BNS CH. 16 FLUID AND CHEMICAL BALANCE NCLEX STYLE Q'S
A hospital client has been experiencing nausea and has a standing order for the administration of an intravenous antiemetic. The nurse knows that the antiemetic must be diluted in 50 mL of IV fluid before being administered and should be given over a period of 20 minutes. The nurse will administer the drug using secondary tubing that has a drop factor of 10 gtts/mL. At what rate should the nurse program the infusion pump? A) 150 mL/hour B) 100 mL/hour C) 200 mL/hour D) 70 mL/hour
A) 150 mL/hour In order to infuse 50 mL of IV fluid in 20 minutes, a rate of 150 mL/hour is necessary. The drop factor of the IV tubing does not influence the rate of administration when measured in mL/hour.
Accurate fluid volume assessment has been ordered for a client who has been acutely ill since the time of admission to the hospital. The nurse can best monitor this client's fluid balance by: A) Accurately measuring and recording the client's intake and output B) Frequently palpating the client's dependent extremities C) Assessing the client's skin turgor every four to six hours D) Testing the client's orientation and alertness on a scheduled basis
A) Accurately measuring and recording the client's intake and output Intake and output (I&O;) is one tool to assess fluid status by keeping a record of a client's fluid intake and fluid loss over a 24-hour-period. This is more accurate than assessing skin turgor. Palpation of a client's extremities and neurological assessment are not accurate indicators of fluid balance, though each is affected by fluid and electrolyte imbalances.
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) Apply a warm compress B) Elevate the client's head C) Position the client on the left side D) Apply antiseptic and a dressing
A) Apply a warm compress 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 position 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 a client with severe edema. Which intervention will the nurse choose to restore fluid balance? (Select all that apply.) A) Ask provider to order a low-salt diet. B) Reduce infusing fluid volume as ordered. C) Increase oral intake and flush excess fluids. D) Administer furosemide as ordered. E) Treat the underlying condition that contributes to increased fluid volume.
A) Ask provider to order a low-salt diet., B) Reduce infusing fluid volume as ordered., D) Administer furosemide as ordered., E) 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.
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) Prepare to give an antihistamine C) Infuse saline at a rapid rate D) Administer oxygen
A) Stop the transfusion immediately. 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
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? A) The pump will continue to infuse fluid even when the needle is displaced. B) The pump compresses the tubing to infuse the solution at a precise, preset, rate. C) The pump will sound an audible and visual alarm warning the nurse of the situation. D) The pump stops pushing the fluid in the client's vein when the needle is displaced
A) 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 it's 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 electric 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 student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response? A) "Fluid outside cells." B) "Fluid in the tissue space between and around cells." C) "Fluid inside cells" D) "Watery plasma, or serum, portion of blood."
B) "Fluid in the tissue space between and around cells." 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 nurse is caring for a client who is to be provided nutrition intravenously for a short duration following a tracheostomy. Which intravenous solution needs to be administered to this client? A) Lipid emulsion B) Crystalloid solution C) Colloid solution D) Plasma expanders
B) Crystalloid solution Crystalloid solutions are to be administered to the client. The crystalloid solutions can be classified as isotonic, hypotonic, and hypertonic. Isotonic solutions are generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Lipid emulsions are administered when the client is severely malnourished and may not be able to consume food for a long period. In this case, lipid emulsion is not necessary because the client will not be able to take food for a short period. In addition, there is a risk of adverse reaction in clients while administering lipid emulsion. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. Plasma expanders are used as economical and virus-free substitutes for blood and blood products when treating hypovolemic shock.
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 36 hours B) Every 72 hours C) Every 12 hours D) Every 24 hours
B) 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.
A 56-year-old male client has been diagnosed with liver cirrhosis and recent laboratory testing reveal significant hypoalbuminemia. The nurse should anticipate that an assessment of the client may reveal: A) Prolific output or dilute urine B) Fluid accumulation in the client's abdominal space C) Pulmonary edema and shortness of breath D) Peripheral edema in the client's feet and ankles
B) Fluid accumulation in the client's abdominal space Fluid that accumulates in a body cavity such as the peritoneum is associated commonly with disorders in which albumin levels are low. Causes of hypoalbuminemia include liver disease. Hypoalbuminemia is not normally associated with peripheral edema, increased urine output or pulmonary edema.
The nurse is monitoring intake and output *I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O; record? (Select all that apply.) A) Eating a sandwich B) Infusion of intravenous solution C) Drinking milk D) Urination E) Vomiting
B) Infusion of intravenous solution. C) Drinking milk, D) Urination, E) Vomiting The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output
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? A) Performing venipuncture B) Ordering type of solution, additive, amount of infusion, and duration C) Preparing solution for administration D) Regulating the rate of administration
B) Ordering type of solution, additive, amount of infusion, and duration The nurse prepares the solution for administration, performs a venipuncture, regulates the rate of administration, monitors the infusion, and discontinues the administration when fluid balance is restored. The healthcare provider, not the nurse, specifics the type of solution, additional additives, the volume (in mL), and the duration of the infusion.
A client has been ordered a blood test. When taking a venous blood sample, which intervention should the nurse perform? A) Apply a tourniquet tightly below the arm B) Tap the skin over the vein several times C) Have the client keep an open fist D) Stroke the skin upward toward the arm
B) Tap the skin over the vein several times The nurse should tap the skin over the vein several times before taking a venous blood sample. The nurse should apply a tourniquet tightly above, not below, the arm, stroke the skin toward the fingers, not upward toward the arm, and have the client make a fist and pump the fist intermittently. This process helps to obtain the blood sample easily.
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? A) "I have never given blood before." B) "My spouse would also like to donate blood." C) "I received a blood transfusion in the United Kingdom." D) "My blood type is B positive."
C) "I received a blood transfusion in the United Kingdom." Because blood is one possible mode of transmitting prions from animals to humans and humans to humans, the collection of blood is banned from anyone who has lived in the UK for a total of 3 months or longer since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.
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? A) "This surgery has a very low change of hemorrhage, so you will not need blood." B) "We now have artificial blood products, so giving your own blood is not necessary." C) "Let me refer you to the blood bank so they can provide you with information." D) "Unfortunately your own blood cannot be re-infused during surgery."
C) "Let me refer you to the blood bank so they can provide you with information." Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be re-infused.
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? A) Hypotonic solution B) Colloid solution C) Hypertonic solution D) Isotonic solution
C) Hypertonic solution 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.
A post-surgical client has been ordered an infusion of normal saline (0.9% NaCl) at 125 mL/hour until such time as the client begins drinking adequately. The infusion of this intravenous fluid will cause: A) A relative decrease in the concentration of blood. B) Water to move from intracellular locations in body tissues into circulation C) Increased fluid volume with no significant redistribution of body fluids D) A shift of body fluids from the vascular space into tissues
C) Increased fluid volume with no significant redistribution of body fluids Normal saline is isotonic. Consequently, administration of NS dose not cause a shift in the distribution of body fluid.
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? A) Severely dehydrated B) Mildly dehydrated C) Moderately dehydrated D) Hypervolemic
C) Moderately dehydrated Hypovolemia refers to a low volume of extracellular fluid. If untreated, it may results 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 is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? A) 1,500 mL/day B) 1,00 mL/day C) 3,500 mL/day D) 2,500 mL/day
D) 2,500 mL/day In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. 1,000 mL/day and 1,500 mL/day are too low, and 3,500 mL/day is too high.
A person with Type A blood is compatible with what blood types? A) A B) B C) O D) A and O
D) A and O
A client has been admitted to the health agency with symptoms of malnutrition. The nurse needs to administer a solution of nutrients to meet the caloric and nutritional needs of the client. The nutrient solution is packaged in a glass container and needs to be administered with tubing that has a drop factor of 60 drops/mL. What type of tubing should the nurse use in this case? A) Unvented tubing B) Needled tubing C) Macrodrip tubing D) Filtered tubing
D) Filtered tubing The nurse should use filtered tubing to administer the nutrient to the client with symptoms of malnourishment. If unvented tubing is inserted into a glass bottle, the nutrient solution will not leave the flass container. Filtered tubing is generally used to administer parenteral solutions. Macrodrip tubing delivers a standard volume of up to 30 drops/mL, which is again not appropriate for the case. "Needled tubing" does not exist.
