Chapter 40 Fluid, Electrolyte, and Acid-Base Balance

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

Correct response: • extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? • 30 gtt/min • 50 gtt/min • 20 gtt/min • 40 gtt/min

Correct response: • 50 gtt/min Explanation: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.

• 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? • AB negative • A positive • O negative • B positive

Correct response: • O negative Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. Rh-negative persons should never receive Rh-positive blood

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? • B positive • A positive • O negative • AB negative

Correct response: • O negative Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. B positive, A positive, and AB negative are not considered compatible in this scenario.

A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take? • Continue to use the current intravenous tubing • Tell the client the infusion will be administered later in the shift • Notify the health care provider to request a new prescription for an intravenous infusion • Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing

Correct response: • Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing Explanation: The tubing is contaminated and, if the nurse continues to use the current tubing, the bag's contents will become contaminated during infusion. This action will result in harming the client and can increase the risk of an systemic infection, resulting form poor medical and surgical aseptic techniques.

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

Correct response: • decreased blood volume and intracellular dehydration Explanation: 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 nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion. Place your answer on the line provided below.

Correct response: 50 gtts/min. Explanation: When administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula:

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. • 5% dextrose in 0.9% NaCl • 0.9% NaCl (normal saline) • Lactated Ringer's solution • 0.33% NaCl (⅓-strength normal saline) • 0.45% NaCl (½-strength normal saline) • 5% dextrose in Lactated Ringer's solution

Correct response: • 0.33% NaCl (⅓-strength normal saline) • 0.45% NaCl (½-strength normal saline) Explanation: 0.33% NaCl (⅓-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia. 5% dextrose in 0.9% NaCl is used to treat SIADH and can temporarily be used to treat hypovolemia if plasma expander is not available. 0.9% NaCl (normal saline) is used to treat hypovolemia, metabolic alkalosis, hyponatremia, and hypochloremia. Lactated Ringer's solution is used in the treatment of hypovolemia, burns, and fluid lost from gastrointestinal sources. 5% dextrose in Lactated Ringer's solution replaces electrolytes and shifts fluid from the intracellular compartment into the intravascular space, expanding vascular volume.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document? • 1 • 2 • 3 • 4

Correct response: • 2 Explanation: Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 in and with purulent drainage.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status?' • Recording intake and output. • Testing skin turgor. • Reviewing the complete blood count. • Measuring weight daily.

Correct response: • Measuring weight daily. Explanation: Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? - Recording intake and output. - Testing skin turgor. - Reviewing the complete blood count. - Measuring weight daily.

Measuring weight daily. Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? - Encourage foods and fluids with high sodium content. - Administer oral K supplements as ordered. - Caution the patient about eating foods high in potassium content. - Discuss calcium-losing aspects of nicotine and alcohol use.

- Administer oral K supplements as ordered. Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? - Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. - Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. - Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. - Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

- Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

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

Correct response: • chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. - "Try to drink at least six to eight glasses of water each day." - "Try to limit your fluid intake to 1 quart of water daily." - "Limit sugar, salt, and alcohol in your diet." - "Report side effects of medications you are taking, especially diarrhea." - "Temporarily increase foods containing caffeine for their diuretic effect." - "Weigh yourself daily and report any changes in your weight."

- "Try to drink at least six to eight glasses of water each day." - "Limit sugar, salt, and alcohol in your diet." - "Report side effects of medications you are taking, especially diarrhea." - "Weigh yourself daily and report any changes in your weight." In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? - Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. - Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. - Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. - Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

- Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? - Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. - Keeping fluids readily available for the patient. - Emphasizing the long-term outcome of increasing fluids when the patient returns home. - Planning to offer most daily fluids in the evening.

- Keeping fluids readily available for the patient. Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? - A pinched and drawn facial expression - Deep, rapid respirations. - Moist crackles heard upon auscultation - Tachycardia

- Moist crackles heard upon auscultation Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? - Reposition the extremity and raise the height of the IV pole. - Apply pressure to the dressing on the IV. - Pull the catheter out slightly and reinsert it. - Put on gloves; remove the catheter

- Put on gloves; remove the catheter This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.

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

Correct response: • "Fluid in the tissue space between and around cells." Explanation: 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 working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? • "I have never given blood before." • "My blood type is B positive." • "I received a blood transfusion in the United Kingdom." • "My spouse would also like to donate blood."

Correct response: • "I received a blood transfusion in the United Kingdom." Explanation: 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.

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." • "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."

Correct response: • "Let me refer you to the blood bank so they can provide you with information." Explanation: 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 client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? • As fast as the client can tolerate • 200 mL/hr • 75 mL/hr for the first 15 minutes then 200 mL/hr • 1 unit over 2 to 3 hours, no longer than 4 hours,

Correct response: • 1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

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? • 3,000 • 500 • 1,000 • 3,750

Correct response: • 3,000 Explanation: 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.

The nurse is calculating the infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtts/min. What is the infusion rate? • 25 gtts/min • 42 gtts/min • 125 gtts/min • 20 gtts/min

Correct response: • 42 gtts/min Explanation: When infusing by gravity, divide the total volume in mL (1,000 mL) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtts/min. The correct answer is 42 gtts/min.

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

Correct response: • 83 mL/hr Explanation: 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 (8). This is 83 mL/hr. Other options are incorrect.

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

Correct response: • Acute Confusion related to cerebral edema Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.

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?" What would the nurse include as a suggestion for this client? • Use an alcohol-based mouthwash to moisten your mouth. • Use regular gum and hard candy. • Eat crackers and bread. • Avoid salty or excessively sweet fluids.

Correct response: • Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? • Yogurt • Turkey • Milk • Banana

Correct response: • Banana Explanation: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

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 (32 mmol/L). For what complications should the nurse be aware, related to the potassium level? • Pulmonary embolus • Cardiac dysrhythmias • Fluid volume excess • Tetany

Correct response: • Cardiac dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

The nurse is providing care for a client with a peripheral intravenous catheter in situ. What intervention should the nurse implement in the care of this IV? • Insert the largest gauge possible to maximize flow and minimize the risk of occlusion. • Clean the insertion site daily using sterile technique. • Flush the catheter every six hours with hypertonic solution if the IV is not in constant use. • Change the site every three to four days.

Correct response: • Change the site every three to four days. Explanation: Peripheral IV sites should be rotated every 72 to 96 hours, depending on the institutional protocol. IV insertion sites are not cleansed daily, but the site should be assessed per institutional protocol or every nursing shift. Flushes are not necessary every six hours. Hypertonic solution is not used for IV flushes. The smallest gauge that is practical should be inserted in order to minimize trauma.

A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)? • Removing a client's PICC in anticipation of the client's discharge • Initiating a client's transfusion of packed red blood cells • Changing the dressing on a client's peripheral IV site • Deaccessing a client's implanted port

Correct response: • Changing the dressing on a client's peripheral IV site Explanation: Changing a peripheral IV dressing poses a lower risk to the client's safety than the other listed nursing actions and this would be the safest task to delegate. It would be inappropriate to delegate a blood transfusion, deaccess an implanted port, or remove a PICC to an LPN.

The nurse is instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium? • Salad • Cauliflower • Cheese • Meat

Correct response: • Cheese Explanation: Dairy products are excellent sources of calcium.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? • Discontinue the IV and relocate it to another site. • Call the primary care provider to see whether 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 • Stop the infusion cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.,

Correct response: • Discontinue the IV and relocate it to another site. Explanation: The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.

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? • Slow the rate of infusion by 50%. • Attempt to aspirate. • Discontinue the IV. • Flush with 3-mL normal saline.

Correct response: • Discontinue the IV. Explanation: 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.

A nurse is caring for four different pediatric clients all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot? • Infant • School-aged child • Preschool-aged child • Toddler

Correct response: • Infant Explanation: The foot is a potential IV insertion site for neonates and infants, but it should not be used once a child can walk.

• 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? • 5% dextrose in 0.9% NaCl • Lactated Ringer's • 5% dextrose in 0.45% NaCl • 0.9% NaCl (normal saline)

Correct response: • Lactated Ringer's Explanation: Lactated Ringer's solution is a roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43- ). It is used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea and in treating mild metabolic acidosis.

A nurse carefully assesses the acid-base balance of a patient whose carbonic acid (H2CO3) level is decreased. This is most likely a patient with damage to the: • Kidneys • Lungs • Adrenal glands • Blood vessels

Correct response: • Lungs Explanation: The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

Mr. Jones is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations should the nurse be alert? • Muscle weakness, fatigue, and constipation • Nausea, vomiting, and constipation • Muscle weakness, fatigue, and dysrhythmias • Diminished cognitive ability and hypertension

Correct response: • Muscle weakness, fatigue, and dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

as observed the nurse changing a peripheral venous access site dressing is idemonstrating inappropriate technique by implementing which action? • Not preforming the intervention under sterile conditions • Not wearing gloves when preforming the intervention • By pulling the dressing toward the insertion site • By applying stablizing pressure to the catherter

Correct response: • Not wearing gloves when preforming the intervention Explanation: The changing of a peripheral venous access site dressing requires the use of clean gloves to minimize the transmission of microorganisms during the procedure and to prevent the nurse from coming into contact with blood. The intervention does not require sterile precautions. The mammer in which the nurse is applying stablizing pressure to the catherter and pulling the adhered dressing toward the insertion site demonstrates appropriate technique.

• A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? • Place the client in the Trendelenburg position to keep the client's airway open. • Notify the primary care provider immediately for possible fluid overload. • Notify the primary care provider immediately because these are signs of speed shock. • Check all clamps on the tubing and check tubing for any kinking.

Correct response: • Notify the primary care provider immediately for possible fluid overload. Explanation: If the client's lung sounds were previously clear, but now some crackles in the bases are auscultated: Notify the primary care provider immediately because the client may be exhibiting signs of fluid overload. The Trendelenburg position is not used to rectify this complication, but to help raise the blood pressure of a client with hypotension.

The nurse is responding to a client's call light. The client states, "I was getting out of bed and caught my IV on the siderail. I think I may have pulled it out." The nurse determines that the intravenous (IV) catheter has been almost completely pulled out of the insertion site. Which action is most appropriate? • Apply a new dressing and observe for signs of infection over the next several hours. • Verify blood return, and then place a transparent dressing over the catheter hub, leaving the length of catheter open to air. • Remove the IV catheter and reinsert another in a different location. • Decontaminate the visible portion of the catheter, and then gently reinsert.

Correct response: • Remove the IV catheter and reinsert another in a different location. Explanation: An IV catheter should not be reinserted. Whether the IV is salvageable depends on how much of the catheter remains in the vein. Because this catheter has been almost completely pulled out of the insertion site, it should be discarded and a new one inserted at a different location. It is not acceptable simply to apply a new dressing and leave the catheter sticking out of the site.

The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the prioritynursing action? • Assess oxygen levels. • Call for assistance. • Stop the transfusion. • Assess for visible rash.

Correct response: • Stop the transfusion. Explanation: Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.

The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? Select all that apply. • The client will likely develop a fever in the presence of fluid overload. • The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. • A symptom of fluid overload is distended neck veins. • The infusion rate must be carefully monitored during the administration of blood. • Fluid overload is more likely in very young children.

Correct response: • The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. • A symptom of fluid overload is distended neck veins. • Fluid overload is more likely in very young children. • The infusion rate must be carefully monitored during the administration of blood. Explanation: Fluid overload can occur if blood components are infused too quickly or too voluminously. Transfusion-associated circulatory overload is more likely in the very young client or the older adult with poor cardiac or renal function. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds. Circulatory overload can be minimized by infusing packed RBCs (rather than whole blood) and volume-reduced platelets for high-risk clients, then carefully monitoring the infusion rate of blood components.

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

Correct response: • cardiac function. Explanation: Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L) a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? • muscle weakness • cardiac irregularities • increased intracranial pressure (ICP) • metabolic acidosis

Correct response: • cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosophorus. Increased intracraniel pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

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

Correct response: • electrolytes. Explanation: 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.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of: • hyponatremia. • fluid volume excess. • hypovolemia. • metabolic acidosis.

Correct response: • fluid volume excess. Explanation: Edema is a characteristic sign of fluid volume excess (hypervolemia). Metabolic acidosis is a decrease of the client's pH and increase in the carbon dioxide. Hyponatremia is a low sodium level and not associated with peripheral edema. Hypovolemia is a decrease in blood pressure. Peripheral edema is not consistent with hypovolemia but hypervolemia.

he nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? • hypertonic • hypotonic, followed by isotonic • hypotonic • isotonic

Correct response: • hypertonic Explanation: A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.

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. • hypothyroidism. • hypoglycemia. • hypocalcemia.

Correct response: • hypokalemia. Explanation: 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.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: • hypernatremia. • hypokalemia. • hyponatremia. • hyperkalemia.

Correct response: • hyponatremia. Explanation: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

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 • palpating the veins on the nondominant hand • placing the tourniquet on the upper arm for 2 minutes • asking the client to pump their fist several times

Correct response: • placing the tourniquet on the upper arm for 2 minutes Explanation: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.

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

Correct response: • replacement of fluids for those lost from vomiting and diarrhea. Explanation: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

A nurse is caring for an older adult with type 2 diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1,200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. • "Try to drink at least six to eight glasses of water each day." • "Try to limit your fluid intake to 1 quart of water daily." • "Limit sugar, salt, and alcohol in your diet." • "Report side effects of medications you are taking, especially diarrhea." • "Temporarily increase foods containing caffeine for their diuretic effect." • "Weigh yourself daily and report any changes in your weight."

Correct response: • "Try to drink at least six to eight glasses of water each day." • "Limit sugar, salt, and alcohol in your diet." • "Report side effects of medications you are taking, especially diarrhea." • "Weigh yourself daily and report any changes in your weight." Explanation: In general, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6-mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? • 1+ pitting edema • 2+ pitting edema • 3+ pitting edema • 4+ pitting edema

Correct response: • 3+ pitting edema Explanation: 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? • Encourage foods and fluids with high sodium content. • Administer oral K supplements as ordered. • Caution the patient about eating foods high in potassium content. • Discuss calcium-losing aspects of nicotine and alcohol use.

Correct response: • Administer oral K supplements as ordered. Explanation: Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? • Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. • Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. • Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. • Discontinue the infusion immediately, apply warm compresses to the site, and restart the IV at another site.

Correct response: • Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. Explanation: The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? • Explaining the mechanisms involved in transporting fluids to and from intracellular compartments. • Keeping fluids readily available for the patient. • Emphasizing the long-term outcome of increasing fluids when the patient returns home. • Planning to offer most daily fluids in the evening.

Correct response: • Keeping fluids readily available for the patient. Explanation: Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3−, 14 mEq/L? • Respiratory acidosis • Respiratory alkalosis • Metabolic acidosis • Metabolic alkalosis

Correct response: • Metabolic acidosis Explanation: A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess? • A pinched and drawn facial expression • Deep, rapid respirations. • Moist crackles heard upon auscultation • Tachycardia

Correct response: • Moist crackles heard upon auscultation Explanation: Moist crackles may indicate fluid volume excess. A person with a severe fluid volume deficit may have a pinched and drawn facial expression. Deep, rapid respirations may be a compensatory mechanism for metabolic acidosis or a primary disorder causing respiratory alkalosis. Tachycardia is usually the earliest sign of the decreased vascular volume associated with fluid volume deficit.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? • Reposition the extremity and raise the height of the IV pole. • Apply pressure to the dressing on the IV. • Pull the catheter out slightly and reinsert it. • Put on gloves; remove the catheter

Correct response: • Put on gloves; remove the catheter Explanation: This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes and secure gauze with tape over the insertion site without applying pressure. The nurse should assess the area distal to the venous access device for capillary refill, sensation and motor function and restart the IV in a new location. Finally the nurse should estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since last assessment, notify the primary health care provider and use an appropriate method for clinical management of the infiltrate site, based on infused solution and facility guidelines (INS, 2016b), and record site assessment and interventions, as well as site for new venous access.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? • Remove the IV from the site and start at another location. • Immediately notify the primary care provider. • Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. • Aspirate the catheter and attempt to flush again.

Correct response: • Remove the IV from the site and start at another location. Explanation: If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? • Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. • Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider stat, administer antihistamine parenterally as needed. • Stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider, and treat symptoms. • Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the health care provider, administer antibiotics stat.

Correct response: • Slow or stop the infusion; monitor vital signs, notify the health care provider, place the patient in upright position with feet dependent. Explanation: The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access site is leaking fluid during flushing. What would be the nurse's priority intervention in this situation? - Remove the IV from the site and start at another location. - Immediately notify the primary care provider. - Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes. - Aspirate the catheter and attempt to flush again.

Remove the IV from the site and start at another location. If the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and if clinical need is present, restart in another location. The primary care provider does not need to be notified first. The nurse should use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes or aspirate and attempt to flush again if the IV does not flush easily.