularities

Which is a common anion? magnesium potassium calcium chloride

chloride

The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which will the nurse document on the I&O record? Select all that apply. client drinking milk client's urination vomiting client eating a sandwich infusion of intravenous solution

client drinking milk client's urination vomiting infusion of intravenous solution

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: colloid solution. nonelectrolytes. interstitial fluid. electrolytes.

electrolytes

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing? allergic reaction hemolytic reaction febrile reaction circulatory overload

febrile reaction

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 isotonic hypotonic hypotonic, followed by isotonic

hypertonic

Which client has more extracellular fluid? adolescent man newborn female school-age child adult woman

newborn

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice? performing venipuncture preparing solution for administration ordering type of solution, additive, amount of infusion, and duration regulating the rate of administration

ordering type of solution, additive, amount of infusion, and duration

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: a systemic blood infection. an infiltration. rapid fluid administration. phlebitis.

phlebitis

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? asking the client to pump their fist several times palpating the veins on the nondominant hand asking if the client is right or left handed placing the tourniquet on the upper arm for 2 minutes

placing the tourniquet on the upper arm for 2 minutes

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

platelets

The nurse is preparing to hang a nitroglycerin drip in a glass bottle for a client with chest pain. Which tubing selection by the nurse is appropriate? primary vented tubing with a filter primary non-vented tubing with a filter primary non-vented tubing primary vented tubing

primary vented tubing

A decrease in arterial blood pressure will result in the release of: renin. insulin. thrombus. protein.

renin

A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose? provide protein supplements replace fluid and electrolytes administer blood products treat the client's infection

replace fluid and electrolytes

A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: replacement of fluids for those lost from vomiting and diarrhea. an access route to replace fluids in combination with blood products. intravenous fluids to be administered on an outpatient basis. an access route to administer medications intravenously.

replacement of fluids for those lost from vomiting and diarrhea.

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

sodium, chloride, and bicarbonate.

When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which complication has most likely occurred? infiltration sepsis thrombus speed shock

thrombus