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

"Fluid in the tissue space between and around cells." Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

What commonly used intravenous solution is hypotonic?

0.45% nacl Half-strength saline (0.45% NaCl) is hypotonic. Normal saline (0.9% NaCl) and lactated Ringer's are isotonic. 10% dextrose in water (D10W) is hypertonic pg 1579

A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply.

A B AB O Persons with type AB blood are often called universal recipients, a fact that is rooted in their lack of agglutinins for either A or B antigens. 1594

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) Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.

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. Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction. Clients with type O blood are universal donors

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?

To assure the IV solution is appropriate for this administration The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is appropriate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.

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

To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar. pg 1605

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:

Winged infusion needles they are short, beveled needles with plastic flaps or wings. They may be used for short-term therapy or when therapy is given to a child or infant.

Potassium is needed for neural, muscle, and:

cardiac function

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

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 The listed symptoms occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever; hypertension; dry, flushed skin; and abdominal pain occur.

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?

hypotonic Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. Hypertonic solutions draw water out of body cells while isotonic solutions have little effect on the distribution of body fluids. Blood transfusions do not cause the entry of water into body cells.

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?

isotonic Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?

metabolic alkalosis Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.

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?

o negative Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. B positive, A positive, and AB negative are not considered compatible in this scenario. pg 1594

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) In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis.

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) In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis. pg 1572

A client with renal disease requires IV fluids. It is important for the nurse to:

place the fluids on an electronic device An IV electronic infusion device usefully and accurately regulates the infusion rate, especially if fluid administration must be watched very carefully, such as when infusing fluid to a renal client or when administering certain medications. pg 1580

A nurse is providing care for client who experienced a stroke. Which nursing intervention reflects the tertiary level of prevention?

provide care transition at discharge for speech therapy Tertiary prevention minimizes the consequences of a disorder through aggressive rehabilitation or appropriate management of the disease. An example is speech therapy to help restore ability. Blood pressure and mental status exams are examples of secondary prevention associated with the acute stroke. Discussing family history is also secondary prevention in terms of assessing for further risk factors.

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 Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

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) In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis. 1572

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 needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility.