class 13 - chapter 41: fluid, electrolyte, and acid-base bThe 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 factoalance

Which is a common anion? magnesium potassium chloride calcium

chloride

What is the lab test commonly used in the assessment and treatment of acid-base balance? Complete blood count Basic metabolic panel Arterial blood gas Urinalysis

Arterial blood gas

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? Visual acuity Neurologic function Cardiac function Skeletal integrity

Cardiac function

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? Infants Toddlers Adolescents School-age children

Infants

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? Calcium Chloride Phosphorous Potassium

Potassium

When considering client safety, what is the primary purpose of the action demonstrated by the nurse involved in preparing for the administration of a prescribed IV solution? Priming of IV tubing Introducing solution into the tubing Preventing embolus Visually assessing solution

Preventing embolus

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 priority nursing action? Slow the rate of IV fluids. Remove the IV. Apply a warm compress. Elevate the arm.

Remove the IV.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? Elevate the client's head. Restart infusion in another vein and apply a warm compress. Position the client on the left side. Apply antiseptic and a dressing.

Restart infusion in another vein and apply a warm compress.

The primary extracellular electrolytes include which of the following? Potassium, phosphate, and sulfate Magnesium, sulfate, and carbon Sodium, chloride, and bicarbonate Phosphorous, calcium, and phosphate

Sodium, chloride, and bicarbonate

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? platelets granulocytes albumin cryoprecipitate

platelets

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: cellular hydration. volume expander. total parenteral nutrition. blood transfusion therapy.

total parenteral nutrition.

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr 60 gtt/min 100 gtt/min 160 gtt/min 600 gtt/min

100 gtt/min

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? Select a primary tubing of about 37 inches (94 cm) long. Ensure that the prescribed solution the expected color and consistency. Use half-instilled IV solutions before infusing a new one. Avoid replacing IV solutions every 24 hours.

Ensure that the prescribed solution the expected color and consistency.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they 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? banana milk yogurt turkey

banana

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? cardiac irregularities muscle weakness increased intracranial pressure (ICP) metabolic acidosis

cardiac irregularities

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

decreased blood volume and intracellular dehydration

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? muscle twitching distended neck veins fingerprinting over sternum nausea and vomiting

distended neck veins

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? hyperphosphatemia hyperchloremia hypokalemia hypomagnesemia

hypokalemia

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 hypokalemia hypercalcemia hypermagnesemia

hypokalemia

A client has been admitted to the medical-surgical floor for management of a fluid and electrolyte imbalance associated with decreased oral intake and excessive use of laxatives. The nurse analyzes assessment findings to identify those that may be caused by electrolyte imbalances. For each asssessment finding below, click to specify the associated electrolyte imbalance: hypokalemia, hyponatremia, or hypocalcemia. Each finding may support more than 1 disease process. Hypokalemia Hypocalcemia Hyponatremia AssesssmentFinding: confusion muscle weakness tetanyedema seizuresHypokalemiaHypocalcemiaHyponatremia

hypokalemia: muscle weakness hyponatremia: confusion, muscle weakness, edema hypocalcemia: seizures, tetany

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 muscle mass. smaller stomach capacity. decreased skin area. increase in fat cells.

increase in fat cells.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by: increasing ventilation through the lungs. increasing the excretion of HCO3− into the urine. decreasing the excretion of H+ ion into the urine. preventing excretion of acids into the urine.

increasing ventilation through the lungs.

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, and arrythmias nausea, vomiting, and constipation diminished cognitive ability and hypertension muscle weakness, fatigue, and constipation

muscle weakness, fatigue, and arrythmias

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? asking the client to pump their fist several times placing the tourniquet on the upper arm for 2 minutes 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

The student nurse asks, "What is interstitial 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."

"Fluid in the tissue space between and around cells."

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I need to drink no more than 1,000 mL/day" "I should drink 1,500 mL/day of fluid." "I should drink 2,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid."

"I should drink 2,500 mL/day of fluid."

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."

"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? As fast as the client can tolerate 1 unit over 2 to 3 hours, no longer than 4 hours 75 mL/hr for the first 15 minutes, then 200 mL/hr 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 1,500 mL/day 2,500 mL/day 3,500 mL/day

2,500 mL/day

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? 3,750 3,000 1,000 500

3,000

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? 20 gtt/min 30 gtt/min 40 gtt/min 50 gtt/min

50 gtt/min

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? 30 drops/mL 60 drops/mL 90 drops/mL 120 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 103 gtts/hr 100 mL/hr 13 mL/hr

83 mL/hr

A client has been diagnosed with excessive levels of aldosterone. The nurse's assessment will include what value? Potassium level Acid-base balance Thirst Calcium level

Acid-base balance

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? Avoid salty or excessively sweet fluids. Use regular gum and hard candy. Eat crackers and bread. Use an alcohol-based mouthwash to moisten your mouth.

Avoid salty or excessively sweet fluids.

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. Prescribing the kind of IV solution. Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution. Determining the amount of IV solution.

Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.

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 Hypermagnesemia Hypokalemia Hypophosphatemia

Hypocalcemia

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 acidosis Respiratory acidosis Metabolic alkalosis Respiratory alkalosis

Metabolic alkalosis

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? B positive O negative A positive AB negative

O negative

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 Regulate flow to allow 25 gtts every 15 seconds Adjust clamp below drip chamber so 75 gtts is provided in 15 seconds

Regulate flow to allow 25 gtts every 15 seconds

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 priority nursing action? Assess oxygen levels. Stop the transfusion. Assess for visible rash. Call for assistance.

Stop the transfusion.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? To assure the IV solution is appropriate for this administration To assure effective administration of the prescribed IV solution To provide for effective time management in the administration of the prescribed IV solution To demonstrate effective nursing care in the administration of the prescribed IV solution

To assure the IV solution is appropriate for this administration

Which statement most accurately describes the process of osmosis? 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 shifts from high-solute areas to areas of lower solute concentration. Plasma proteins facilitate the reabsorption of fluids into the capillaries.

Water moves from an area of lower solute concentration to an area of higher solute concentration.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today a 60-year-old who is 3 days post-myocardial infarction and has been stable. a 47-year-old who had a colon resection yesterday and is reporting pain a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

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 18-gauge needle. a winged infusion needle. an intermittent infusion device. a central venous access.

a winged infusion needle.

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: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l)

pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l)

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? 42 gtt/min 83 gtt/min 167 gtt/min 5,000 gtt/min

83 gtt/min

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? Packed red blood cells An isotonic solution A hypertonic solution A hypotonic solution

A hypotonic solution

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) A peripheral venous catheter inserted to the antecubital fossa A peripheral venous catheter inserted to the cephalic vein A midline peripheral catheter

An implanted central venous access device (CVAD)

A student has joined the marching band at high school and the band begins practicing outside during hot summer weather. Which health promotion guidance will the school nurse teach the student? Eat high-potassium foods on the morning of practices Consume commercial oral rehydration drinks on practice days. Avoid drinking when not thirsty to prevent hyponatremia Ensure adequate glucose intake on practice days

Consume commercial oral rehydration drinks on practice days.

An older adult client who takes diuretics for management of hypertension, informs the nurse that they take laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of what health problem? Hypocalcemia Hypothyroidism Hypoglycemia Hypokalemia

Hypokalemia

Which statement accurately describes appropriate nursing interventions in unexpected situations when removing a peripherally inserted central catheter (PICC)? If resistance is encountered when removing a PICC, apply sufficient force to the catheter to pull it out. If resistance is encountered when removing a PICC line, stop removal, tape it down, and do not attempt to remove again. If a portion of the catheter breaks when removing it, tape the catheter down and notify the health care provider. If a portion of the catheter breaks when removing it, apply a tourniquet to the upper arm and notify the health care provider.

If a portion of the catheter breaks when removing it, apply a tourniquet to the upper arm and notify the health care provider.

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. Metabolic alkalosis Hypokalemia Respiratory acidosis Hypernatremia Hypercalcemia

Metabolic alkalosis Hypokalemia

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 Auscultate lung sounds Monitor oxygen saturation Provide breathing treatments and medications as prescribed Elevate head of bed

Monitor arterial blood gasses Auscultate lung sounds Monitor oxygen saturation Provide breathing treatments and medications as prescribed Elevate head of bed

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action? Not performing the intervention under sterile conditions Not wearing gloves when performing the intervention By applying stabilizing pressure to the catheter By pulling the dressing toward the insertion site

Not wearing gloves when performing the intervention

A client's course of intravenous medications have been completed and the nurse is removing the IV catheter. What is the nurse's best action? Nurse pulling out IV with gloves (hand on top of IV) Nurse pulling out IV with gloves by removing transparent tape Nurse removing transparent dressing with gloves Nurse pulling out IV w/o gloves

Nurse pulling out IV with gloves (hand on top of IV)

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 O negative A positive AB negative

O negative

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

Offer small amounts of preferred beverage frequently.

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 side rail. 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 is the appropriate action for the nurse? Remove the IV catheter and reinsert another in a different location. Decontaminate the visible portion of the catheter, and then gently reinsert. 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.

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? Decrease the rate of the intravenous fluids. Remove the peripheral intravenous catheter. Place a warm compress over the swollen site. Elevate the swollen extremity on a pillow.

Remove the peripheral intravenous catheter.

The nurse is inserting a medication lock for a client receiving intermittent intravenous antibiotics. To prevent the locked intravenous catheter from becoming obstructed between uses, which action will the nurse take during this procedure? Slowly remove the syringe before the fluid is completely instilled. Swab the rubber port on the medication lock with alcohol. Apply pressure over the tip of the catheter or needle. Apply pressure to the venipuncture site for 30 to 45 seconds.

Slowly remove the syringe before the fluid is completely instilled.

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

Start an IV of normal saline as prescribed.

What signs of complications and their probable causes may occur when administering an IV solution to a client? Select all that apply. Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. Local or systemic manifestations may indicate an infection is present at the site. A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when an air embolus is present. Bleeding at the site when the IV is discontinued indicates an infection is present. Engorged neck veins, increased blood pressure, and dyspnea occur when a thrombus is present.

Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. Redness, swelling, heat, and pain at the site may indicate phlebitis. Local or systemic manifestations may indicate an infection is present at the site.