Ch. 40 Fluid, Electrolyte, and Acid-Base Balance

The movement of the solvent water from an area of lesser solute concentration to an area of greater solute concentration until equilibrium is established is known as: a. Osmosis b. Diffusion c. Active transport d. Filtration

a. Osmosis Water moves by osmosis. Gases move by diffusion (b). Active transport (c) is a process that requires energy for the movement of substances through a cell membrane from an area of lesser to higher concentration. Filtration (d) is the passage of fluids through a permeable membrane from an area of high pressure to one of low pressure

Plasma, the liquid constituent of blood, is correctly identified as which of the following? a. Interstitial fluid b. Intravascular fluid c. Intracellular fluid d. 40% of total body fluid

b. Intravascular fluid Intravascular fluid or plasma is extracellular fluid and composes 5% of total body fluid

A patient has been encouraged to increase her fluid intake. Which measure would be most effective for the nurse to implement? a. Explaining the mechanisms involved in transporting fluids to and from intracellular compartments b. Keeping fluids readily available for the patient c. Emphasizing the long-term outcome of increasing fluids when she returns home d. Planning to offer most daily fluids in the evening

b. Keeping fluids readily available for the patient Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provide further reinforcement, and additional fluids should be taken earlier in the day

The nurse alertly assesses the acid-base balance of a patient because she is aware that the patient will be unable to effectively control his carbonic acid supply. This is most likely a patient with bad damage to which of the following? a. Kidneys b. Lungs c. Adrenal glands d. Blood vessels

b. Lungs The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys (a) are the primary controller of the body's bicarbonate supply. The adrenal glands (c) secrete catecholamines and steroid hormones. The blood vessels (d) act only as a transport system.

The nurse instructs a patient to focus on breathing more slowly as the most effective intervention for which acid-base imbalance? a. Respiratory acidosis (carbonic acid excess) b. Respiratory alkalosis (carbonic acid deficit) c. Metabolic acidosis (base bicarbonate deficit) d. Metabolic alkalosis (base bicarbonate excess)

b. Respiratory alkalosis (carbonic acid deficit) Breathing more slowly causes accumulation of carbon dioxide to reverse carbonic acid deficit or respiratory alkalosis. Breathing more slowly would further increase a patient's respiratory acidosis (a) due to the increased carbon dioxide. Decreasing the respiratory rate would not be effective for a metabolic acid-base balance (c).

When developing the teaching plan for a patient at risk for hyperkalemia, which foods would the nurse instruct the patient to avoid? a. Carrots and squash b. Canned soups and potato chips c. Bananas and apricots d. Whole-grain cereals and milk

c. Bananas and apricots Hyperkalemia is an elevated serum potassium level; bananas and apricots are foods high in potassium and should be avoided in this situation. The other foods listed would be allowed. Canned foods and potato chips (b) would

Which of the following is the most common etiologic factor related to the nursing diagnosis of Excess Fluid Volume? a. Increased need for fluids secondary to fever b. Abnormal fluid loss from vomiting c. Excessive IV infusion d. Decreased fluid intake secondary to depression

c. Excessive IV infusion Excessive IV infusion is the most common factor associated with excess fluid volume. The other alternatives are related to deficient fluid volume.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values (pH, 7.30; PaCO2, 36 mm Hg; HCO3 , 14 mEq/L)? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

c. Metabolic acidosis A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis (d). Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis (a); increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis (b).

Potassium functions as which of the following? a. The chief electrolyte of extracellular fluid b. The most abundant electrolyte in the body c. The major cation of intracellular fluid d. The chief extracellular anion

c. The major cation of intracellular fluid Potassium is the major cation of the intracellular fluid. Sodium is the chief electrolyte of extracellular fluid (a), calcium is the most abundant electrolyte in the body (b), and chloride is the chief extracellular anion (d).

Which of the following would the nurse need to keep in mind when preparing to assist the physician with insertion of a nontunneled percutaneous central venous catheter? a. This catheter usually remains in place for 2 to 3 months. b. The catheter is introduced via the basilic or cephalic veins in the antecubital space. c. Nursing responsibility includes accessing the catheter with an angled needle. d. A chest radiograph is required to confirm placement.

d. A chest radiograph is required to confirm placement. A chest radiograph is needed to ensure proper placement for any central venous access device. In addition, nontunneled percutaneous central venous catheters remain in place for 3 to 7 days, are introduced into the subclavian or internal jugular vein, and are never accessed through an angled needle (c) (used with an implanted port).

Which of the following would the nurse use as the most reliable indicator of a patient's fluid balance status? a. Intake and output b. Skin turgor c. Complete blood count d. Daily weight

d. Daily weight Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output (a) are not always as accurate and may involve a subjective component. Measurement of skin turgor (b) is subjective, and the complete blood count (c) does not necessarily reflect fluid balance

While administering a blood transfusion, when would the nurse assess the patient for a blood transfusion reaction? a. 15 minutes after the infusion is started b. After the blood is all infused c. Every hour d. Every 15 minutes

d. Every 15 minutes The nurse should closely observe a patient for the first 15 minutes and then check the patient thereafter every 15 minutes while he or she is receiving the blood transfusion.

Which site would be most appropriate for initiating IV therapy for a patient who has sustained multiple injuries after an automobile accident and has a cast on his right arm? a. Left antecubital b. Dorsal aspect of either foot c. Right hand d. Left forearm

d. Left forearm The left forearm is the best site selection because of the condition of the patient's right arm. The left forearm is preferable to the antecubital space of the left arm (a) or the lower extremities (b).

When implementing the plan of care for a patient receiving IV therapy, which intervention would be most appropriate? a. Changing the IV catheter and entry site daily b. Changing the tubing every 8 hours c. Increasing the rate to catch up if the correct amount has not been infused at the end of the shift d. Monitoring the flow rate at least every hour

d. Monitoring the flow rate at least every hour The flow rate requires close monitoring, at least every hour. The IV catheter and entry site should be changed every 48 to 72 hours in most circumstances (a). The tubing is changed according to agency policy but not at the frequency of every 8 hours (b). Increasing the rate may lead to fluid overload (c).

Which assessment finding would lead the nurse to suspect that a patient's IV has infiltrated? a. In the past hour, only 50 mL of fluid has infused. b. The insertion site is red, hot, and swollen. c. The patient's temperature has risen to 101F (38.3C). d. The site is pale, cool, swollen, and painful

d. The site is pale, cool, swollen, and painful A decrease in flow rate may indicate an infiltration but is not as significant as the other signs of a pale, cool, swollen, and painful site. Phlebitis is an inflammatory process and results in redness, warmth, and possibly a temperature elevation (b and c).