Chap 41 Prep U
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"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."
Lab Studies to Assess for Imbalances
* Complete blood count. * Serum electrolytes, blood urea nitrogen, and creatinine levels. * Urine pH and specific gravity. * Arterial blood gases.
Nurse responsibilities for IV therapy
-Location of catheter -Size of catheter -Administering IV solution -Determine the amount of IV solution
A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply.
-orthostatic hypotension -decreased urine output -slow-filling peripheral veins
Urine Specific Gravity
1.010-1.025
magnesium
1.5-2.5 mEq/L
sodium
135-145 mEq/L
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?
2,500 ml/day
Phosporus
2.5-4.5
Potassium
3.5-5.0 mEq/L
Calcium
8.5-10.5 mg/dL
Chloride
95-107
A client is receiving a transfusion of packed red blood cells, and the nurse has obtained the first set of vital signs after initiating the transfusion. These closely match the pretransfusion vital signs with the exception of a 1°F (0.5°C) increase in the oral temperature. The client denies other symptoms and is not in distress. What is the nurse's most appropriate action?
Administer acetaminophen as prescribed.
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?
An implanted central venous access device (CVAD)
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial Blood gas
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?
Distended neck veins
A nurse is caring for a client who has recently suffered burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this client?
Lactated Ringers
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
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?
O negative
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
Offer small amounts of preferred beverage frequently.
ABG levels
PH 7.35 - 745 PCO2 45-35 HCO3 22-28
The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next?
Remove the peripheral IV catheter
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take?
Start an IV of normal saline as prescribed
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?
Stop the transfusion immediately
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
an infant age 4 months
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?
calcium and phosphorous
The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching?
cardiac functions
Common Anions
chloride, bicarbonate, phosphate
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
decreased potassium levels.
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?
distended neck veins
Flow rate equation
gtt/min= milliliters per hour x drop factor(gtt/ml) divided by min/hr
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?
hemolytic transfusion reaction: incompatibility of blood product
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect?
hypocalcemia
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 likely to find?
hypokalemia
When providing chemotherapeutic agents, which catheter is accessed with a non-coring needle?
implanted venous access catheter
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address?
increased hydrostatic pressure
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)?
metabolic alkalosis
A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert?
muscle weakness, fatigue, arrythmias
Which finding best indicates to the nurse that the client has a therapeutic outcome from a recent blood transfusion?
no signs of chills, fever or shortness of breath
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding?
pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?
phlebitis
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:
phlebitis
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the torniquet on the upper arm for 2 mins The tourniquet should not be applied longer than 1 minute
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and fatigue and the nurse's assessment reveals an irregular heart rate. The nurse should assess the client's levels of which electrolyte?
potassium
Primary extracellular electrolytes
sodium, chloride, bicarbonate
best place for nurse to access older client skin turgor
sternum
