U-prep questions Fluid, Electrolyte, and Acid Balance

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

Acute confusion related to cerebral edema

Which is a common anion?

Chloride

A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation? -Discontinue the IV and relocate it to another spot. -Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site. -Call the physician and ask if anti-inflammatory drugs should be administered. -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.

Discontinue the IV and relocate it to another spot.

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

Not wearing gloves when preforming 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? -O negative -AB negative -A positive -B positive

O Negative

Potassium is needed for neural, muscle, and:

cardiac function

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.

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

total parenteral nutrition.

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?

3.5 cm H2O -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.

The nurse is working with a colleague and observes the colleague changing the bag of a client's IV solution as pictured above. What is the nurse's most appropriate response? -Encourage the colleague to hang the bag on the IV pole before spiking it. -Bring a pair of nonsterile gloves and give them to the colleague. -Observe the colleague and take no further action. -Offer to double-check whether the bag has the prescribed solution.

Observe the colleague and take no further action.

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

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? -asking if the client is right or left handed -placing the tourniquet on the upper arm for 2 minutes -asking the client to pump their fist several times -palpating the veins on the nondominant hand

placing the tourniquet on the upper arm for 2 minutes

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

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: -an access route to replace fluids in combination with blood products. -an access route to administer medications intravenously. -replacement of fluids for those lost from vomiting and diarrhea. -intravenous fluids to be administered on an outpatient basis.

replacement of fluids for those lost from vomiting and diarrhea

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? -"Fluid in the tissue space between and around cells." -"Watery plasma, or serum, portion of blood." -"Fluid outside cells." -"Fluid inside cells."

"Fluid in the tissue space between and around cells."

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." -"This surgery has a very low chance of hemorrhage, so you will not need blood." -"We now have artificial blood products, so giving your own blood is not necessary." -"Unfortunately, your own blood cannot be reinfused during surgery."

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

The nurse is preparing to change the IV tubing of a client receiving a peripheral venous IV infusion 5% dextrose and water based on the understanding that IV tubing is generally changed at which interval?

Every 96 hours.

Which statement accurately describes appropriate nursing interventions in unexpected situations when removing a peripherally inserted central catheter (PICC)?

If a portion of the catheter breaks when removing it, apply a tourniquet to the upper arm and notify the health care provider.

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

Total parenteral nutrition is hypertonic. What is the percentage of dextrose in these solutions? -50% dextrose -5% dextrose -2.5% dextrose -10% dextrose

50% dextrose

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?

Potassium -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.

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?

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

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? -100 mL/hr -103 gtts/hr -13 mL/hr -83 mL/hr

83 mL/hr

A client suffers from a genetic bleeding deficiency involving a deficit in factor VIII. Which blood product will the nurse most likely administer?

Cryoprecipitate

The primary extracellular electrolytes are:

sodium, chloride, bicarbonate

The nurse is assisting with a client's blood transfusion. What type of reactions may occur during this procedure? Select all that apply. -Dyspnea, dry cough, and pulmonary edema may occur during a bacterial reaction. -Hives, itching, and anaphylaxis may occur during an allergic reaction. -Fever, chills, headache and malaise may occur during a febrile reaction. -Shortness of breath and auscultated crackles bilaterally in the bases may occur during a febrile reaction. -Fever, hypertension, abdominal pain and dry, flushed skin may occur during circulatory overload. -Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.

-Hives, itching, and anaphylaxis may occur during an allergic reaction. -Fever, chills, headache and malaise may occur during a febrile reaction. -Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.

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 -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.

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

Offer small amounts of preferred beverage frequently.

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding? -pH: 7.32; PaCO2: 26; HCO3: 18 -pH: 7.60; PaCO2: 64; HCO3: 42 -pH: 7.28; PaCO2: 52; HCO3: 32 -pH: 7.32; PaCO2: 28; HCO3: 24

pH: 7.60; PaCO2: 64; HCO3: 42 -In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high HCO3, such as 64; and a high PaCO2, such as 42. The numbers correlate with metabolic alkalosis, which is indicated by the hyperventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis.

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: -rapid fluid administration. -an infiltration. -phlebitis. -a systemic blood infection.

phlebitis.