Electrolyte, Fluid Balance Quiz
A client has been diagnosed with a gastrointestinal bleed and the physician has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours. Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.
A nurse flushing a capped peripheral venous access device finds that the IV does not flush easily. What is the most appropriate intervention in this situation?
Aspirate and attempt to flush the line again. If the IV does not flush easily, assess the insertion site. Infiltration and/or phlebitis may be present. If present, remove and restart in another location. In addition, the catheter may be blocked or clotted due to a kinked catheter at the insertion site. Aspirate and attempt to reflush. If resistance remains, do not force. Forceful flushing can dislodge a clot at the end of the catheter. Remove and restart in another location. If assessment reveals the catheter has pulled out a short distance, do not reinsert it; it is no longer sterile. Remove and restart in another location.
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?
Hemolytic transfusion reaction: incompatibility of blood product. The listed symptoms occur when a blood product is incompatible. Hives, itching, and anaphylaxis occur in allergic reactions; fever, chills, headache, and malaise occur in febrile reactions. In a bacterial reaction, fever; hypertension; dry, flushed skin; and abdominal pain occur.
The nurse understands that administering a hypertonic solution to a patient will shift water from the _____ to the _____ space
Intracellular; extracellular
The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as
Osmosis
Which assessment finding should cause a nurse to question administering a sodium-containing isotonic intravenous fluid?
Pitting Edema
The nurse knows that intravenous fluid therapy has been effective for a patient with hypernatremia when
Serum sodium concentration returns to normal.
A nurse is measuring the intake and output of a client who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse should use as a comparison?
2600 mL The average adult daily fluid source is 1,300 mL from ingested water, 1,000 mL from ingested food, and 300 mL from metabolic oxidation, totaling 2,600 mL fluid.
A client is receiving a transfusion of packed red blood cells and the nurse has obtained the first set of vital signs after initiating the transfusion. These closely match the pre-transfusion vital signs with the exception of oral temperature, which shows the client has developed a fever. The client denies other symptoms and is not in distress. What is the nurse's most appropriate action?
Administer acetylsalicylic acid (ASA; aspirin), as ordered. If the client's only sign or symptom is an increase in temperature, there is no need to wholly discontinue the transfusion. The primary care provider should be informed, however, and the client may receive acetaminophen or an antihistamine.
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 of the following actions? Select all that apply.
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. Tubing for a transfusion is primed with normal saline, not lactated Ringer's. Vital information is checked with the assistance of another nurse. Blood pressure and heart rate are not expected to rise after the infusion begins and the infusion should be at a slow rate for the first few minutes. There is no need to collect cultures unless the client experiences a suspected transfusion reaction.
The nurse is caring for a patient with hyperkalemia. Which body system would be most important for the nurse plan to monitor closely?
Cardiac
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. 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 is 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?
Discontinue the IV. 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 client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action?
Flush the IV with 3 mL of normal saline. If fluid is slow to infuse, the nurse should reposition the client's arm and/or flush the IV. Changing to IV infusion will not resolve the problem and heparin is not used for clearing peripheral IVs. Deep vein thrombosis is unrelated to slow IV fluid infusion.
A nurse is caring for a client who has recently suffered burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this client?
Lactated Ringer's 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.
The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most concerned about?
Potassium imbalance
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?
Provide ongoing verification of the IV solution and the infusion rate with the physician's order. The nurse's ongoing verification of the IV solution and the infusion rate with the physician's order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 50 mL of fluid remains in the original container. Generally, sets should be changed no more frequently than every 96 hours.
A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation?
Reapply the dressing and notify the physician for further instructions. When a PICC line is not dislodged all the way, the nurse should notify the physician. The physician will most likely order a chest x-ray to determine where the end of the PICC line is. A dressing should be reapplied before the chest x-ray, to prevent further dislodgement.
When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which of the following complications has most likely occurred?
Thrombus. Phlebitis and thrombus present as local acute tenderness, redness, warmth, and slight edema of the vein above the site. Sepsis manifests as a red and tender insertion site with fever, malaise, and other vital sign changes. Infiltration or the escape of fluid into the subcutaneous tissue manifests as swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea.
Which assessment finding would the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?
Tingling of the extremities and tetany