prep u questions

The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?

Intracellular

A client is prescribed a diuretic as part of the treatment plan for heart failure. The nurse educates the client about the drug and dietary measures to prevent complications. The nurse determines that the client needs more education when he states that he will increase his consumption of:

Spinach. The client needs to increase his consumption of potassium-containing foods such as apricots, orange juice, and carrots. Spinach is high in calcium and magnesium but not potassium.

The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction?

"The kidneys store and release antidiuretic hormone to increase water retention." The pituitary glands store and release antidiuretic hormone rather than the kidneys. The other statements are correct regarding fluid and electrolyte balance.

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? (Select all that apply.)

Ask provider to order a low-salt diet. Administer furosemide as ordered. Reduce infusing fluid volume as ordered. Treat the underlying condition that contributes to increased fluid volume. 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.

The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?

Cardiac volume intolerance. The elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. The elderly typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.

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) -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.

The nurse is caring for a client whose baseline weight is 125 pounds. The client weighs 115 today. How does the nurse document the client's status?

Moderately dehydrated Hypovolemia refers to a low volume of extracellular fluid. If untreated, it may result in dehydration. Mild dehydration is present when there is a 3% to 5% loss of body weight; moderate dehydration is associated with a 6% to 10% loss of body weight; and severe dehydration, a life-threatening emergency, occurs with a loss of more than 9% to 15% of body weight. This client has lost 8% of body weight (10 pounds), and is therefore moderately dehydrated.

The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?

Renal failure. Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

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

Sodium is regulated by the renin-angiotensin-aldosterone system. Normal serum sodium levels range from 135 to 145 mEq/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.

After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?

every 72 hours IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first. IV tubings are not replaced after every solution is over or after every 12, 24, or 36 hours.

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

2,500 mL/day

A nurse identifies a nursing diagnosis of Excess Fluid Volume related to heart failure as evidenced by edema and weight gain. The nurse reviews the client's laboratory test results. Which plasma osmolality value would support the nurse's nursing diagnosis?

260mOSm/kg. Normal osmolality is 280 to 300 mOsm/kg. Plasma osmolality decreases in water excess and elevates in water deficit. Therefore a result of 260 mOsm/kg would support the diagnosis of excess fluid volume.

Which fluid should be administered slowly to prevent circulatory overload?

5% NaCl When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% NaCl and 5% NaCl.

The nurse is instructed by the physician that the client needs an intravenous fluid that is not likely to pull fluids into the vascular space. The nurse recognizes that the physician is suggesting which kind of fluid?

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.

Which age group is at risk for fluid and electrolyte imbalances resulting from fad dieting?

Adolescents Fad diets or purging to lose weight can cause severe fluid and electrolyte imbalances.

Major control over the extracellular concentration of potassium within the human body is exerted by:

Aldosterone exerts major control over the extracellular concentration of potassium. It also enhances renal secretion of potassium.

The nurse is providing care to a client who has been experiencing emesis for 24 hours. Which fluid should the nurse anticipate incorporating into the client's plan of care?

hypotonic. A hypotonic solution contains fewer dissolved substances than normally found in plasma. It is administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. The other fluids are not appropriate to administer.

The nurse is caring for a client whose baseline weight is 125 pounds. The client weighs 115 today. How does the nurse document the client's status?

moderately dehydrated: Hypovolemia refers to a low volume of extracellular fluid. If untreated, it may result in dehydration. Mild dehydration is present when there is a 3% to 5% loss of body weight; moderate dehydration is associated with a 6% to 10% loss of body weight; and severe dehydration, a life-threatening emergency, occurs with a loss of more than 9% to 15% of body weight. This client has lost 8% of body weight (10 pounds), and is therefore moderately dehydrated.

Which is not a primary intracellular electrolyte?

Chloride

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

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

Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?

Febrile reaction to blood components can occur because of the recipient's hypersensitivity to the donor's white blood cells. In this reaction, the client develops a fever and chills and may complain of a headache and malaise.

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?

Hypertonic 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.

The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which of the following statements made by students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply.

"The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." The adrenal glands regulate blood volume by secreting aldosterone." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst."

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L Potassium: 3.2 mEq/L Calcium: 4.4 mEq/L Magnesium: 1.6 mEq/L Chloride: 100 mEq/L Phosphate: 1.8 mEq/L Based on these levels, the nurse would identify which imbalance?

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). Therefore the client has hypokalemia.

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase, which may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?

Hypertonic Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.

A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate?

Offer the client sugar-free candy to help combat thirst. To minimize thirst for clients on fluid restriction, offer sugar-free candy and gum to help minimize thirst. Salty or very sweet fluids should be avoided. Rinsing the mouth with water and then having the client spit it out before swallowing may be helpful. Alcohol-based mouthwashes should be avoided because they have a drying effect. A water-based gel, not petroleum based, can be applied to the client's lips to moisten and prevent drying and cracking.

A nurse is teaching a client about his newly prescribed diuretic and how it affects his fluid and electrolyte balance. In addition to water, the nurse would explain that the drug also affects which electrolyte? Select all that apply.

Sodium Chloride Potassium Magnesium Diuretics are prescribed to increase the excretion of sodium, chloride, and water in clients with high blood pressure or with chronic heart, renal, or liver problems. At times, the medications may remove too much ECF from the body, resulting in a deficit. Diuretics, except for the potassium-sparing diuretics, also promote the excretion of potassium and magnesium from the body, increasing the risk of electrolyte deficits as well. Imbalances of calcium and phosphate are usually not associated with diuretic therapy.

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, which amount would the nurse anticipate as the usual average?

The fluid lost through insensible loss is about 300 to 400 mL/day. Insensible water loss occurs when water molecules move from an area of higher concentration, such as the body, to an area of lower concentration, like the atmosphere. Loss of fluid through the skin as perspiration accounts for an average daily loss of 100 to 200 mL of fluid. Loss of fluid through the gastrointestinal system in the form of feces is approximately 200 mL. Normal urine output for 24 hours is approximately 1500 mL if intake is normal.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?

The renal system retains more water. 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.

A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?

To prevent compromising circulation The nurse looks for a large vein when using a needle with a large gauge to prevent compromising circulation. To reduce the potential for blood clots and restrict a client's mobility, the nurse does not use foot or leg veins. The nurse avoids using veins on the inner surface of the wrist to prevent pain and discomfort.

A nurse is caring for an obese client with lung cancer who needs intermittent infusion of IV solution and medication for several months. Which of the following central venous catheters is most suitable for long-term access in a cancer client without the catheter protruding from the skin? Select all that apply.

Tunneled catheters Peripherally inserted central catheter Implanted access device A surgically implanted central access device is often used for clients with cancer so that they can be free of external tubing between treatments. They allow long-term access without having a catheter protrude from the skin. Tunneled catheters are also suitable because they may be used for months, even years, for continuous or intermittent therapy. An advantage of peripherally inserted central catheters (PICCs) is that surgical insertion is not required and it is appropriate for long-term therapy in the hospital or home. Because of the risk of complications, the multilumen, nontunneled catheters are used only in hospitalized client populations. These lines are associated with fewer severe complications such as pneumothorax, air embolism, and sepsis than other central lines.

Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L. For what manifestations will you be alert?

Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. 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.

A nurse is choosing a vein to start an IV infusion in a client. What are recommended veins to use when initiating an IV infusion? (Select all that apply.)

cephalic vein metacarpal basilic veins superficial veins on the dorsal aspect of the hand The cephalic vein, accessory cephalic vein, metacarpal, and basilic vein are appropriate sites for infusion (INS, 2006). The superficial veins on the dorsal aspect of the hand can also be used successfully for some people, but can be more painful). The antecubital vein should not be used if another vein is available because flexion of the arm can displace the IV catheter over time. Leg veins should not be used unless other sites are inaccessible because of the danger of stagnation of peripheral circulation and possible serious complications.

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:

electrolytes.The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have non-electrolytes, colloid solution, or interstitial fluid restored. Non-electrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.

During a blood transfusion, a client displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?

hemolytic transfusion reaction: incompatibility of blood product. The symptoms in answer C 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 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 would the nurse most likely address?

increased hydrostatic pressure. 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.

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's:

low calcium. Explanation: Normal total serum calcium levels range between 8.9 and 10.1 mg/dL.

A child is eating a peanut butter sandwich. He is ingesting an excellent source of:

magnesium. Good dietary sources of magnesium include green leafy vegetables, legumes, citrus fruit, peanut butter, and chocolate.

A nurse is providing care to a client with an ECF volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply.

orthostatic hypotension decreased urine output slow-filling peripheral veins The signs and symptoms of an ECF volume deficit reflect decreases in fluid volume in the vascular and interstitial spaces. The signs and symptoms of a decrease in vascular volume include orthostatic or postural changes in pulse rate and blood pressure (i.e., an increase in pulse rate and decrease in blood pressure when the person moves from a lying to a standing position); weak, rapid pulse; decreased urine output; and slow-filling peripheral veins. The signs and symptoms of decreased interstitial volume include dry mucous membranes and poor skin turgor.

A nurse is preparing a presentation for a group of older adults at a local senior center about the importance of fluid intake. As part of the presentation, the nurse plans to discuss how the intake and output of fluids is typically balanced each day. When describing the normal daily output of fluids, which component would the nurse identify as accounting for the smallest amount of fluid output?

perspiration Normal urine output for 24 hours is approximately 1,500 mL if intake is normal. Loss of fluid through the skin as perspiration accounts for an average daily loss of 100 to 200 mL of fluid. In addition to perspiration, insensible fluid loss through the skin amounts to about 300 to 400 mL per day. Loss of fluid through the gastrointestinal system in the form of feces is usually minimal, approximately 200 mL per day. Loss of water through respiration is approximately 300 mL per day.

Calcium is important for which functions? Select all that apply.

wound healing synaptic transmission in nervous tissue membrane excitability blood clotting Calcium is important in wound healing, synaptic transmission in nervous tissue, membrane excitability, and is essential for blood clotting.

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 most likely find?

Hypokalemia. 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 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.

A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?

The pump will continue to infuse fluid even when the needle is displaced. The nurse should be aware that an infusion pump continues to infuse fluid even when the needle is displaced. The pump continues to infuse fluid into the tissue until the machine's maximum preset pressure reaches its limit. The infusion pump adjusts the pressure according to the resistance it meets. The pump does not compress the tubing to infuse the solution at a precise, preset rate, which is done by a volumetric controller. An electronic infusion device would sound an audible alarm if the infusion container is empty, air is detected in the tubing, or resistance is met in delivering the fluid. The infusion pump does not stop pushing the fluid in the client's vein when the needle becomes displaced.

The nurse is caring for a client who was found after spending 2 days without food or water in the desert and was admitted through the emergency department. The client is severely dehydrated. What are reasons why the human body requires fluid? Select all that apply.

facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes Water in the body functions primarily to provide a medium for transporting nutrients to cells and wastes from cells; to provide a medium for transporting substances such as hormones, enzymes, blood platelets, and red and white blood cells throughout the body; to facilitate cellular metabolism and proper cellular chemical functioning; to act as a solvent for electrolytes and nonelectrolytes; to help maintain normal body temperature; to facilitate digestion and promote elimination; and to act as a tissue lubricant. Water does not, by itself, provide hydrogen or glucose.

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 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.