Chapter 41: Fluid, Electrolyte, and Acid-Base Balance

A client has been diagnosed with excessive levels of aldosterone. The nurse's assessment will include what value?

Potassium level Explanation: Aldosterone regulates the extracellular concentration of potassium. An excess would create a risk for hypokalemia. Acid-base balance, thirst level and calcium would be affected to a lesser degree.

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. Explanation: 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.

The primary extracellular electrolytes include which of the following?

Sodium, chloride, and bicarbonate Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.

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?

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

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?

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.

The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtt [drops]/1mL. What is the infusion rate?

42 gtt/min Explanation: When infusing by gravity, divide the total volume in mL (1,000 mL) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtt/mL. The correct answer is 42 gtt/min.

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?

60 drops/mL Explanation: 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).

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?

83 gtt/min Explanation: 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

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) Explanation: 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.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels Explanation: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

An adult client has developed gastric esophageal reflux disease and is treating it with frequent doses of antacids. The nurse will assess for what acid-base disorder?

Metabolic alkalosis Explanation: Ingestion of large amounts of antacids cause metabolic alkalosis due to the increase in stomach pH. This alkalosis is unrelated to respiratory function.

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action?

Not wearing gloves when performing the intervention Explanation: The changing of a peripheral venous access site dressing requires the use of clean gloves to minimize the transmission of microorganisms during the procedure and to prevent the nurse from coming into contact with blood. The intervention does not require sterile precautions. The manner in which the nurse is applying stabilizing pressure to the catheter and pulling the adhered dressing toward the insertion site demonstrates appropriate technique.

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?

Offer small amounts of preferred beverage frequently. Explanation: 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.

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?

Phlebitis Explanation: 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.

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?

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.

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?

Remove the peripheral intravenous catheter. Explanation: 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.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?

Sodium is regulated by the renin-angiotensin-aldosterone system. Explanation: Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.

What signs of complications and their probable causes may occur when administering an IV solution to a client? Select all that apply.

Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. Local or systemic manifestations may indicate an infection is present at the site. Explanation: If the IV catheter has become dislodged and IV fluid is flowing into the tissues, then infiltration has occurred. Infiltration is indicated with swelling, pain, coolness, or pallor at the insertion site. Redness, swelling, heat, and pain at the site may indicate phlebitis of the vein. If the site has become infected, it may be contained as a localized infection, or it can spread throughout the bloodstream as a systemic infection. A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when fluids are administered too rapidly (speed shock). Bleeding at the IV site indicates the need for additional pressure to be applied to the site. This can occur if the client is taking anticoagulants or has a bleeding disorder. Engorged neck veins, increased blood pressure, and dyspnea occur when fluid overload has occurred.

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.

The nurse has inserted a peripheral intravenous catheter. When applying a transparent dressing, what is the nurse's best action?

The transparent dressing should be placed in such a manner as to allow full coverage and visibility of the insertion site, without excessively covering the tubing.

Which statement most accurately describes the process of osmosis?

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.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?

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.

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?

hemolytic transfusion reaction: incompatibility of blood product 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.

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?

hypokalemia Explanation: Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia. Sodium and chloride levels would be low, not elevated. Changes in magnesium levels typically would not be associated with diarrhea.

The nurse is caring for an 86-year-old client who fell at home and was not found for 2 days. The client is severely dehydrated. The client is at increased risk for fluid imbalance due to:

increase in fat cells. Explanation: The decreasing percentage of body fluid in an older adult client is related to an increase in fat cells. In addition, an older adult client looses muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in an older adult client. An older adult client does not have an increase in muscle mass, smaller stomach capacity, or a decrease skin area.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by:

increasing ventilation through the lungs. Explanation: The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. To compensate for respiratory alkalosis, the kidneys increase the excretion of HCO3− to the urine. Kidneys compensate for respiratory acidosis by increasing the excretion of H+ ion into the urine. The kidneys respond to metabolic alkalosis by retaining acid and excreting HCO3−.

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?

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

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes Explanation: 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.

When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which complication has most likely occurred?

thrombus Explanation: Phlebitis and thrombus present as local acute tenderness, redness, warmth, and slight edema of the vein above the site. Sepsis manifests as a red and tender insertion site with fever, malaise, and other vital sign changes. Infiltration (or the escape of fluid into the subcutaneous tissue) manifests as swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

"I should drink 2,500 mL/day of fluid." 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.

Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply.

0.9% NaCl (normal saline) Lactated Ringer's solution 5% dextrose in 0.9% NaCl Explanation: 0.9% NaCl (normal saline) and Lactated Ringer's solution are isotonic solutions that have a total osmolality close to that of the ECF and help replace the ECF in the treatment of hypovolemia. 5% dextrose in 0.9% NaCl is a hypertonic solution that can temporarily be used to treat hypovolemia if plasma expander is not available. 10% dextrose in water (D10W) is a hypertonic solution that is used in peripheral parenteral nutrition. 0.45% NaCl (½-strength normal saline) is a hypotonic solution that provides Na+, Cl-', and free water and is used as a basic fluid for maintenance needs. 5% dextrose in water (D5W) is used in fluid loss, dehydration and hypernatremia, and should not be used in excessive volumes because it does not contain any sodium.

A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted?

10- to 15-degree angle Explanation: The IV catheter should be inserted at a 10- to 15-degree angle.

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 Explanation: 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.

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

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.

The health care provider writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse? Record your answer using a whole number.

25 Explanation: Amount to infuse in milliliters x rate of infusion in minutes / drop factor of tubing = drops per minute 150 mL x 60 minutes / 10 drop factor = 25 drops per minute

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?

50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

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 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.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?

Apply pressure to insertion site for at least 3 minutes. Explanation: The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.

What is the lab test commonly used in the assessment and treatment of acid-base balance?

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.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation?

Discontinue the IV and relocate it to another site. Explanation: The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.

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?

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

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?

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.

The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect?

Hypocalcemia Explanation: The parathyroid gland regulates calcium levels, and partial removal can cause hypocalcemia. Hypocalcemia is manifested by numbness and tingling as well as tetany. The signs and symptoms do not relate to altered magnesium or potassium levels. Calcium and phosphorus have an inverse relationship, so with low calcium, the nurse will expect a high, not a low, phosphorus level.

An older adult client who takes diuretics for management of hypertension, informs the nurse that they take laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of what health problem?

Hypokalemia -Explanation: The frequent use of laxatives and diuretics promotes the excretion of potassium from the body, increasing the risk for hypokalemia. This combination of medications does not create a risk for hypothyroidism, hypoglycemia or hypocalcemia.

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the health care provider of what abnormal value?

Low calcium Explanation: Normal total serum calcium levels range between 8.9 and 10.1 mg/dL (2.225 to 2.525 mmol/L). The other values are within reference ranges.

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)?

Metabolic alkalosis Explanation: 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.

A client is receiving IV fluids. The solution has an osmolarity of 280 mOsm/L. The nurse would expect which event to occur with the body's fluids?

No shifting of fluids occurs. Explanation: Isotonic fluids have an osmolarity of 250 to 375 mOsm per liter, which is the same osmotic pressure as that found within the cell. Isotonic fluids are used to expand the intravascular compartment and thus increase circulating volume. Because these solutions do not alter serum osmolarity, interstitial and intracellular compartments remain unchanged and no fluid shifts occur. Hypotonic fluids have an osmolarity lower osmotic pressure than the cell. When a hypotonic solution is infused, it lowers serum osmolarity, causing body fluids to shift out of the blood vessels and into the cells and interstitial space. Hypertonic fluids have an osmolarity higher and a greater osmotic pressure than the cell. When a hypertonic solution is infused, serum osmolarity is increased, pulling fluid from the cells and the interstitial tissues into the vascular space.

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

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

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?

O negative Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. Rh-negative persons should never receive Rh-positive blood.

A client's blood pressure has dropped from 146/92 mmHg to 107/68 mmHg over the course of several minutes. Increased levels of which of the following will be released into the client's bloodstream?

Renin Explanation: Decreased arterial blood pressure can stimulate renin release as part of a compensatory response. Low BP does not prompt the release of insulin, erythropoietin or protein.

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?

Restart infusion in another vein and apply a warm compress. Explanation: 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.

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?

Sacral area Explanation: 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.

The nurse is determining a site for an IV infusion. What guideline should the nurse consider?

Scalp veins should be selected for infants because of their accessibility. Explanation: Potential sites for neonates and children include: veins of the scalp (neonates under 6 months) because of the accessibility, and dorsal veins of the foot (toddlers). The antecubital veins are not a good choice for infusion because flexion of the client's arm can displace the IV catheter. The veins in the leg of an adult should not be used, unless other sites are inaccessible, because of the danger of stagnation of peripheral circulation and possible serious complications, such as deep vein thrombosis. Veins in surgical areas are not recommended and would not increase the potency of medication.

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

Start an IV of normal saline as prescribed. Explanation: 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.

During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first?

Stop the transfusion immediately. 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.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Explanation: 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).

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 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.

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?

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.

A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply.

crackles in the lungs distended neck veins Explanation: Right-sided heart failure leads to a back up of volume which is unable to effectively flow back to the left side of the heart. The result is fluid volume excess in the peripheral circulation which eventually leads to fluid overload. Fluid excess or hypervolemia will manifest in clinical symptoms that lead the nurse to hear crackles in the lungs upon chest auscultation. Fluid volume excess leads to translocation of large volumes of intravascular fluid to the interstitial compartment or to areas with only potential spaces such as the peritoneal cavity, pericardium, and pleural space such as in the lungs. Circulatory overload from fluid volume excess will lead to the client having distended neck veins. Fluid volume deficit causes low blood pressure whereas a volume excess would result in the client becoming hypertensive. Poor skin turgor is often seen in clients with fluid volume deficits or in dehydration. A client with a fluid volume excess would more likely have edema. A client who is hypervolemic is retaining fluid in the intravascular space preventing urinary elimination from occurring. Urinary retention rather than excessive elimination would be seen in this case.

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 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.

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?

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.

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?

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.

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address?

increased hydrostatic pressure Explanation: The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.

Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking?

muscle cramping and tetany Explanation: Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. 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.

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:

phlebitis. Explanation: 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.

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?

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.