Nursing Fundamentals Chapter 39

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

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

50 gtt/min

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?

60 drops/mL

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?

Acute Confusion related to cerebral edema

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?

An implanted central venous access device (CVAD)

Which of the following is not true regarding calcium?

Approximately 60% of the body's calcium is found within the bones and teeth.

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium?

Apricots

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

Arterial blood gas

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern?

Banana

What food would the nurse provide for a client who has hypokalemia?

Bananas

The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?

Cardiac volume intolerance

The nurse is instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium?

Cheese

Which is a common anion?

Chloride

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L Potassium: 3.2 mEq/L Calcium: 4.4 mEq/L Magnesium: 1.6 mEq/L Chloride: 100 mEq/L Phosphate: 1.8 mEq/L Based on these levels, the nurse would identify which imbalance?

Hypokalemia

The nurse is instructed by the physician that the client needs an intravenous fluid that is not likely to pull fluids into the vascular space. The nurse recognizes that the physician is suggesting which kind of fluid?

Hypotonic

Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease?

Increased plasma levels of antidiuretic hormone lead to water excess.

Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L. For what manifestations will you be alert?

Muscle weakness, fatigue, and dysrhythmias

When educating a client about foods that affect fluid balance, the nurse would advise the client to decrease:

Na

Which client has more extracellular fluid?

Newborn

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium?

Normal serum potassium ranges from 5.5 to 6.0 mEq/L.

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation?

Notify the primary care provider immediately for possible fluid overload.

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 indicative of what?

Phlebitis

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?

Sodium is regulated by the renin-angiotensin-aldosterone system.

Potassium is needed for neural, muscle, and:

cardiac function.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:

fluid overload.

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. This assessment finding is suggestive of:

fluid volume excess.

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 nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

renal failure

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.

What nursing interventions would be appropriate for a patient diagnosed with deficient fluid volume? (Select all that apply.)

• Intravenous therapy • Electrolyte management • Nutrition management

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

Total parenteral nutrition

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

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

What is the rate of administration for packed red blood cells?

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

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.

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

Ensure that the prescribed solution is clear and transparent.

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

renin.

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

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

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. For what assessment findings will the nurse be looking?

muscle cramping and tetany

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system?

Diarrhea

Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client?

ECF Deficient Fluid Volume

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. What is the most likely complication that has occurred?

Thrombus

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:

hyponatremia.

A woman age 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.

A nurse is caring for a client who is on total parenteral nutrition (TPN). Which of the following clients are candidates for TPN? Select all that apply.

• Clients with major trauma or burns • Clients with liver and renal failure • Clients with inflammatory bowel disease

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism would the nurse most likely address?

• increased hydrostatic pressure