Ch. 40: Fluid, Electrolytes, and Acid-Base Balances

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? -13 mL/hr -83 mL/hr -103 gtts/hr -100 mL/hr

-83 mL/hr When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (12). This is 83 mL/hr. Other options are incorrect.

A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? -Give the client a glass of orange juice with added sugar. -Allow nothing by mouth. -Start an IV of normal saline as prescribed. -Encourage fluid intake.

-Start an IV of normal saline as prescribed. To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.

Potassium is needed for neural, muscle, and: -optic function. -skeletal function. -auditory function. -cardiac function.

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

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? -500 -3,000 -1,000 -3,750

-3,000 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 health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? -5,000 gtt/min -42 gtt/mn -83 gtt/min -167 gtt/min

-83 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min

Edema happens when there is which fluid volume imbalance? -water excess -extracellular fluid volume excess -water deficit -extracellular fluid volume deficit

-extracellular fluid volume excess When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

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

-"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).

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? -"Unfortunately, your own blood cannot be reinfused during surgery." -"We now have artificial blood products, so giving your own blood is not necessary." -"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."

-"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 reinfused.

A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action? -Attempt to aspirate. -Slow the rate of infusion by 50%. -Discontinue the IV. -Flush with 3-mL normal saline.

-Discontinue the IV. Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor. Aspiration is never performed from a peripheral IV. Flushing or slowing the infusion will not alleviate this problem.

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

-Offer small amounts of preferred beverage frequently. Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. -Rate of the IV solution -Client's reaction to the procedure -Type of IV solution -Gauge and length of the IV catheter -Location of the IV catheter access -Manufacturer of the IV catheter

-Rate of the IV solution -Client's reaction to the procedure -Type of IV solution -Gauge and length of the IV catheter -Location of the IV catheter access The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client's reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

Which hormone regulates the extracellular concentration of potassium within the human body? -aldosterone -testosterone -progesterone -androgen

-aldosterone Aldosterone regulates the extracellular concentration of potassium. It also enhances renal secretion of potassium.

Which is a common anion? -calcium -chloride -magnesium -potassium

-chloride Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? -decreased blood volume and intracellular dehydration -increased blood volume and intracellular dehydration -increased blood volume and extracellular overhydration -decreased blood volume and extracellular overhydration

-decreased blood volume and intracellular dehydration Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.

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: -nonelectrolytes. -electrolytes. -interstitial fluid. -colloid solution.

-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 nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes 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.

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

-fluid volume excess and acidosis 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.

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? -preparing solution for administration -regulating the rate of administration -performing venipuncture -ordering type of solution, additive, amount of infusion, and duration

-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 health care provider, not the nurse, specifies the type of solution, additional additives, the volume (in mL), and the duration of the infusion.

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

-phlebitis. Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, 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.

The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? -"My spouse would also like to donate blood." -"I received a blood transfusion in the United Kingdom." -"I have never given blood before." -"My blood type is B positive."

-"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, lived anywhere in Europe for a total of 6 months since 1980, or received a blood transfusion in the UK. The other statements do not require nursing intervention.

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? -"Infiltration occurs when an IV is improperly placed, and phlebitis indicates circulatory overload." -"Infiltration is the inflammation of the vein, while phlebitis is a localized irritation." -"Infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed." -"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."

-"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." Infiltration is the escape of IV fluid into the tissue, and phlebitis is the inflammation of a vein. All other options are incorrect.