Chapter 40 Fluid and Electrolytes and Acid Base Balance PREP U

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Fluid in the tissue space between and around cells." "Watery plasma, or serum, portion of blood." "Fluid outside cells." "Fluid inside cells."

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

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? 3,750 3,000 500 1,000

3,000

The nurse should notify the physician when a critically ill patient's hourly urine output first falls below: A. 20 mL B. 30 mL C. 60 mL D. 120 mL

30 mL

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. Administering the IV solution. Deciding the location of the IV catheter. Deciding the size of the IV catheter. Prescribing the kind of IV solution. Determining the amount of IV solution.

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

The physician orders a 2-gram sodium diet for a patient with hypertension. Which food should the nurse teach the patient to avoid? A. American cheese B. Shredded wheat C. Potatoes D. Chashews

American cheese

What is the lab test commonly used in the assessment and treatment of acid-base balance? Urinalysis Basic metabolic panel Complete blood count Arterial blood gas

Arterial blood gas

The patient is receiving a diuretic that contributes to the loss of potassium. The nurse should teach the patient that the best source of potassium is: A. Baked potato B. Bran flakes C. Lean meat D. Table salt

Baked potato

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? yogurt turkey milk banana

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? muscle weakness cardiac irregularities metabolic acidosis increased intracranial pressure (ICP)

Cardiac irregularities

The nurse determines that inflammation of a vein may have occurred at an intravenous insertion site if when touching the area it: A. Feels soft B. Seems cool C. Produces pallor D. Causes discomfort

Causes discomfort

Which is a common anion? chloride magnesium potassium calcium

Chloride

The nurse understands that excess fluid in the interstitial compartment results from increased: A. Oncotic pressure B. Diffusion pressure C. Hydrostatic pressure D. Intraventricular pressure

Hydrostatic pressure

A patient is admitted to the hospital for a fever of unknown origin. The nurse assessment reveals profuse diaphoresis, dry, sticky mucous membranes, weakness, disorientation, and a decreasing level of consciousness. The nurse infers that the patient has: A. Hyperkalemia B. Hypercalcemia C. Hypernatremia D. Hypermagnesemia

Hypernatremia

A patient receiving a tube feeding develops diarrhea. The nurse understands that the primary reason tube feedings cause diarrhea is because they are: A. Icteric B. Isotonic C. Hypotonic D. Hypertonic

Hypertonic

When the nurse assesses a patient, which adaptation indicates a potassium deficiency? A. Increased blood pressure B. Muscle weakness C. Chest pain D. Dry hair

Muscle weakness.

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? A positive AB negative B positive O negative

O negative

While interpreting the arterial blood gas findings of a patient, the nurse concludes that the patient has moderate hypoxemia. Which assessment finding led the nurse to reach this conclusion? A. PaO2 level of 30 mmHg B. PaO2 level of 50 mmHg C. PaCO2 level of 40 mmHg D. PaCO2 level of 50 mmHg

PaO2 level of 50 mmHg

A decrease in arterial blood pressure will result in the release of: insulin. thrombus. protein. renin.

Renin.

The nurse suspects that an older patient may have a problem with excess fluid volume when the patient's skin appears: A. Dry and scaly B. Taut and shiny C. Red and irritated D. Thin and inelastic

Taut and shiny

A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action?

The nurse should carefully remove the tape from the outside to the insertion point while supporting the catheter. Gloves should be worn.

When assessing a patient, the nurse understands that an adaptation common to both excess fluid volume and deficit fluid volume is: A. Hypotension B. Weakness C. Agitation D. Dyspnea

Weakness

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: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l)

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

The primary extracellular electrolytes are: potassium, phosphate, and sulfate. magnesium, sulfate, and carbon. sodium, chloride, and bicarbonate. phosphorous, calcium, and phosphate.

sodium, chloride, and bicarbonate.

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Watery plasma, or serum, portion of blood." "Fluid inside cells." "Fluid in the tissue space between and around cells." "Fluid outside cells."

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

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? A. "We now have artificial blood products, so giving your own blood is not necessary." B. "Let me refer you to the blood bank so they can provide you with information." C. "Unfortunately, your own blood cannot be reinfused during surgery." D. "This surgery has a very low chance of hemorrhage, so you will not need blood."

"Let me refer you to the blood bank so they can provide you with information."

When the nurse identifies patient adaptations that include either oliguria or polyuria, the nurse should be most concerned about a risk for: A. Diarrhea B. Cachexia C. Fluid volume deficit D. Impaired skin integrity

Fluid volume deficit

When the nurse evaluates a patient's fluid intake and output, the fluid intake should be: A. Slightly more than the fluid output B. Lower than the urine output C. Higher than the fluid output D. Equal to the urine output

Slightly more than the fluid output

The physician orders a patient's IV fluids to be discontinued. When discontinuing a patient's intravenous infusion, it is essential that the nurse: A. Withdraw the catheter along the same angle of its insertion B. Use an alcohol swab to scrub the insertion site C. Flush the line with normal saline D. Don sterile gloves

Withdraw the catheter along the same angle of it s insertion

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? hypercalcemia hypermagnesemia hypokalemia hyponatremia

Hypokalemia

When caring for a patient with hypertension, the nurse should anticipate that the physician will first limit the patient's intake of: A. potassium B. Sodium C. Protein D. Fluids

Sodium

When a patient is under extreme stress there is an increased production of antidiuretic hormone (ADH) and aldosterone. Considering the effect of these hormones in the body, the nurse should expect a decrease in the patient's: A. Blood pressure B: Urinary output C: Body temperature D. Insensible fluid loss

Urinary output

Which clinical manifestations does the nurse find in a patient with hypomagnesemia? Select all that apply. 1. Seizures 2. Hypotension 3. Heart block 4. Mood swings 5. Tachyarrhythmias

1. Seizures 4. Mood swings 5. Tachyarrhythmias

What are the best ways to evaluate an elevated serum potassium level in a pt with renal failure? Select all that apply. 1. Measure urine output 2. Obtain serial serum potassium levels 3. Evaluate pt's LOC 4. Monitor pt's EKG 5. Evaluate muscle strength

2. Obtain serial serum potassium levels 3. Evaluate pt's LOC 4. Monitor pt's EKG

Which fluid should be administered slowly to prevent circulatory overload? lactated Ringer's 0.45% NaCl 5% dextrose in 0.9% NaCl 0.9% NaCl

5% dextrose in 0.9% NaCl

The nurse is caring for a patient who has a reduced fluid intake. The nurse understands that this reduced intake will contribute to: A. A decreased urine output B. Incontinence of urine C. A retention of urin D. Frequent urination

A decreased urine output

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) A peripheral venous catheter inserted to the antecubital fossa A peripheral venous catheter inserted to the cephalic vein A midline peripheral catheter

An implanted central venous access device (CVAD)

A client is scheduled to receive a blood transfusion. The blood is ready and the nurse, along with another licensed staff member, are at the client's bedside to verify the information. They would compare the laboratory blood record with which information for verification? Select all that apply. Blood ABO group Client's name Client's identification number Order for the transfusion Blood unit number

Blood ABO group Client's name Client's identification number Blood unit number

The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom(s) does the nurse document that correlates with the admitting diagnosis? Select all that apply. Report of excessive urination Blood clotting Slurred speech Report of numbness and tingling of the mouth Seizure activity Report of muscle cramps

Blood clotting Report of numbness and tingling of the mouth Seizure activity Report of muscle cramps

The nurse is providing dietary teaching for a patient with the diagnosis of osteoporosis. The nurse should teach the patient that the best source of calcium is: A. Cheese B. Lettuce C. Peppers D. Oranges

Cheese

A patient has a continuous bladder irrigation. What should the nurse do with the irrigant on the I&O sheet when calculating the fluid balance for this patient? A. Add it to the oral intake column B. Deduct it from the total urine output C. Subtract it from the intravenous flow sheet as output D. Document the intake hourly in the urine output column

Deduct it from the total urine output

A practitioner orders an IV infusion containing potassium. What is the most important nursing intervention before administering this solution to the patient? A. Assess skin turgor B. Obtain the BP C. Measure depth of edema D. Determine the presence of urinary output

Determine the presence of urinary output

The nurse is monitoring a patient who is receiving intravenous fluid. The nurse identifies that the patient is experiencing a fluid overload when assessment reveals: A. Chills, fever, and generalized discomfort. B. Blood in the tubing close to the insertion site. C. Dyspnea, headache, and increased blood pressure. D. Pallor, swelling, and discomfort at the insertion site.

Dyspnea, headache, and increased blood pressure

Which is most important when the nurse assesses adult patients for the effects of vomiting? A. Electrolyte values B. Mouth condition C. Bowel function D. Body weight

Electrolyte values

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. hypothyroidism. hypoglycemia. hypocalcemia.

Hypokalemia

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Ask the client every hour to drink more fluid. Offer small amounts of preferred beverage frequently. Have a loved one tell the client to drink more. Leave water on the bedside table.

Offer small amounts of preferred beverage frequently.

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? cryoprecipitate platelets albumin granulocytes

Platelets.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? Remove the IV. Slow the rate of IV fluids. Elevate the arm. Apply a warm compress.

Remove the IV.

When the nurse cares for an older adult, which assessment best reflects fluid and electrolyte balance? A. Intake and output results B. Serum laboratory values C. Condition of the skin D Presence of tenting

Serum laboratory values

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? increased blood volume and extracellular overhydration decreased blood volume and extracellular overhydration decreased blood volume and intracellular dehydration increased blood volume and intracellular dehydration

decreased blood volume and intracellular dehydration

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse likely to find? hyperphosphatemia hypomagnesemia hypokalemia hyperchloremia

hypokalemia

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? 200 mL/hr 1 unit over 2 to 3 hours, no longer than 4 hours 75 mL/hr for the first 15 minutes, then 200 mL/hr As fast as the client can tolerate

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

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 600 gtt/min 60 gtt/min 160 gtt/min

100 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 30 drops/mL 90 drops/mL 120 drops/mL

60 drops/mL

When a patient exhibits an increasing blood pressure and 2-pound weight gain over two days, the nurse should further assess the patient for: A. A decrease in heart rate B. An increase in skin turgor C. An increase in pulse volume D. A decrease in pulse pressure

An increase in pulse volume

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? Use an alcohol-based mouthwash to moisten your mouth. Avoid salty or excessively sweet fluids. Use regular gum and hard candy. Eat crackers and bread.

Avoid salty or excessively sweet fluids.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? A. Avoid replacing IV solutions every 24 hours. B. Select a primary tubing of about 37 inches (94 cm) long. C. Ensure that the prescribed solution the expected color and consistency. D. Use half-instilled IV solutions before infusing a new one.

Ensure that the prescribed solution the expected color and consistency.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? A. Ensure that the prescribed solution the expected color and consistency. B. Select a primary tubing of about 37 inches (94 cm) long. C. Use half-instilled IV solutions before infusing a new one. D. Avoid replacing IV solutions every 24 hours.

Ensure that the prescribed solution the expected color and consistency.

The nurse understands that various mechanisms in the body help move fluid from one compartment to another. Which transport mechanism is governed by oncotic and hydrostatic pressures? A. Osmosis B. Diffusion C. Filtration D. Active transport

Filtration

The nurse checks a meal tray for a patient on a clear liquid diet. The item that is acceptable is: A. Ginger ale B. Lemon sherbet C. Vanilla ice cream D. Cream of chicken soup

Ginger ale

The physician progresses a patient's diet from clear liquid to full liquid. Which can the nurse include on the full-liquid diet that is not included on the clear-liquid diet? A. Cranberry juice B. Ginger ale C. Jell-O D. Milk

Milk

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? Diminished cognitive ability and hypertension Nausea, vomiting, and constipation Muscle weakness, fatigue, and dysrhythmias Muscle weakness, fatigue, and constipation

Muscle weakness, fatigue, and dysrhythmias

To encourage a confused patient to drink more fluid, the nurse should: A. Serve fluid at a tepid temperature B. Explain the reason for the desired intake C. Offer the patient something to drink every hour D. Leave a pitcher of water at the patient's bedside

Offer the patient something to drink every hour

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect? Sepsis Air embolism Infiltration Phlebitis

Phlebitis

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect? Sepsis Infiltration Air embolism Phlebitis

Phlebitis

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: a systemic blood infection. rapid fluid administration. phlebitis. an infiltration.

Phlebitis.

The physician orders hydrochlorothiazide, a diuretic for a patient who is retaining fluid. The nurse should encourage the patient to ingest nutrients rich in: A. Magnesium B. Potassium C. Calcium D. Sodium

Potassium

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Encourage fluid intake. Start an IV of normal saline as prescribed. Give the client a glass of orange juice with added sugar. Allow nothing by mouth.

Start an IV of normal saline as prescribed.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Give the client a glass of orange juice with added sugar. Encourage fluid intake. Allow nothing by mouth. Start an IV of normal saline as prescribed.

Start an IV of normal saline as prescribed.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? increased blood volume and intracellular dehydration increased blood volume and extracellular overhydration decreased blood volume and intracellular dehydration decreased blood volume and extracellular overhydration

decreased blood volume and intracellular dehydration

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 fingerprinting over sternum nausea and vomiting muscle twitching

distended neck veins

Edema happens when there is which fluid volume imbalance? water deficit water excess extracellular fluid volume deficit extracellular fluid volume excess

extracellular fluid volume excess