Nursing Application for Fluids and Electrolytes

Fred started his first unit of packed red blood cells. His vital signs were normal. Here is what you see after 15 minutes, after which he started complaining of chills.

Febrile non-hemolytic reaction ​

Latika is started on the intravenous (IV) fluid noted in the picture. It is a 1000 mL bag going at 250 mL/hour through her peripheral IV. She is complaining of pain at the IV site. After reviewing the bag, which is the most likely cause of her pain?

potassium: 20 mEq per 1000 ml

Which of the following cues suggests the need for immediate intravenous (IV) access?​ Select all that apply.

*BP: 81/44 *HR: 141 *Pain: 6/10 *Cheif complaint: Nausea and vomiting

While Deborah improved with the fluid bolus, she is being prepped for surgery. The surgeon is planning a subclavian central line to be inserted before surgery. Deborah's power of attorney asks about what the immediate potential complications of a subclavian central line insertion is. Which of the following is accurate? Select all that apply.

*Bleeding *Collapsed lung

Deborah recovered from surgery well and central line was removed recently. She has a 20 gauge intravenous (IV) catheter that was placed in her left forearm. She rings the call bell and says that her IV site is hurting. It is currently a saline lock. Which of the following should be assessed based on her complaint? Select all that apply.

*Date of insertion *Intact dressing *Tenderness or swelling around the site *Color surrounding the catheter *Whether it flushes

Which of the following can suggest an acute hemolytic reaction after starting a blood transfusion? Select all that apply.

*Fever *Blood in urine *Hypotension

After reviewing Latika's symptoms and her intake and output, which of the following could be suspected? Select all that apply.

*Hypovolemia *Hypokalemia

Delayed complications of a peripheral intravenous (IV) catheter include which of the following? Select all that apply.

*Infection *Pain *Infiltration *Bleeding

Fred was admitted with a ruptured abdominal aortic aneurysm. After surgery, his bleeding is now under control, but he has lost a fair amount of blood. His blood pressure is 90/50, and his pulse rate is 130 bpm (beats per minute). His hemoglobin is 7.0 and his hematocrit is low. Which of the following fluids would be appropriate based on the vitals, labs, and circumstances? Select all that apply.

*Normal Saline *Packed red blood cells

Fred appears to be experiencing a febrile non-hemolytic reaction. Which of the following nursing actions would you would perform? Select all that apply.​

*Save the blood container, tubing, attached labels, and transfusion record for return to the blood bank. Collect blood and urine specimens per health care provider order or protocol. *Prepare to administer emergency drugs such as antihistamines, vasopressors, fluids, and corticosteroids per health care provider order or protocol. *Report to the health care provider or emergency response team. Remain with the patient, Record signs, symptoms, and monitor vital signs at 5 minute intervals. *Stop the transfusion immediately. Change the IV tubing down to the catheter hub with new tubing and running 0.9% sodium chloride (normal saline).

After reviewing the client's record, choose which of the following fluids is appropriate as a bolus?​

0.9% Normal Saline (500mL bag)

Before starting the blood transfusion, you evaluate Fred's IV site. Please select your assessment from the items below:​

1. IV secured and looped properly 2. No sign of redness or edema​ 3. Good color in the nailbeds​ 4. No date marked​

Review the client record and then answer the following question: Given Deborah's current situation, what would be the most appropriate intravenous (IV) access to obtain?​

Peripheral IV 18g in the right antecubital​

Fred started his first unit of packed red blood cells. His vital signs were normal. After 15 minutes he started complaining of chills. Indicate if each of the following assessment finding is normal or abnormal.​

T: Abnormal BP: Normal P: Normal RR: Normal O2: Normal Urine Output: Normal Urine Color: Normal

A client with a low sodium level and a low serum osmolality indicates which of the following?

The client is in a hypotonic state.

Fred was typed and crossmatched for 4 units of packed red blood cells. The blood is delivered to the unit and you are reviewing it in his room with another nurse.

Walters, Fred A+ DOB: 6/24/1943 Hospital ID: 15964270