Chap. 27 PrepU
Which question about fluid balance would be appropriate when conducting a health history for a client?
"Describe your usual urination habits."
A nurse is measuring the intake and output of a patient who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?
2600 mL
By what route do oxygen and carbon dioxide exchange in the lung?
Diffusion
A nurse who has diagnosed a patient as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
Distended neck veins
Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client 's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client?
ECF deficient fluid volume
A physician writes an order to "force fluids." What will be the first action the nurse will take in implementing this order?
Explain to the client why this is needed.
Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL. For what assessment findings will you be looking?
Muscle cramping and tetany
What blood type might be used in an emergency situation when the patient's blood type is not available?
Type O
A patient has been admitted to the hospital with a diagnosis of acute renal failure, a health problem that necessitates vigilant monitoring of the patient's fluid balance. What is the most accurate way that the care team can achieve this assessment goal?
Weighing the patient once per day
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 administering an oral liquid potassium supplement to a client. What will the nurse do to disguise the taste and decrease gastric irritation?
dilute it
A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which of the following statements accurately describe this process? Select all that apply.
• The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. • The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. • The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. • The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.
A healthy patient eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this patient's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL?
3000
A nurse is preparing to measure jugular venous distention in a client. To ensure accuracy, the nurse would elevate the head of the client's bed to which of the following?
45 degrees
The oncoming nurse is assigned to the following patients. Which patient should the nurse assess first?
A newly admitted 88-year-old with a two-day history of vomiting and loose stools
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Acute Confusion related to cerebral edema
A nurse is caring for a post-operative client who complains that he feels dizzy when getting up from bed. The nurse suspects extracellular fluid (ECF) volume deficit and assesses the effect that position change has on pulse rate and blood pressure. Which of the following would the nurse interpret as indicative of ECF volume deficit?
An increase in pulse rate of more than 20 beats per minute
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?" Which of the following would the nurse include as a suggestion for this client?
Avoid salty or excessively sweet fluids.
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
Cardiac Irregularities
The nurse is administering albumin to a patient to promote movement of fluid into the capillaries. What is the "pulling force" of fluid by use of a protein such as albumin known as?
Colloid osmotic pressure
A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?
Compare the total intake and output of fluids for the 24 hours.
A nurse is caring for a patient who has a PICC line. Which nursing action is recommended?
Flush using normal saline and/or heparin solution according to facility policy
A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded?
Fruit consumption
A nurse suspects a patient with electrolyte imbalances is experiencing hypomagnesemia. What nursing assessment finding may indicate hypomagnesemia?
Hyperactive deep tendon reflexes (DTRs)
During an assessment of an elderly 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. The nurse recognizes that what medical diagnosis may be responsible?
Hypovolemia
The nurse is caring for Mrs. Roberts, an 86-year-old patient, who fell at home and was not found for two days. Mrs. Roberts is severely dehydrated. The nurse is aware that elderly people are at increased risk for fluid imbalance for which of the following reasons?
Increase in fat cells
A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by which of the following?
Increasing ventilation through the lungs
Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?
Infants have more total body fluid and ECF than adults.
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which of the following fluid compartments?
Intracellular
The nurse writes a nursing diagnosis for a patient of "Fluid Volume: Excess." What risk factor would the nurse assess in this patient?
Renal failure
A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?
Risk for Deficient Fluid Volume
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area?
Sacral area
The nurse is determining a site for an IV infusion. What guideline should the nurse consider?
Scalp veins should be selected for infants because of their accessibility.
A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which of the following actions should the nurse perform?
Weigh the client's wet linen or dressing.
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. For what complications should the nurse be aware, related to the potassium level?
cardiac dysrythmias
A patient has metabolic (nonrespiratory) acidosis. What type of respirations would be assessed?
increased depth and rate
What IV solutions would the nurse expect to be ordered for a patient who has hypovolemia? (Select all that apply.)
• 0.9% NaCl (normal saline) • Lactated Ringer's solution • 5% dextrose in 0.9% NaCl
The nurse is caring for a client who was found after spending two days without food or water in the desert and was admitted through the Emergency Department. The client is severely dehydrated. Which of the following are reasons why the human body requires fluid? Select all that apply.
• Acts as a solvent for electrolytes • Helps maintain normal body temperature • Facilitates cellular metabolism
A nursing instructor is preparing a class presentation for a group of nursing students on fluid balance and developmental considerations. Which of the following would the instructor most likely include when describing newborns and infants? Select all that apply.
• Insensible fluid losses are greater in this age group. • Water makes up a larger percentage of their body weight. • Greater amounts of water are found in the extracellular fluid compartment.
What nursing interventions would be appropriate for a patient diagnosed with deficient fluid volume? (Select all that apply.)
• Intravenous therapy • Electrolyte management • Nutrition management
What nursing actions would be performed when preparing an IV solution and tubing when starting an IV infusion? (Select all that apply.)
• Maintain aseptic technique when opening sterile packages and IV solution. • Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. • Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. • Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.
The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply.
• Osmosis • Filtration • Diffusion • Active transport
Following preparation of the IV solution and tubing, what nursing actions would be performed by the nurse when selecting a site and palpating a vein to start an IV infusion? (Select all that apply.)
• Select an appropriate site and palpate accessible veins. • Direct the ends of the tourniquet away from the site and check that the radial pulse is still present. • If a vein cannot be felt, release the tourniquet and have the patient lower the arm below the level of the heart to fill the veins.
The nurse is teaching a patient about the function of sodium in the body. What teaching points would the nurse make? (Select all that apply.)
• Sodium is the primary regulator of ECF volume • Sodium is normally maintained in the body within a relatively narrow range, and deviations quickly result in serious health problems. • Sodium participates in the generation and transmission of nerve impulses.
What signs of complications and their probable causes may occur when administering an IV solution to a patient? (Select all that apply.)
• Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. • Redness, swelling, heat, and pain at the site may indicate phlebitis. • Local or systemic manifestations may indicate an infection is present at the site.
