Chapter 40: Fluid, Electrolyte, and Acid-Base Balance
What commonly used intravenous solution is hypotonic? 0.45% NaCl lactated Ringer's 0.9% NaCl 10% dextrose in water
0.45% NaCl
the nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? 3+ 1+ 4+ 2+
1+
A health care provider has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? 120 drops/mL 60 drops/mL 30 drops/mL 90 drops/mL
60 drops/mL
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? 83 mL/hr 13 mL/hr 103 gtts/hr 100 mL/hr
83 mL/hr
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? A midline peripheral catheter A peripheral venous catheter inserted to the cephalic vein A peripheral venous catheter inserted to the antecubital fossa An implanted central venous access device (CVAD)
An implanted central venous access device (CVAD)
The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply. Cardiac arrythmia Nausea and vomiting Polyuria Polydipsia Muscle weakness
Cardiac arrythmia Muscle weakness
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. Fluid restriction Hypervolemia management Electrolyte management Monitoring edema Nutrition management Intravenous therapy
Electrolyte management Nutrition management Intravenous therapy
A client with stage III breast cancer has been prescribed 10 weeks of chemotherapy. Which intravenous (IV) access does the nurse anticipate will be needed? Groshong catheter tunneled into the subclavian vein 18 gauge peripheral IV port in the left forearm PICC catheter inserted in the axillary vein percutaneous catheter in the jugular vein
Groshong catheter tunneled into the subclavian vein
A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status? pH: 6.45 SaO2: 89% PaCO2: 48 mm Hg (6.38 kPa) HCO3: 25 mEq/L (25 mmol/L)
HCO3: 25 mEq/L (25 mmol/L)
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? Respiratory acidosis Metabolic alkalosis Respiratory alkalosis Metabolic acidosis
Metabolic alkalosis
A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply. crackles in the lungs excessive urination poor skin turgor blood pressure 100/48 mm Hg distended neck veins
crackles in the lungs distended neck veins
The process of filtration begins at the: Bowman's capsule. Loop of Henle. glomerulus. collecting ducts.
glomerulus.
The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? hypertonic isotonic plasma hypotonic
hypertonic
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: hypoglycemia. hypokalemia. hypothyroidism. hypocalcemia.
hypokalemia.
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? blockage of the lymph nodes increased capillary permeability decreased colloid oncotic pressure increased hydrostatic pressure
increased hydrostatic pressure
Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance? increased respiratory rate renal retention of H ions hypoventilation increased excretion of bicarbonate ions by the kidneys
increased respiratory rate
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? maintenance of blood volume transportation of nutrients maintenance of cell size removal of waste
maintenance of cell size
Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? muscle cramping and tetany nausea, vomiting, and constipation muscle weakness, fatigue, and constipation diminished cognitive ability and hypertension
muscle cramping and tetany
A decrease in arterial blood pressure will result in the release of: thrombus. insulin. renin. protein.
renin
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? A positive O negative AB negative B positive
O negative
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? Hands Abdomen Sacral area Face
Sacral area
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Start an IV of normal saline as prescribed. Encourage fluid intake. Give the client a glass of orange juice with added sugar. Allow nothing by mouth.
Start an IV of normal saline as prescribed.
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? diminished cognitive ability and hypertension muscle weakness, fatigue, and arrythmias muscle weakness, fatigue, and constipation nausea, vomiting, and constipation
muscle weakness, fatigue, and arrythmias
A nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance? hyponatremia hypermagnesemia hypercalcemia hypokalemia
hypokalemia
During an assessment of an older adult 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. Which medical diagnosis may be responsible? hypovolemia circulatory overload edema hypervolemia
hypovolemia
The 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? hypotonic hypertonic hypotonic, followed by isotonic isotonic
distended neck veins
The nurse working at the blood bank is speaking with a potential blood donor client. The client has been living in South America where there was a Zika outbreak. Which statement by the nurse is most appropriate? "Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions." "To prevent the spread of microorganisms, anyone who has lived out of the country for over 6 months is unable to donate blood." "As long as you did not receive any blood transfusions while living in South America, you may donate blood." "While living in South America, you may have been exposed to a lot of different diseases, which makes you ineligible to donate blood."
"Because you lived in South America for more than 3 months, there is risk of transmitting the Zika virus through blood transfusions."
he student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Watery plasma, or serum, portion of blood." "Fluid outside cells." "Fluid inside cells." "Fluid in the tissue space between and around cells."
"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." "Unfortunately, your own blood cannot be reinfused during surgery." "We now have artificial blood products, so giving your own blood is not necessary." "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."
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? 75 mL/hr for the first 15 minutes, then 200 mL/hr As fast as the client can tolerate 1 unit over 2 to 3 hours, no longer than 4 hours 200 mL/hr
1 unit over 2 to 3 hours, no longer than 4 hours
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? 1,000 mL/day 3,500 mL/day 1,500 mL/day 2,500 mL/day
2,500 mL/day
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? Apply pressure to insertion site for at least 3 minutes. Apply petroleum-based ointment and sterile occlusive dressing. Instruct client to remain flat for 30 minutes. Ask client to perform Valsalva maneuver.
Apply pressure to insertion site for at least 3 minutes.
A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate? Select a large-gauge needle. Consider venipuncture in the foot where veins are less visible. Use the client's nondominant hand to hold the vein in place. Avoid use of a tourniquet.
Avoid use of a tourniquet.
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Decreased oxygen levels Increased potassium levels Increased sodium levels Decreased potassium levels
Decreased potassium levels
client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed? Osmolar Isotonic Hypotonic Hypertonic
Hypertonic
A nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply. Hypernatremia Respiratory acidosis Hypokalemia Metabolic alkalosis Hypercalcemia
Hypokalemia Metabolic alkalosis
When providing chemotherapeutic agents, which catheter is accessed with a non-coring needle? Hickman catheter Groshong catheter Implanted venous access catheter Peripheral central catheter
Implanted venous access catheter
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)? Respiratory acidosis Metabolic acidosis Respiratory alkalosis Metabolic alkalosis
Metabolic alkalosis
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Leave water on the bedside table. Ask the client every hour to drink more fluid. Have a loved one tell the client to drink more. Offer small amounts of preferred beverage frequently.
Offer small amounts of preferred beverage frequently.
A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the prioritynursing action? Slow the rate of IV fluids. Apply a warm compress. Remove the IV. Elevate the arm.
Remove the IV.
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). Sodium is regulated by the renin-angiotensin-aldosterone system. Sodium is not regulated by natriuretic peptides. If sodium is low, it means that there is not enough water.
Sodium is regulated by the renin-angiotensin-aldosterone system.
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use: an intermittent infusion device. a central venous access. an 18-gauge needle. a winged infusion needle.
a winged infusion needle.
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? potassium and sodium potassium and chloride calcium and phosphorus chloride and magnesium
calcium and phosphorus
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? increased intracranial pressure (ICP) cardiac irregularities muscle weakness metabolic acidosis
cardiac irregularities
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? daily weights daily electrolyte monitoring output measurements daily BUN and serum creatinine monitoring
daily weights
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 intracellular dehydration decreased blood volume and extracellular overhydration decreased blood volume and intracellular dehydration increased blood volume and extracellular overhydration
decreased blood volume and intracellular dehydration
Edema happens when there is which fluid volume imbalance? water excess water deficit extracellular fluid volume deficit extracellular fluid volume excess
extracellular fluid volume excess
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? palpating the veins on the nondominant hand asking if the client is right or left handed placing the tourniquet on the upper arm for 2 minutes asking the client to pump their fist several times
placing the tourniquet on the upper arm for 2 minutes
A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action? to prevent pain and discomfort to prevent compromising circulation to reduce the potential for blood clots to avoid restriction of mobility
to prevent compromising circulation
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: total parenteral nutrition. volume expander. cellular hydration. blood transfusion therapy.
total parenteral nutrition.
he student nurse asks, "What is intravascular fluid?" What is the appropriate nursing response? "Fluid inside cells." "Fluid outside cells." "Fluid in the tissue space between and around cells." "Watery plasma, or serum, portion of blood."
"Watery plasma, or serum, portion of blood."
The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply. 100 ml from melted ice chips bowl of chili cup of ice cream infusion of intravenous solution barbecue sandwich serving of jello
100 ml from melted ice chips cup of ice cream infusion of intravenous solution serving of jello
A health care provider orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate? 50 gtt/min 20 gtt/min 40 gtt/min 30 gtt/min
50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.
A home care nurse is visiting a client with acute kidney injury 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 regular gum and hard candy. Use an alcohol-based mouthwash to moisten your mouth. Eat crackers and bread. Avoid salty or excessively sweet fluids.
Avoid salty or excessively sweet fluids.
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 infusion rate must be carefully monitored during the administration of blood. The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. The client will likely develop a fever in the presence of fluid overload. 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. 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.
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 muscle twitching nausea and vomiting fingerprinting over sternum
distended neck veins
Which is a common anion? magnesium calcium potassium chloride
chloride
A client with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving? A hypotonic solution A hypertonic solution Packed red blood cells An isotonic solution
A hypotonic solution
A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances? School-age children Adolescents Toddlers Infants
Infants
Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? a man age 50 years a woman age 45 years an adolescent age 17 years an infant age 4 months
an infant age 4 months
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? every 72 hours every 24 hours every 36 hours every 12 hours
every 72 hours
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? hypotonic solution colloid solution isotonic solution hypertonic solution
hypertonic solution
In which fluid compartment is most of the body's fluid is located? intracellular interstitial intravascular extracellular
intracellular
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? hypotonic hypertonic colloid isotonic
isotonic
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I've had a fever for the past 3 days that just doesn't seem to go away." "I've had a GI virus for the past 3 days with severe diarrhea." "I've been taking antacids almost every 2 hours over the past several days." "I was breathing so fast because I was so anxious and in so much pain."
"I've been taking antacids almost every 2 hours over the past several days."
What is the lab test commonly used in the assessment and treatment of acid-base balance? Complete blood count Urinalysis Arterial blood gas Basic metabolic panel
Arterial blood gas
A client has been prescribed 2 units of packed red blood cells. A type and cross-match has been performed and the first unit has arrived on the floor from the blood bank. When administering this client's blood transfusion, the nurse should perform which actions? Select all that apply. Obtain appropriate tubing and prime it with normal saline or lactated Ringer's. Take baseline vital signs and expect slight increases in blood pressure and heart rate after the infusion begins. Start the administration slowly for the first 15 minutes of the transfusion. Collect the last 5 mL of the packed cells and send to the laboratory for culturing. Ask another nurse to assist with confirming the order, blood group, and other vital information.
Ask another nurse to assist with confirming the order, blood group, and other vital information. Start the administration slowly for the first 15 minutes of the transfusion.
A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply. Blood pressure 126/80 mm Hg Blood pressure 104/68 mm Hg Pulse rate 72 bpm Blood pressure 112/70 mm Hg Pulse rate 90 bpm
Blood pressure 104/68 mm Hg Pulse rate 90 bpm
A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? Notify the health care provider of the client's response. Stop the transfusion and infuse normal saline using the blood tubing. Stop the transfusion and infuse normal saline using a new administration set. Check the client's vital signs.
Stop the transfusion and infuse normal saline using a new administration set.
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. Administer oxygen. Prepare to give an antihistamine. Infuse saline at a rapid rate.
Stop the transfusion immediately.
The nurse is caring for an 86-year-old client who fell at home and was not found for 2 days. The client is severely dehydrated. The client is at increased risk for fluid imbalance due to: increase in fat cells. smaller stomach capacity. decreased skin area. increase in muscle mass.
increase in fat cells.
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the health care provider of the client's: high sodium. high magnesium. low calcium. low potassium.
low calcium.
A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells? plasma normal saline solution granulocytes albumin
plasma
A client with emphysema has aPaCO2 is 80 mm Hg on an arterial blood gas report. Which action(s) will the nurse take? Select all that apply. Monitor arterial blood gasses Elevate head of bed Provide breathing treatments and medications as prescribed Monitor oxygen saturation Auscultate lung sounds
Monitor arterial blood gasses Elevate head of bed Provide breathing treatments and medications as prescribed Monitor oxygen saturation Auscultate lung sounds
The nurse is caring for a client who has a prescription for a peripheral intravenous (IV) infusion of a liter of 0.9 sodium chloride solution over 10 hours by gravity infusion. The drop factor is 60 gtts/mL. After reviewing the image, what is best action by the nurse to provide the appropriate drops per minute of medication? Administer 10 gtt/min over 30 seconds Ensure 50 gtt/min is given over 1 minute Adjust clamp below drip chamber so 75 gtts is provided in 15 seconds Regulate flow to allow 25 gtts every 15 seconds
Regulate flow to allow 25 gtts every 15 seconds
During an assessment of an older adult 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. Which medical diagnosis may be responsible? circulatory overload edema hypovolemia hypervolemia
hypovolemia
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 83 gtt/min 42 gtt/min 167 gtt/min
83 gtt/min
The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? The client has anti-B antibodies. The client is a universal donor. The client has both anti-A and anti-B antibodies. The client has anti-A antibodies.
The client has anti-A antibodies.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a newly admitted 88-year-old with a 2-day history of vomiting and loose stools a 47-year-old who had a colon resection yesterday and is reporting pain a 60-year-old who is 3 days post-myocardial infarction and has been stable. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
A nurse is caring for a clients who may require total parenteral nutrition (TPN). Which client(s) is a candidate for TPN? Select all that apply. client who is recovering from cataract surgery client with liver and renal failure client with major trauma or burns client who has not eaten for 1 day client with inflammatory bowel disease
client with liver and renal failure client with major trauma or burns client with inflammatory bowel disease
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? Tighten the roller clamp to stop the infusion. Twist the tubing around a pencil. Milk the air in the direction of the drip chamber. Tap the tubing below the air bubbles.
Tighten the roller clamp to stop the infusion
Which statement most accurately describes the process of osmosis? Plasma proteins facilitate the reabsorption of fluids into the capillaries. Water shifts from high-solute areas to areas of lower solute concentration. Water moves from an area of lower solute concentration to an area of higher solute concentration. Solutes pass through semipermeable membranes to areas of lower concentration.
Water moves from an area of lower solute concentration to an area of higher solute concentration.
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: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l) pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l) pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l)
pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)
a client with renal disease requires IV fluids. It is important for the nurse to: administer the fluids through the dialysis access. catch the rate up when it falls behind. check the intravenous rate once a shift. place the fluids on an electronic device.
place the fluids on an electronic device.
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I should drink 1,500 mL/day of fluid." "I need to drink no more than 1,000 mL/day" "I should drink more than 3,500 mL/day of fluid." "I should drink 2,500 mL/day of fluid."
"I should drink 2,500 mL/day of fluid."
The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by the students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply. "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." The adrenal glands regulate blood volume by secreting aldosterone." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." "The kidneys react to hypovolemia by stimulating fluid retention."
"The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." The adrenal glands regulate blood volume by secreting aldosterone." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions."
The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate? "We do not record fluids absorbed into undergarments." "You only record urine output in an adult undergarment; you do not record diarrhea output." :If the undergarment is soiled, document this fact but do not estimate its contents." "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."
"Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)."
A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted? 20- to 25-degree angle 10- to 15-degree angle 30- to 35-degree angle 40- to 45-degree angle
10- to 15-degree angle
A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. Deciding the size of the IV catheter. Prescribing the kind of IV solution. Deciding the location of the IV catheter. Determining the amount of IV solution. Administering the IV solution.
Deciding the size of the IV catheter. Prescribing the kind of IV solution. Deciding the location of the IV catheter.
The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? Bowel motility will be restored within 24 hours after beginning supplemental K+. ECG will show no cardiac arrythmias within 24 hours after beginning supplemental K+. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet. ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
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 intravenous catheter. Elevate the swollen extremity on a pillow. Place a warm compress over the swollen site. Decrease the rate of the intravenous fluids.
Remove the peripheral intravenous catheter.
The primary extracellular electrolytes are: phosphorous, calcium, and phosphate. magnesium, sulfate, and carbon. sodium, chloride, and bicarbonate. potassium, phosphate, and sulfate.
sodium, chloride, and bicarbonate.
