Taylor chapter-39 Review Questions. Fluid, Electrolyte, and Acid Base Balance

The student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response?

"Watery plasma, or serum, portion of blood." 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).

What commonly used intravenous solution is hypotonic?

0.45% NaCl Explanation: 0.45% NaCl is hypotonic. Normal saline and Lactated Ringer's are isotonic. 5% dextrose in 0.45% NaCl is hypertonic.

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

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.

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. 500 B. 1,000 C. 3,750 D. 3,000

3,000 Explanation: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? A. 9.5 cm H2O B. 3.5 cm H2O C. 12 cm H2O D. 5 cm H2O

3.5 cm H2O Explanation: The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.

Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? A. Acute Confusion related to cerebral edema B. Pain related to surgical incision C. Risk for Infection related to inadequate personal hygiene D. Constipation related to immobility

Acute Confusion related to cerebral edema Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.

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

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.

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

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.

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? A. Tetany B. Fluid volume excess C. Pulmonary embolus D. Cardiac dysrhythmias

Cardiac dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

A client is diagnosed with body fluid hypoosmolality. Treatment involves restricting his intake of free water. Which fluids would the nurse most likely restrict? Select all that apply. A. Broth B. Milk Tea C. Tomato juice D. Apple juice

Correct response: Apple juice Tea Explanation: Management of water excess typically involves free water restriction. Limited fluids include water, coffee, tea, and simple fruit juices such as apple juice. More concentrated fluids such as milk, broth, or tomato juice may be given.

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.

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation? A. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV. B. Call the physician and ask if anti-inflammatory drugs should be administered. C. Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site. D. Discontinue the IV and relocate it to another spot.

Discontinue the IV and relocate it to another spot. Explanation: 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 physician for anti-inflammatory medications.

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

Ensure that the prescribed solution is clear and transparent. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, 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.

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. Hypotonic B. Colloid C. Isotonic D. Hypertonic

Isotonic Explanation: Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

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

Metabolic alkalosis Explanation: Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.

Which client has more extracellular fluid? A. Newborn B. Adult woman C. Adolescent man D. Female school-age child

Newborn Explanation: Newborns have more extracellular fluid than intracellular fluid. Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1473.

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

Offer small amounts of preferred beverage frequently.

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. Sodium B. Phosphorous C. Chloride D. Potassium

Potassium Explanation: 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.

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

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.

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

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.

How is control over the extracellular concentration of potassium within the human body is exerted? A. albumin. B. progesterone. C. aldosterone. D. testosterone.

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

Potassium is needed for neural, muscle, and: A. optic function. B. skeletal function. C. auditory function. D. cardiac function.

cardiac function. Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

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. cardiac irregularities C. muscle weakness D. metabolic acidosis

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 dysrhythmias. Muscle weakness is associated with low magnesium or high phosophorus. Increased intracraniel 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.

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

glomerulus. Explanation: The process of filtration begins at the glomerulus.

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

hypokalemia. Explanation: 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.

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

istended 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 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. removal of waste B. transportation of nutrients C. maintenance of cell size D. maintenance of blood volume

maintenance of cell size Explanation: 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.

The passageways of the kidney permit the urine to flow to the bladder and: A. act as a valve that covers the junction between the ureters and the bladder. B. control external sphincter of the urethra and permit the control of urination. C. selectively reabsorb or secrete substance to maintain fluids and electrolytes. D. surround the Bowman's capsule, which is where the formation of urine begins.

selectively reabsorb or secrete substance to maintain fluids and electrolytes. Explanation: The capillaries of the glomerulus are porous, and, as the blood passes through the glomerular capillaries, some constituents of the blood are filtered out.

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

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

A nurse is measuring intake and output for a client who has congestive heart failure. What does not need to be recorded? A.Fruit consumption B. . Frozen fluids C. Parenteral fluids D. Sips of water

Fruit consumption Explanation: Any water consumption must be recorded in order to closely monitor a client who has congestive heart failure. Many of these clients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.

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

Hypertonic Explanation: 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 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? A. Hyperchloremia B. Hypernatremia C. Hypomagnesemia D. Hypokalemia

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

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

fluid volume excess and acidosis Explanation: Fluid volume excess can be caused by malfunction of the kidneys (i.e., renal failure). The kidneys are also responsible for acid-base balance, and in the presence of renal failure, the kidneys cannot regulate hydrogen ions and bicarbonate ions, so the client develops metabolic acidosis.

Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance? A. increased respiratory rate B. renal retention of H ions C. increased excretion of bicarbonate ions by the kidneys D. hypoventilation

increased respiratory rate Explanation: Hyperventilation results in increased CO exhalation and a consequent increase in pH, with the goal of attaining the ideal of 7.35 to 7.45. Retention of hydrogen ions, increased excretion of bicarbonate ions, and hypoventilation are all processes that contribute to decreased pH and an exacerbation of acidosis.

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

total parenteral nutrition. Explanation: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.

The student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response?

"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).

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

"I've been taking antacids almost every 2 hours over the past several days." Explanation: 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.

What is the rate of administration for 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. IV push over 3 minutes D. 200 mL/hr

1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours. Platelets can be infused as fast as the client can tolerate. Cryoprecipitate can be given by IV push over 3 minutes. Fresh-frozen plasma should be administered at 200 mL/hr.

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? A. Use an alcohol-based mouthwash to moisten your mouth. B. Eat crackers and bread. C. Avoid salty or excessively sweet fluids. D. Use regular gum and hard candy.

Answer: a. Avoid salty of 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. 15-30 minutes later, however, oral membranes may be even drier than before. Dry food, such as crackers and bread, also 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.

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

Answer: a. Phlebitis Rationale: Phlebitis is a local infection at the sit of an intravenous catheter. Signs and symptoms include redness, pus, 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.

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. Position the client on the left side. B. Elevate the client's head. C. Apply antiseptic and a dressing. D. Apply a warm compress.

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.

The nurse is caring for older adult clients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these clients? A. Increased renal blood flow B. Cardiac volume intolerance C. Increase in nephrons in the kidneys D. An increased sense of thirst

Cardiac volume intolerance Explanation: The older adult client is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability. Older adults typically experience a decreased sense of thirst, loss of nephrons, and decreased renal blood flow.

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

ECG will show no cardiac dysrhythmias 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 dysrhythmias 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.

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? A. Congestive Heart Failure related to edema B. Fluid Volume Excess related to loss of sodium and potassium C. Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea D. Fluid Volume Deficit related to congestive heart failure, as evidenced by shortness of breath

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid.

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. Hypovolemia B. Circulatory overload C. Edema D. Hypervolemia

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.

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? A. Muscle weakness, fatigue, and dysrhythmias B. Nausea, vomiting, and constipation C. Muscle weakness, fatigue, and constipation D. Diminished cognitive ability and hypertension

Muscle weakness, fatigue, and dysrhythmias Explanation: 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.

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? A. AB negative B. A positive C. B positive D. O negative

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.

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

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 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. Assess for visible rash. B. Call for assistance. C. Assess oxygen levels. D. Stop the transfusion.

Stop the transfusion. 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.

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. Urine becomes more diluted. C. The renal system retains more water. D. The frequency of voiding increases.

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.

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply. A. The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. B. Fluid overload is more likely in very young children. C. A symptom of fluid overload is distended neck veins. D. The client will likely develop a fever in the presence of fluid overload. E. The infusion rate must be carefully monitored during the administration of blood.

The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. A symptom of fluid overload is distended neck veins. Fluid overload is more likely in very young children. The infusion rate must be carefully monitored during the administration of blood. Explanation: Fluid overload can occur if blood components are infused too quickly or too voluminously. Transfusion-associated circulatory overload is more likely in the very young client or the older adult with poor cardiac or renal function. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds. Circulatory overload can be minimized by infusing packed RBCs (rather than whole blood) and volume-reduced platelets for high-risk clients, then carefully monitoring the infusion rate of blood components.

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?

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.

When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which guideline should the nurse follow? A. Use small veins before larger veins. B. Use veins of the lower extremities. C. Use distal veins before proximal veins. D. Use the brachial plexus vein.

Use distal veins before proximal veins. Explanation: Use larger veins and the distal portion of the vein, leaving the more proximal sites for later venipunctures.

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy should the nurse do first? A. Perform venipuncture. B. Regulate the rate of administration. C. Verify the orders for type of solution and amount of infusion. D. Prepare solution for administration.

Verify the orders for type of solution and amount of infusion. Explanation: The nurse should verify the order from the healthcare provider first. The order for intravenous therapy should include the type of solution, the volume, possible additives, and the duration of the infusion. After verifying the order the nurse can prepares the solution for administration, performs a venipuncture, and regulates the rate of administration.

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

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 re absorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.

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:

You Selected: decreased skin area. Correct response: increase in fat cells. Explanation: The decreasing percentage of body fluid in older adults is related to an increase in fat cells. In addition, older adults lose 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 older adults. Older adults do not have an increase muscle mass, smaller stomach capacity, or decrease skin area.

A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply. A. Blood pressure 104/68 mm Hg B. Blood pressure 126/80 mm Hg C. Pulse rate 90 bpm D. Blood pressure 112/70 mm Hg E. Pulse rate 72 bpm

b) Blood pressure 104/68 mm Hg d) Pulse rate 90 bpm

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. Colloid B. Isotonic C. Hypertonic D. Hypotonic

b) Isotonic fluids Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

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

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.

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? A. every 24 hours B. every 36 hours C. every 12 hours D. every 72 hours

every 72 hours Explanation: 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.

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? A. hemolytic transfusion reaction: incompatibility of blood product B. allergic reaction: allergy to transfused blood : C. febrile reaction: fever develops during infusion D. bacterial reaction: bacteria present in the blood

hemolytic transfusion reaction: incompatibility of blood product Explanation: The symptoms of facial flushing, fever, chills, headache, low back pain, and shock occur when a blood product is incompatible and the client is experiencing a hemolytic transfusion reaction. 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.

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

hypertonic Explanation: 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.

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.

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 physician of the client's: A. low calcium. B. high sodium. C. low potassium. D. high magnesium.

low calcium. Explanation: Normal total serum calcium levels range between 8.9 and 10.1 mg/dL (2.225 to 2.525 mmol/L).

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.

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? A. granulocytes B. albumin C. platelets D. cryoprecipitate

platelets Explanation: Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia.

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

renin. Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.