Prep U: Taylor Ch. 39- Fluid, Electrolyte, and Acid-Base Balance

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?

ordering type of solution, additive, amount of infusion, and duration

The nurse is monitoring intake and output (I&O;) for a client who has diarrhea. What will the nurse document as input on the I&O;record? (Select all that apply.)

100 mL from melted ice chips serving of jello infusion of intravenous solution cup of ice cream The nurse will document all fluid intake and fluid loss. This includes drinking liquids and intravenous fluids. The liquid equivalent of melted ice chips is fluid intake. Foods that are liquid by the time they are swallowed, such as gelatin, ice cream, and thin cooked cereal, are documented as fluid intake. A bowl of chili is a solid food as is a barbecue sandwich. While the amount eaten may be documented in the chart, it is not part of the fluid intake.

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?

"I received a blood transfusion in the United Kingdom."

The nurse is calculating an infusion rate for the following order: Infuse 1000 ml of 0.9% Na Cl over 12 hours using an electronic infusion device. What is the infusion rate?

83 ml/hour When calculating the infusion rate with an electronic device, divide the total volume to be infused (1000 ml) by the total amount of time in hours (8). This is 83 ml/hour. Other options are incorrect.

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)

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level?

Cardiac dysrhythmias

A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of:

hypokalemia 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.

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 indicative of:

plebitis

What is the rate of administration for packed red blood cells?

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

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

3,000

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O?

55-year old with congestive heart failure on furosemide Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O.

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation?

Notify the primary care provider immediately for possible fluid overload

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

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 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).

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?

apricots

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he 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?

banana

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?

cardiac irregularities

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

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client?

Avoid salty or excessively sweet fluids.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parenteral nutrition