Chapter 39: Fluid, Electrolyte, and Acid-Base Balance
The oncoming nurse is assigned to the following patients. Which patient should the nurse assess first?
A newly admitted 88-year-old with a two-day history of vomiting and loose stools
Which client will have more adipose tissue and less fluid?
A woman
A client with dehydration will have an increase in
Aldosterone
A nurse is changing a peripheral venous access dressing for a patient. Which of the following is a recommended step in this procedure?
Apply chlorhexidine using a back and forth friction scrub for at least 30 seconds.
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas
A nurse flushing a capped peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation?
Aspirate and attempt to flush the line again.
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?" Which of the following would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids.
Potassium is needed for neural, muscle, and
Cardiac function
A patient who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor?
Decreased blood volume and intracellular dehydration
A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which of the following actions should the nurse perform to avoid further complications and provide relief to the client?
Discontinue the IV promptly
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 client who is admitted to the health care facility has been diagnosed with cerebral edema. Which of the following intravenous solutions needs to be administered to this client?
Hypertonic solution
A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe?
Infiltration
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
Which client has more extracellular fluid?
Newborn
A nurse monitoring a patient's IV infusion auscultates the patient's lung sounds and finds crackles in the bases in lungs that were previously clear. What would be the appropriate intervention in this situation?
Notify primary care provider immediately for possible fluid overload
A 50-year-old client with hypertension is being treated with a diuretic. The client complains of muscle weakness and falls easily. The nurse should assess which electrolyte?
Potassium
Mr Powell, a dehydrated 35 year old has intravenous fluid running at 250 cc/h. for rapid rehydration. He is complaining of burning at the site. You see no redness, swelling, heat, or coolness upon inspection. You suspect
That the fluid is infusing too rapidly for comfort
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as
Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system
The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?
25 gtt/min
Which of the following fluids should be administered slowly to prevent circulatory overload?
5% NaCl When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% (NaCl) and 5% saline (NaCl).
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 The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.
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
Major control over the extracellular concentration of potassium within the human body is exerted by insulin and
Aldosterone Two hormones exert major control over the extracellular concentration of potassium: insulin and aldosterone. Aldosterone enhances renal secretion of potassium
The nurse is caring for a patient who had a parathyroidectomy. Upon evaluation of the patient's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
Calcium and phosphorus The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus.
A patient's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. What signs and symptoms should the nurse vigilantly monitor for?
Cardiac irregularities
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse caring for the client knows that the client needs restoration of which of the following?
Electrolytes
Which of the following statements is an appropriate nursing diagnosis for an 80-year-old client with the diagnosis of congestive heart failure with symptoms of edema, orthopnea, and confusion?
Extracellular volume excess related to heart failure as evidenced by edema and orthopnea
When an elderly 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
Mr. Smith is admitted to your unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is which of the following?
Fluid volume excess
A dialysis unit nurse caring for a patient with renal failure will expect the patient to exhibit which fluid and electrolyte imbalances?
Fluid volume excess and acidosis The kidneys are also responsible for acidbase balance, and in the presence of renal failure, the kidneys cannot regulate hydrogen ions and bicarbonate ions, so the patient develops metabolic acidosis.
When an 80-year-old client who takes diuretics for management of hypertension informs the nurse she take laxatives daily to promote bowel movements, the nurse assesses the client for possible symptoms of
Hypokalemia
Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. What is this electrolyte imbalance known as?
Hyponatremia
During an assessment of an elderly client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. The nurse recognizes that what medical diagnosis may be responsible?
Hypovolemia The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN).
Which of the following solutions 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
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?
It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.
A nurse is caring for a patient who has burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this patient?
Lactated Ringer's solution is a roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43-). It is used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea and in treating mild metabolic acidosis.
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's
Low calcium
A child is eating a peanut butter sandwich. He is ingesting an excellent source of
Magnesium Good dietary sources of magnesium include green leafy vegetables, legumes, citrus fruit, peanut butter, and chocolate.
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
Upon assessment of a patient's peripheral intravenous site, the nurse notices the area is red and warm. The patient complains of pain when the nurse gently palpates the area. What are these signs and symptoms indicative of?
Phlebitis
A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation?
Reapply the dressing and notify the physician for further instructions.
A decrease in arterial blood pressure will result in the release of
Renin Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release
A 58-year-old woman 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 uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?
The pump will continue to infuse fluid even when the needle is displaced.
Which of the following statements accurately describes the role of antidiuretic hormone in the regulation of body fluids? When antidiuretic hormone is present,
The renal tubules become permeable to water
Which of the following statements accurately describes a guideline when using a venous access?
The system is accessed with a noncoring needle and patency is maintained by periodic flushing.
You are the nurse caring for Jason Kent, a 16-year-old who got lost while on a desert hike. He was found after spending two days without food or water and was admitted to your unit through the Emergency Department. He is severely dehydrated and sunburned. You remember that which of the following are reasons why the human body requires fluid? Choose all that apply.
• Facilitates cellular metabolism • Helps maintain normal body temperature • Acts as a solvent for electrolytes
A nurse is caring for an obese client with lung cancer who needs intermittent infusion of IV solution and medication for several months. Which of the following central venous catheters is most suitable for long-term access in a cancer client without the catheter protruding from the skin? Select all that apply.
• Tunneled catheters • Peripherally inserted central catheter • Implanted access device
What is the rate of administration for packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours