Chapter 40: Fluid, Electrolyte, and Acid-Base Balance

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

-Deciding the location of the IV catheter. -Deciding the size of the IV catheter. -Administering the IV solution. Rationale: The nurse is responsible for deciding the location and size of the IV catheter, as well as for administering the solution. The primary care provider is responsible for prescribing the kind and amount of solution. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1602-1610. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1602-1610

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? A. Include more bananas in the diet. B. Include more cheese in the diet. C. Include more canned vegetables in the diet. D. Include more bread in the diet.

A. Include more bananas in the diet. Explanation: Hypokalemia is a below-normal potassium level. Bananas are high in potassium. Adding bananas to the diet can help increase the serum potassium level. Canned vegetables, cheese, and bread do not have a high potassium content. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, Developing a Dietary Plan, p. 1576.

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? A. calcium and phosphorus B. potassium and sodium C. potassium and chloride D. chloride and magnesium

A. calcium and phosphorus Explanation: The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1560.

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? A. muscle weakness, fatigue, and arrythmias B. nausea, vomiting, and constipation C. diminished cognitive ability and hypertension D. muscle weakness, fatigue, and constipation

A. muscle weakness, fatigue, and arrythmias Rationale: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and arrythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1566. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1566

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? A. normal saline solution B. plasma C. albumin D. granulocytes

B. plasma Explanation: The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells. Albumin pulls third-spaced fluid by increasing colloidal osmotic pressure but does not restore clotting factors. The infusion of granulocytes improves the ability of the body to overcome infection. Normal saline is an isotonic solution that replaces fluid loss but does not replace clotting factors. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, Administering Blood and Blood Products, p. 1593.

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

C. "Fluid in the tissue space between and around cells." Rationale: 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). Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1556

Which client would be a candidate for total parenteral nutrition? A. a client receiving intravenous antibiotics B. a postoperative appendectomy client C. a client with colitis and bloody diarrhea D. a client with diabetic ketoacidosis

C. a client with colitis and bloody diarrhea Explanation: Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing. A client with bloody diarrhea and colitis requires complete bowel rest. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1597.

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

C. sodium, chloride, and bicarbonate. Rationale: The primary extracellular electrolytes are sodium, chloride, and bicarbonate. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1558. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1558

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? A. 2+ B. 4+ C. 3+ D. 1+

D. 1+ Explanation: The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1565.

Edema happens when there is which fluid volume imbalance? A. extracellular fluid volume deficit B. water deficit C. water excess D. extracellular fluid volume excess

D. extracellular fluid volume excess Rationale: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

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? A. An implanted central venous access device (CVAD) B. A peripheral venous catheter inserted to the antecubital fossa C. A peripheral venous catheter inserted to the cephalic vein D. A midline peripheral catheter

A. An implanted central venous access device (CVAD) Rationale: 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. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1583. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1583

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? A. 42 gtt/min B. 83 gtt/min C. 167 gtt/min D. 5,000 gtt/min

B. 83 gtt/min Rationale: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1602-1610. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1602-1610

A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? A. 20 gtt/min B. 30 gtt/min C. 40 gtt/min D. 50 gtt/min

D. 50 gtt/min Rationale: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1627. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1627

Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. -Hypervolemia management -Fluid restriction -Intravenous therapy -Electrolyte management -Monitoring edema -Nutrition management

-Intravenous therapy -Electrolyte management -Nutrition management Rationale: If a client is at a fluid volume deficit, intravenous therapy may be ordered by the primary care provider to replenish fluids and electrolytes, warranting fluid and electrolyte management. Nutrition management may help to increase and maintain electrolyte levels by adding foods high in certain electrolytes to the diet. Hypervolemia refers to fluid volume excess. Fluid restriction would be contraindicated because the client is already at a deficit. Edema would be monitored in the case of fluid volume excess. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply. -Metabolic alkalosis -Hypokalemia -Respiratory acidosis -Hypernatremia -Hypercalcemia

-Metabolic alkalosis -Hypokalemia Rationale: If sufficient gastric juice (ECF with additional acid) is lost from the stomach, then consequently hydrogen, sodium, and chloride ions are depleted, increasing the risk of ECF volume deficit and/or metabolic alkalosis. Gastric fluid also is high in potassium, and excessive losses may contribute to hypokalemia. Respiratory acidosis would be more likely to occur with an underlying lung disorder, such as asthma or emphysema. Vomiting leads to a loss of sodium, so elevated sodium levels would be unlikely. Imbalances of calcium are not typically associated with imbalances associated with vomiting. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1565. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1565

The nurse working at the blood bank is speaking with a potential blood donor client. The client has been living in South America where there was a Zika outbreak. Which statement by the nurse is most appropriate? A. "Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions." B. "As long as you did not receive any blood transfusions while living in South America, you may donate blood." C. "To prevent the spread of microorganisms, anyone who has lived out of the country for over 6 months is unable to donate blood." D. "While living in South America, you may have been exposed to a lot of different diseases, which makes you ineligible to donate blood."

A. "Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions." Explanation: In February 2016, the U.S. Food and Drug Administration (FDA) issued recommendations to reduce the risk of transmission of the Zika virus through blood transfusion. The FDA recommends deferral of people from donating blood if they have been to areas with active Zika virus transmission, potentially have been exposed to the virus, or have had a confirmed Zika virus infection (FDA, 2016). Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1595.

What commonly used intravenous solution is hypotonic? A. 0.45% NaCl B. lactated Ringer's C. 0.9% NaCl D. 10% dextrose in water

A. 0.45% NaCl Explanation: 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. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1579.

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? A. 2,500 mL/day B. 3,500 mL/day C. 1,000 mL/day D. 1,500 mL/day

A. 2,500 mL/day Explanation: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. 1,000 mL/day and 1,500 mL/day are too low, and 3,500 mL/day is too high. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1573.

A home care nurse is visiting a client with acute kidney injury 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? A. Avoid salty or excessively sweet fluids. B. Use regular gum and hard candy. C. Eat crackers and bread. D. Use an alcohol-based mouthwash to moisten your mouth.

A. Avoid salty or excessively sweet fluids. Rationale: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1578. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1578

A nurse is inspecting the IV site of a client and notices that the site is swollen, red, warm to the touch, and painful. Which action by the nurse is appropriate? A. Discontinue the IV and relocate it to another spot. B. Call the health care provider and ask if anti-inflammatory drugs should be administered. C. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours. D. Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site.

A. Discontinue the IV and relocate it to another spot. Rationale: The nurse should inspect the IV site for presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleaning with alcohol or chlorhexidine is not recommended and does not reduce the phlebitis. The nurse does not need to call the health care provider for anti-inflammatory medications. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1614. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1614

The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate? A. Discontinue the infusion and record the volume left in the blood bag. B. Fully open the roller clamp on the infusion set and infuse the remaining PRBCs as rapidly as possible. C. Continue to infuse the PRBCs until they are completely infused. D. Insert a larger gauge IV catheter and transfer the infusion to the new insertion site.

A. Discontinue the infusion and record the volume left in the blood bag. Explanation: Transfusions must be completed within 4 hours due to the potential for bacterial growth in a blood product at room temperature. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1620-1624.

A client has been diagnosed with stage II breast cancer and will require 8 weeks of chemotherapy. Which intravenous access would the nurse anticipate? A. Groshong catheter tunneled under the subclavian vein B. PICC catheter inserted in the axillary vein C. 18 gauge peripheral IV port in the left forearm D. percutaneous catheter in the jugular vein

A. Groshong catheter tunneled under the subclavian vein Rationale: A Groshong catheter is a tunneled catheter that is frequently used for extended therapy. The tunneling helps to secure the catheter, as well as reduce the potential for infection. The other catheter choices are not the most appropriate. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1595. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1595

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)? A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A. Metabolic alkalosis Rationale: Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1574. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1574

A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? A. Sacral area B. Face C. Hands D. Abdomen

A. Sacral area Rationale: The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. The edema cannot be assessed in the face, hands and abdomen, as these are not dependent areas. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

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? A. Stop the transfusion immediately. B. Administer oxygen. C. Infuse saline at a rapid rate. D. Prepare to give an antihistamine.

A. Stop the transfusion immediately. Explanation: 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. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1622.

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? A. The client has anti-A antibodies. B. The client has anti-B antibodies. C. The client has both anti-A and anti-B antibodies. D. The client is a universal donor.

A. The client has anti-A antibodies. Rationale: 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. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1594. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1594

The nurse is preparing to access an implanted port when administering intravenous fluids and medications. What best practice should be used when accessing this port? A. The system is accessed with a noncoring needle and patency is maintained by periodic flushing. B. A smaller gauge (17-gauge) is preferred for administration of blood products. C. When venous access is desired, the location of the injection port must be located via an x-ray. D. In general, a ½-in, 18-gauge needle is most frequently used. If the client has a significant amount of subcutaneous tissue, a longer length (1 or 1½ in) may be selected.

A. The system is accessed with a noncoring needle and patency is maintained by periodic flushing. Explanation: The system is accessed with a noncoring needle, and patency is maintained by periodic flushing. When venous access is desired, the location of the injection port must be palpated and an x-ray is used after initial insertion. In general, a ¾-in (2-cm) 20-gauge needle is most frequently used. A longer length of 1 or 1 1/2 inches is not used. A larger gauge (19-gauge) is preferred for administration of blood products. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1584.

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? Select all that apply. A. Treat the underlying condition that B. contributes to increased fluid volume. B. Ask provider to order a low-salt diet. C. Reduce infusing fluid volume as ordered. D. Administer furosemide as ordered. E. Increase oral intake to flush excess fluids.

A. Treat the underlying condition that B. contributes to increased fluid volume. B. Ask provider to order a low-salt diet. C. Reduce infusing fluid volume as ordered. D. Administer furosemide as ordered. Explanation: Control of edema, and thus restoration of fluid balance, can be accomplished by treating the disorder contributing to the increased fluid volume, restricting or limiting oral fluids, reducing salt consumption, discontinuing IV fluid infusions or reducing the infusing volume, and/or administering drugs that promote urine elimination. Increasing oral intake to flush excess fluids is not an appropriate intervention. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. A. Type of IV solution B. Client's reaction to the procedure C. Location of the IV catheter access D. Rate of the IV solution E. Manufacturer of the IV catheter F. Gauge and length of the IV catheter

A. Type of IV solution B. Client's reaction to the procedure C. Location of the IV catheter access D. Rate of the IV solution F. Gauge and length of the IV catheter Explanation: The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client's reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1611-1613.

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? A. banana B. milk C. yogurt D. turkey

A. banana Rationale: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1576. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1576

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? A. cardiac irregularities B. muscle weakness C. increased intracranial pressure (ICP) D. metabolic acidosis

A. cardiac irregularities Rationale: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac arrythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1566. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1566

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

A. decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556.

client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? A. hypertonic solution B. hypotonic solution C. isotonic solution D. colloid solution

A. hypertonic solution Rationale: Hypertonic solutions are used in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. Hypotonic solutions are administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. However, these solutions are not related to clients with cerebral edema. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1561. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1561

A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? A. maintenance of cell size B. maintenance of blood volume C. transportation of nutrients D. removal of waste

A. maintenance of cell size Rationale: The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1554-1556. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1554-1556

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. phlebitis. B. an infiltration. C. a systemic blood infection. D. rapid fluid administration.

A. phlebitis. Ratioanel: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1589-1590. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1589-1590

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? A. "I was breathing so fast because I was so anxious and in so much pain." B. "I've been taking antacids almost every 2 hours over the past several days." C. "I've had a fever for the past 3 days that just doesn't seem to go away." D. "I've had a GI virus for the past 3 days with severe diarrhea."

B. "I've been taking antacids almost every 2 hours over the past several days." Rationale: Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1574. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1574

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. "Unfortunately, your own blood cannot be reinfused during surgery." B. "Let me refer you to the blood bank so they can provide you with information." C. "This surgery has a very low chance of hemorrhage, so you will not need blood." D. "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." Rationale: Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be reinfused. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1621. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1621

The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate? A. "We do not record fluids absorbed into undergarments." B. "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." C. "You only record urine output in an adult undergarment; you do not record diarrhea output." D. :If the undergarment is soiled, document this fact but do not estimate its contents."

B. "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." Explanation: Fluid output is the sum of liquid eliminated from the body, including urine, emesis (vomitus), blood loss, diarrhea, wound or tube drainage, and aspirated irrigations. In cases in which an accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, diapers, or dressings, and subtracts the weight of a similar dry item. An estimate of fluid loss is based on the equivalent: 1 lb (0.47 kg) = 1 pint (475 mL). Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556.

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? A. As fast as the client can tolerate B. 1 unit over 2 to 3 hours, no longer than 4 hours C. 75 mL/hr for the first 15 minutes, then 200 mL/hr D. 200 mL/hr

B. 1 unit over 2 to 3 hours, no longer than 4 hours Rationale: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1623. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1623

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 A. 60 gtt/min B. 100 gtt/min C. 160 gtt/min D. 600 gtt/min

B. 100 gtt/min Rationale: 100gtt/min is the correct rate. 1000 mL divided by 10 hours = 100 mL per hour x 60 gtt/minute, divided by 60 minutes/hour. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1587. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1587

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? A. 30 drops/mL B. 60 drops/mL C. 90 drops/mL D. 120 drops/mL

B. 60 drops/mL Rationale: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL). Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1588. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1588

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? A. Respiratory alkalosis B. Metabolic alkalosis C. Respiratory acidosis D. Metabolic acidosis

B. Metabolic alkalosis Rationale: Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1574. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1574

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

B. Offer small amounts of preferred beverage frequently. Rationale: Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1576. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1576

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? A. Sepsis B. Phlebitis C. Infiltration D. Air embolism

B. Phlebitis Rationale: Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1590. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1590

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? A. Apply a new dressing and observe for signs of infection over the next several hours. B. Remove the IV catheter and reinsert another in a different location. C. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. D. Decontaminate the visible portion of the catheter, and then gently reinsert.

B. Remove the IV catheter and reinsert another in a different location. Explanation: An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1611-1613.

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? A. Slow the rate of IV fluids. B. Remove the IV. C. Apply a warm compress. D. Elevate the arm.

B. Remove the IV. Rationale: The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1578-1579. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1578-1579

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? A. Decrease the rate of the intravenous fluids. B. Remove the peripheral intravenous catheter. C. Place a warm compress over the swollen site. D. Elevate the swollen extremity on a pillow.

B. Remove the peripheral intravenous catheter. Rationale: The assessment findings of a swollen IV site with surrounding tissue swelling and cool to touch indicate infiltration. The correct action for an infiltrated IV is to remove the IV. Decreasing the rate of fluids requires the health care provider's prescription and is not indicated for infiltration. Placing a warm compress is not indicated for infiltration. Elevating the swollen extremity is for peripheral edema, not infiltration. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1588-1589. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1588-1589

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? A. Elevate the client's head. B. Restart infusion in another vein and apply a warm compress. C. Position the client on the left side. D. Apply antiseptic and a dressing.

B. Restart infusion in another vein and apply a warm compress. Rationale: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1590. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1590

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? A. The client has a decreased sensation of thirst. B. The renal system retains more water. C. The frequency of voiding increases. D. Urine becomes more diluted.

B. The renal system retains more water. Explanation: When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1560.

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. an intermittent infusion device. B. a winged infusion needle. C. a central venous access. D. an 18-gauge needle.

B. a winged infusion needle. Explanation: Winged infusion needles 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. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1580.

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? A. fingerprinting over sternum B. distended neck veins C. nausea and vomiting D. muscle twitching

B. distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564.

A dialysis unit nurse caring for a client with acute kidney injury will expect the client to exhibit which fluid and electrolyte imbalances? A. fluid volume deficit and alkalosis B. fluid volume excess and acidosis C. fluid volume excess and alkalosis D. fluid volume deficit and acidosis

B. fluid volume excess and acidosis Explanation: Fluid volume excess can be caused by malfunction of the kidneys (i.e., acute kidney injury). The kidneys are also responsible for acid-base balance, and in the presence of acute kidney injury, the kidneys cannot regulate hydrogen ions and bicarbonate ions; thus, the client develops metabolic acidosis. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1575.

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? A. hyponatremia B. hypokalemia C. hypercalcemia D. hypermagnesemia

B. hypokalemia Rationale: All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1565-1566. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1565-1566

During an assessment of an older adult 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. Which medical diagnosis may be responsible? A. hypervolemia B. hypovolemia C. circulatory overload D. edema

B. hypovolemia Explanation: 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). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564.

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

B. pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) Rationale: 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. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1572. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1572

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? A. asking the client to pump their fist several times B. placing the tourniquet on the upper arm for 2 minutes C. asking if the client is right or left handed D. palpating the veins on the nondominant hand

B. placing the tourniquet on the upper arm for 2 minutes Rationale: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1605-1606. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1605-1606

A client is preparing for discharge to home following a diagnosis of hypoparathyroidism with associated low parathyroid hormone. Which food(s) will the nurse include when creating a diet-based teaching plan for the client? Select all that apply. A. peaches B. tofu C. broccoli D. yogurt E. bananas F. peanuts

B. tofu C. broccoli D. yogurt Explanation: The parathyroid produces the hormone parathormone (PTH), which regulates serum calcium levels. A low level of PTH results in hypocalcemia. The nurse's diet-based teaching plan should include foods that include high levels of calcium, such as dairy products like yogurt and cheese. Dark green vegetables like broccoli, spinach, or greens are important sources of calcium. Oysters, salmon, and sardines are also great sources of calcium. Peanuts will help raise the levels of sodium, but not calcium. Other sources of sodium are bouillon, canned soups, and snack foods. A client can increase their levels of potassium by eating fruits such as peaches and other fruits, vegetables, or juices like orange and tomato juices. Bananas are excellent sources of magnesium, as well as potassium. Other sources of magnesium include eggs, milk, and whole grains. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, Table 40-1 Major Electrolytes, p. 1561.

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

C. "Fluid in the tissue space between and around cells." Explanation: 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). Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556.

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? A. "I need to drink no more than 1,000 mL/day" B. "I should drink 1,500 mL/day of fluid." C. "I should drink 2,500 mL/day of fluid." D. "I should drink more than 3,500 mL/day of fluid."

C. "I should drink 2,500 mL/day of fluid." Rationale: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1556

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. A hypertonic solution B. An isotonic solution C. A hypotonic solution D. Packed red blood cells

C. A hypotonic solution Explanation: 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. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1579.

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

C. Arterial blood gas Rationale: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1572. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1572

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? A. Increased sodium levels B. Increased potassium levels C. Decreased potassium levels D. Decreased oxygen levels

C. Decreased potassium levels Rationale: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1559. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1559

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? A. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet. B. Bowel motility will be restored within 24 hours after beginning supplemental K+. C. ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. D. ECG will show no cardiac arrythmias within 24 hours after beginning supplemental K+.

C. ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Explanation: If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac arrythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1565-1566.

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

C. Ensure that the prescribed solution the expected color and consistency. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution's color and consistency matches that expected based on the prescription, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1602.

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? A. Osmolar B. Isotonic C. Hypertonic D. Hypotonic

C. Hypertonic Explanation: A hypertonic solution has a greater osmolarity than plasma, which causes water to move out of the cells and be drawn into the intravascular compartment. A hypotonic solution has a lower osmolarity than plasma; therefore, fluid would move out of the intravascular space rather than pulling fluids from the tissues into the vascular space. An isotonic fluid remains in the intravascular compartment without any net flow across the semipermeable membrane. The concentration of particles in a solution is referred to as the osmolarity of a solution. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1561.

A nurse is presenting an in-service program to a group of graduate nurses about blood component therapy. The nurse determines that the education was successful when the group identifies which complication as the primary cause of transfusion-related client death in the United States? A. Septic reaction B. Transfusion-associated circulatory overload C. Transfusion-related acute lung injury D. Hemolytic reaction

C. Transfusion-related acute lung injury Explanation: Although transfusion-associated circulatory overload (TACO), septic reaction, and hemolytic reaction are possible complications of blood transfusion therapy, transfusion-related acute lung injury (TRALI) is the number one cause of client death related to blood transfusion in the United States. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1593.

Which statement most accurately describes the process of osmosis? A. Solutes pass through semipermeable membranes to areas of lower concentration. B. Plasma proteins facilitate the reabsorption of fluids into the capillaries. C. Water moves from an area of lower solute concentration to an area of higher solute concentration. D. Water shifts from high-solute areas to areas of lower solute concentration.

C. Water moves from an area of lower solute concentration to an area of higher solute concentration. Explanation: Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the reabsorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1558.

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? A. increased intracranial pressure (ICP) B. muscle weakness C. cardiac irregularities D. metabolic acidosis

C. cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac arrythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1566.

Which is a common anion? A. magnesium B. potassium C. chloride D. calcium

C. chloride Rationale: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1557. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1557

The process of filtration begins at the: A. Loop of Henle. B. collecting ducts. C. glomerulus. D. Bowman's capsule.

C. glomerulus. Explanation: The process of filtration begins at the glomerulus. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1562.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? A. febrile reaction: fever develops during infusion B. bacterial reaction: bacteria present in the blood C. hemolytic transfusion reaction: incompatibility of blood product D. allergic reaction: allergy to transfused blood

C. hemolytic transfusion reaction: incompatibility of blood product Explanation: 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. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1597.

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? A. isotonic B. hypotonic C. hypertonic D. hypotonic, followed by isotonic

C. hypertonic Rationale: A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1565. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1565

A client who is admitted to the health care facility has been diagnosed with cerebral edema. Which intravenous solution needs to be administered to this client? A. colloid solution B. hypotonic solution C. hypertonic solution D. isotonic solution

C. hypertonic solution Explanation: Hypertonic solutions are used in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. Hypotonic solutions are administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. However, these solutions are not related to clients with cerebral edema. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1561.

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? A. hypertonic B. colloid C. isotonic D. hypotonic

C. isotonic Rationale: Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

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

C. renin. Rationale: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1559. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1559

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: A. cellular hydration. B. volume expander. C. total parenteral nutrition. D. blood transfusion therapy.

C. total parenteral nutrition. Rationale: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1597. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1597

A client is receiving a transfusion of packed red blood cells, and the nurse has obtained the first set of vital signs after initiating the transfusion. These closely match the pretransfusion vital signs with the exception of a 1°F (0.5°C) increase in the oral temperature. The client denies other symptoms and is not in distress. What is the nurse's most appropriate action? A. Promptly discontinue the transfusion, and remove the client's IV. B. Call the blood bank and obtain diagnostic tubes. C. Discontinue transfusion immediately, and infuse normal saline with new tubing. D. Administer acetaminophen as prescribed.

D. Administer acetaminophen as prescribed. Explanation: If the client's only sign or symptom is an increase in temperature, which is less than 2°F (1°C), there is no need to wholly discontinue the transfusion. The health care provider should be informed, however; and the client may receive acetaminophen or an antihistamine, as prescribed. A febrile reaction includes a fever of 2°F (1°C) or higher, tachycardia, and presence of headaches or backache. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1620-1624.

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

D. Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1572.

A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action? A. Flush the IV with 2 mL of 100 U/mL heparin. B. Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. C. Change from infusion with an electronic pump to infusion by gravity. D. Flush the IV with 3 mL of normal saline.

D. Flush the IV with 3 mL of normal saline. Explanation: If fluid is slow to infuse, the nurse should reposition the client's arm and/or flush the IV. Changing to IV infusion will not resolve the problem and heparin is not used for clearing peripheral IVs. Deep vein thrombosis is unrelated to slow IV fluid infusion. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1602-1610

A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? A. Transparent semipermeable B. membrane dressing C. Occlusive dressing D. Gauze dressing E. Sealed IV dressing

D. Gauze dressing Explanation: A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. Transparent semipermeable membranes are a type of sealed IV dressing. Occlusive dressings would not be appropriate. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, VENOUS ACCESS CARE AND MANAGEMENT, p. 1591.

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? A. Calcium B. Chloride C. Phosphorous D. Potassium

D. Potassium Rationale: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. Signs of potassium defecit, or hypokalemia, include muscle weakness and leg cramps, fatigue, paresthesias, and arrythmias. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1566. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1566

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

D. Start an IV of normal saline as prescribed. Rationale: 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. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, skill 40-1, p. 1605. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1605

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action? A. Call for assistance. B. Assess oxygen levels. C. Assess for visible rash. D. Stop the transfusion.

D. Stop the transfusion. Explanation: Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1597.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? A. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today B. a 60-year-old who is 3 days post-myocardial infarction and has been stable. C. a 47-year-old who had a colon resection yesterday and is reporting pain D. a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

D. a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Rationale: Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med). Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1564. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1564

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? A. an adolescent age 17 years B. a woman age 45 years C. a man age 50 years D. an infant age 4 months

D. an infant age 4 months Explanation: An infant has considerably more total body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits. An adolescent at 17 years is considered to have an adultlike body system similar to the 45-and 50-year-old. Reference: Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1556.

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: A. hypocalcemia. B. hypothyroidism. C. hypoglycemia. D. hypokalemia.

D. hypokalemia. Rationale: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits. Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, pp. 1565-1566. Chapter 40: Fluid, Electrolyte, and Acid-Base Balance - Page 1565-1566