prep-u: chapter 41 - fluid, electrolyte, and acid-base balance

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause?

"I've been taking antacids almost every 2 hours over the past several days."

The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?

"Watery plasma, or serum, portion of blood."

What commonly used intravenous solution is hypotonic?

0.45% NaCl

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

100 gtt/min

The nurse is caring for a client whose breast cancer necessitated a total mastectomy and lymph node dissection. The nurse will prioritize what assessment related to potential fluid and electrolyte imbalance?

Assessment for edema

A client suffers from a genetic bleeding deficiency involving a deficit in factor VIII. Which blood product will the nurse most likely administer?

Cryoprecipitate

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

An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching?

Include more bananas in the diet.

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

Metabolic alkalosis

A client has been diagnosed with excessive levels of aldosterone. The nurse's assessment will include what value?

Potassium level

The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next?

Remove the peripheral intravenous catheter.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?

Stop the transfusion immediately.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?

The client has anti-A antibodies.

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.

Which statement most accurately describes the process of osmosis?

Water moves from an area of lower solute concentration to an area of higher solute concentration.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

an infant age 4 months

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?

calcium and phosphorus

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

daily weights

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

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

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by:

increasing ventilation through the lungs.

In which fluid compartment is most of the body's fluid is located?

intracellular

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

"I should drink 2,500 mL/day of fluid."

A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status?

HCO3: 25 mEq/L (25 mmol/L)

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 side rail. 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 is the appropriate action for the nurse?

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

An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use:

a winged infusion needle.

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 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

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?

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

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+

A health care provider 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

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?

Start an IV of normal saline as prescribed.

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

A hypotonic solution

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another site.

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?

ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.

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 client is receiving IV fluids. The solution has an osmolarity of 280 mOsm/L. The nurse would expect which event to occur with the body's fluids?

No shifting of fluids occurs.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply.

Rate of the IV solution Location of the IV catheter access Client's reaction to the procedure Type of IV solution Gauge and length of the IV catheter

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

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:

phlebitis.

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?

plasma

The student nurse asks the instructor how buffer systems work in the body to maintain the pH of the blood. The instructor explains the buffer systems to the students. Which buffer systems will be discussed by the instructor? Select all that apply.

• Carbonic acid-sodium bicarbonate buffer system • Phosphate buffer system • Protein buffer system

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.

• Intravenous therapy • Electrolyte management • Nutrition management

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. -Start the administration slowly for the first 15 minutes of the transfusion.

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 jello infusion of intravenous solution cup of ice cream

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and fatigue and the nurse's assessment reveals an irregular heart rate. The nurse should assess the client's levels of which electrolyte?

Potassium

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?

Restart infusion in another vein and apply a warm compress.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they 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

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

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

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 will nurse likely address?

increased hydrostatic pressure

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?

83 mL/hr

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

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? Select all that apply.

Fever Hematuria Low back pain Facial flushing

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 with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?

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

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)

The nurse is reviewing the arterial blood gas results of a client on nasogastric suctioning. The test reveals a pH of 7.52, a PaO2 level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L). The nurse suspects the client is most likely experiencing which condition?

Metabolic alkalosis

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels

A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert?

muscle weakness, fatigue, and arrythmias

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