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

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. Infuse saline at a rapid rate. c. Prepare to give an antihistamine. d. Administer oxygen.

a. Stop the transfusion immediately.

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

Which is a common anion? a. magnesium b. potassium c. chloride d. calcium

c. chloride

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? a. excessive use of laxatives b. diaphoresis c. renal failure d. increased cardiac output

c. renal failure

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. "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)." b. "We do not record fluids absorbed into undergarments." c. "Estimate the amount of fluid that you think was excreted into the undergarment." d. "You only record urine output in an adult undergarment; you do not record diarrhea output."

a. "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)."

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)

A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply. a. Fever b. Facial flushing c. Low back pain d. Urticaria e. Hematuria

a. Fever b. Facial flushing c. Low back paine. Hematuria

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 siderail. 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 action is most appropriate? a. Remove the IV catheter and reinsert another in a different location. b. Decontaminate the visible portion of the catheter, and then gently reinsert. c. Apply a new dressing and observe for signs of infection over the next several hours. d. Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air.

a. Remove the IV catheter and reinsert another in a different location.

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? a. muscle cramping and tetany b. nausea, vomiting, and constipation c. diminished cognitive ability and hypertension d. muscle weakness, fatigue, and constipation

a. muscle cramping and tetany

A nurse is teaching a client regarding a newly implanted venous access system. Which statement by the nurse is incorrect? a. "The implanted venous access is hidden under the skin." b. "You won't have to endure any more needlesticks." c. "The catheter will need to be flushed periodically with heparin." d. "Implanted catheters have a self-sealing port."

b. "You won't have to endure any more needlesticks."

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. a. Prescribing the kind of IV solution. b. Deciding the location of the IV catheter. c. Deciding the size of the IV catheter. d. Administering the IV solution. e. Determining the amount of IV solution.

b. Deciding the location of the IV catheter. c. Deciding the size of the IV catheter. d. Administering the IV solution.

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

b. Ensure that the prescribed solution is clear and transparent.

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action? a. Not performing the intervention under sterile conditions b. Not wearing gloves when performing the intervention c. By applying stabilizing pressure to the catheter d. By pulling the dressing toward the insertion site

b. Not wearing gloves when performing the intervention

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

b. O negative

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.

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.

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. muscle twitching b. distended neck veins c. fingerprinting over sternum d. nausea and vomiting

b. distended neck veins

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

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

c. 2,500 mL/day

A nurse is calculating the output of a client with renal failure and takes into account all modes of fluid loss. When addressing the client's insensible fluid loss via respiration, which amount would the nurse anticipate as the usual average? a. 100 to 200 mL/day b. 200 mL/day c. 300 mL/day d. 1500 mL/day

c. 300 mL/day

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

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

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. allergic reaction: allergy to transfused blood b. febrile reaction: fever develops during infusion c. hemolytic transfusion reaction: incompatibility of blood product d. bacterial reaction: bacteria present in the blood

c. hemolytic transfusion reaction: incompatibility of blood product

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

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? a. Dairy products b. Apricots c. Processed meat d. Bread products

b. Apricots

A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: a. an access route to administer medications intravenously. b. replacement of fluids for those lost from vomiting and diarrhea. c. an access route to replace fluids in combination with blood products. d. intravenous fluids to be administered on an outpatient basis.

b. replacement of fluids for those lost from vomiting and diarrhea.

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

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? a. 3,750 b. 3,000 c. 1,000 d. 500

b. 3,000

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

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

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

c. Metabolic alkalosis

The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to: a. increase in muscle mass. b. smaller stomach capacity. c. decreased skin area. d. increase in fat cells.

d. increase in fat cells.