Exam 3 fundies
"What is intravascular fluid
"Watery plasma, or serum, portion of blood."
febrile
(adj.) feverish; pertaining to or marked by fever; frenetic
Intracellular fluid
(fluid inside cells) represents the greatest proportion of water in the body.
The nurse should recognize that hypovolemia
, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.
3+ pitting edema
-Deep pit (6mm) -Remains several seconds after pressing -Skin swelling obvious by general inspection
2+ pitting edema
-Deeper pit after pressing (4mm) -Lasts longer than 1+ -Fairly normal contour
K+
A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte?
rheumatoid arthritis
A chronic systemic disease characterized by inflammation of the joints, stiffness, pain, and swelling that results in crippling deformities a chronic autoimmune disorder in which the joints and some organs of other body systems are attacked
daily weights
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?
hypokalemia
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 most likely find?
Flush the IV with 3 mL of normal saline.
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?
Decreased potassium levels
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
hypertonic solution
A 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?
hypertonic solution '
A 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?
An implanted central venous access device (CVAD)
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?
maintenance of cell size
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 cell size .
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?
edema +2 or 3+
A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm.
edema +4
A measurement of 4+ indicates severe edema of 8 mm or more.
3.5 cm H2O
A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit?
clients with major trauma or burns clients with liver and renal failure clients with inflammatory bowel disease
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN?
clients with major trauma or burns clients with liver and renal failure clients with inflammatory bowel disease
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN?
Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution.
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?
nuts
A nurse is educating a group of adults on dietary requirements. What food should the nurse recommend as a significant source of phosphorous?
rub in a side to side motion use a back and forth motion
A nurse is preparing the site for insertion of a peripheral venous catheter using chlorhexidine. Which actions would be appropriate for the nurse to do?
Ensure that the prescribed solution is clear and transparent.
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Lactated Ringer's solution 0.9% NaCl (normal saline)
A nurse must administer an isotonic intravenous solution to a client who has lost fluid. Which fluids are isotonic? Select all that apply.
distended neck veins
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?
"I should drink 2,500 mL/day of fluid."
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?
60 drops/mL
A physician 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?
50
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?
Changing the dressing on a client's peripheral IV site
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)?
replacement of fluids for those lost from vomiting and diarrhea.
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:
IV formula
Amount to infuse in milliliters x rate of infusion in minutes / drop factor of tubing = drops per minute 150 mL x 60 minutes / 10 drop factor = 25 drops per minute
a winged infusion needle.
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:
Offer small amounts of preferred beverage frequently.
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
Why is calcium important
Calcium is important in wound healing, synaptic transmission in nervous tissue, membrane excitability, and is essential for blood clotting. Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Slurred speech and reports of excessive urination are indicative of hypercalcemia.
may result from hyperchloremia.
Diminished cognitive ability and hypertension Constipation is a sign of hypercalcemia.
Stop the transfusion immediately.
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?
hemolytic transfusion reaction: incompatibility of blood product
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect?
hypovolemia
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?
Phlebitis Grade 1
Erythema at access site with or without pain
The nurse is assisting with a client's blood transfusion. What type of reactions may occur during this procedure?
Hives, itching, and anaphylaxis may occur during an allergic reaction. Fever, chills, headache and malaise may occur during a febrile reaction. Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.
aldosterone
How is control over the extracellular concentration of potassium within the human body is exerted?
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?
IV tubings are generally changed every 72 hours or as per the facility's policy. Solutions are replaced when they finish infusing or every 24 hours, whichever occurs first. IV tubings are not replaced after every solution is over or after every 12, 24, or 36 hours.
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?
Isotonic. Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.
1+ pitting edema
Mild • Slight indentation (2 mm) disappears rapidly • Normal contours • Associated with interstitial fluid volume 30% above normal
muscle cramping and tetany
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?
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?
Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.
Ca ranges
Normal total serum calcium levels range between 8.9 and 10.1 mg/dL (2.225 to 2.525 mmol/L).
Phlebitis Grade 2
Pain at access site with erythema and/or edema
Phlebitis Grade 3
Pain at access site with erythema and/or edema Streak formation Palpable venous cord
Prolonged
Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication?
Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
Sodium is regulated by the renin-angiotensin-aldosterone system.
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?
normal values
Sodium: Potassium: Calcium: Magnesium: Chloride: Phosphate:
edema +1
The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension.
Phlebitis s/s
The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect?
1+
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?
Hives, itching, and anaphylaxis may occur during an allergic reaction. Fever, chills, headache and malaise may occur during a febrile reaction. Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.
The nurse is assisting with a client's blood transfusion. What type of reactions may occur during this procedure?
Discontinue the infusion and record the volume left in the blood bag.
The nurse is assuming care for a client who is receiving an infusion of packed red blood cells (PRBCs). The PRBCs were hung 4 hours ago, and 100 mL is left to infuse. Which action is most appropriate?
Regulate flow to allow 25 gtts every 15 seconds
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?
facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes
The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply.
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet
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?
ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.
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?
Stop the transfusion
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?
Report of muscle cramps Report of numbness and tingling of the mouth Seizure activity Blood clotting
The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom does the nurse document that correlates with the admitting diagnosis?
Apply pressure to insertion site for at least 3 minutes
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.
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?
The client has anti-A antibodies.
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?
ordering type of solution, additive, amount of infusion, and duration
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice?
Anchoring extension tubing near entry site with tape
The nurse is preparing to flush a client's peripheral venous access device. Which observable intervention best assures continued effective venous access at this location?
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?
The nurse is responsible for deciding the location and size of the IV catheter, as well as for administering the solution. The primary care provider is responsible for prescribing the kind and amount of solution.
2500 ml
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?
"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)."
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?
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy
The nurse recognizes that the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.
The nurse has inserted a client's peripheral IV catheter and is now flushing the device. What is the nurse's best action?
The nurse should stabilize the catheter while flushing, making sure not to contaminate by touching the port. Reaching over a client to perform this actions is poor body mechanics.
insertion of a peripheral venous catheter using chlorhexidine
The nurse would prepare the site with a single application of 2% chlorhexidine in 70% isopropyl alcohol, using gentle pressure in a side to side, back and forth motion.
renal failure
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?
renal failure '
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client?
Discard the tubing, prime new tubing and administer the infusion at the prescribed rate of flow
The nursing is caring for a client who has a peripheral intravenous (IV) catheter in place. The nurse is flushing the new IV tubing to hang the infusion. After reviewing the actions performed by the nurse in the image, which step should the nurse take next?
25
The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?
intracellular
The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment?
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.
0.45% NaCl
What commonly used intravenous solution is hypotonic?
To assure the IV solution is appropriate for this administration
What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution?
fluid overload
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:
Apply a warm compress
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?
Apply a warm compress.
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?
apply warm compress
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?
low calcium
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 physician of the client's:
a client with colitis and bloody diarrhea
Which client would be a candidate for total parenteral nutrition?
Chloride (Cl)
Which is a common anion?
Intravenous therapy Electrolyte management Nutrition management '
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume?
Intravenous therapy Electrolyte management Nutrition management
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply.
isotonic
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?
malaise
a feeling of depression, uneasiness, or queasiness
systemic lupus erythematosus (SLE)
a more severe form of lupus involving the skin, joints, and often vital organs autoimmune disease in which immune system attacks connective tissue throughout body such as in joints and skin chronic autoimmune inflammatory disease of collagen in skin, joints, and internal organs
lungs
a nurse carefully assesses the acid base balance of a patient whose carbonic acid (H2CO3) level is decreased. this is most likely a pt with damage to the?
measuring weight daily
a nurse is assessing infants 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?
try to drink at least 6 to 8 glasses of water each day limit sugar, salt, alcohol report side effects of medications you are taking, especially diarrhea weight yourself daily and report any changes
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 1,200ML daily. what pt teaching would the nurse provide for this patient?
remove the IV from the site and start at another location
a nurse is flushing pts peripheral venous access device. the nurse finds that the access site is leaking fluid during flushing. what would be the nurses priority intervention in this situation?
administer oral K+ supplements as ordered
a nurse is monitoring a pt who is diagnosed with HYPOkalemia which nursing intervention would be appropriate for this pt?
discontinue the infusion immediately, monitor vital signs, and report finding to the primary care provider
a nurse is monitoring a pt who is receiving an IV infusion of normal saline the pt is apprehensive and presents with a pounding headache, rapid pulse rate, chills and dyspnea. what would be the nurse's priority intervention related t these symptoms?
0.33% NaCl, 0.45% NaCl
a nurse is preparing and IV solution for a patient who has Hypernatremia. which solution is the best for this condition?
keeping fluids readily available for the patient
a patient has been encouraged to increase fluid intake which measure would be most effective for the nurse to implement?
Transfusions must
be completed within 4 hours due to the potential for bacterial growth in a blood product at room temperature.
Prolonged use of the same vein
can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.
Hypokalemia
client's serum electrolyte levels which are as follows: Based on these levels, the nurse would identify which imbalance? 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: 5.75 mg/dL (1.8 mEq/L)
Raynaud disease, Raynaud syndrome
cyanosis of the fingers or toes due to vascular constriction, usually caused by cold temperatures or emotional stress
A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?
decreased K+ levels. Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
4+ pitting edema
deep pit (8mm) -remains for a prolonged time after pressing, possibly minutes. -frank swelling
pt displaying S/S of circulatory overload. too much blood administered
during the transfusion, the pt displays signs of dyspnea, dry cough, and pulmonary edema. what would be the nurses PRIORIRY action related to these symptoms?
a bacterial reaction
fever; hypertension; dry, flushed skin; and abdominal pain occur.
Valsalva maneuver
forcible exhalation against a closed glottis, resulting in increased intrathoracic pressure
metabolic alkalosis
high pH, high HCO3 pH > 7.45 HCO3 > 26
An allergic reaction to transfused blood results in
hives, itching, and anaphylactic reaction symptoms. If a fever develops during a transfusion (febrile reaction) the symptoms are typically headache, fever, chills and malaise. Incompatibility of blood products results in a hemolytic reaction, which is characterized by facial flushing, fever, chills, headache, low back pain, and shock. Dyspnea, dry cough, pulmonary edema, shortness of breath, and crackles heard in the lungs are symptoms of circulatory overload. A bacterial reaction occurs if bacteria is present in the transfusion and is characterized by symptoms such as fever, hypertension, abdominal pain and dry, flushed skin.
0.33% NaCl (1/3 strength), 0.45% (1/2 strength) NaCl
hypotonic solution
Hypertonic solutions are used
in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly because it is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment.
fever, chills, headache, and malaise occur
in febrile reactions.
Manifestations of hypercalcemia
include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech.
Manifestations of hypocalcemia
include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures.
Excess fluid volume may result from
increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.
parenterally
injection into a muscle or a vein
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).
If a client is at a fluid volume deficit,
intravenous therapy may be ordered by the primary care provider to replenish fluids and electrolytes, warranting fluid and electrolyte management. Nutrition management may help to increase and maintain electrolyte levels by adding foods high in certain electrolytes to the diet. Hypervolemia refers to fluid volume excess. Fluid restriction would be contraindicated because the client is already at a deficit. Edema would be monitored in the case of fluid volume excess.
Osmosis
is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the reabsorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.
The main function of the intracellular fluid
is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.
metabolic acidosis
low pH, low HCO3. which acid base imbalance would the nurse suspect after assessing the following arterial blood gas values; PH 7.3, PaCo2 36, HCO3 14?
slow or stop the infusion, monitor vital signs, notify health care provider, place pt in upright position with feet dependent
nurse is administering a blood transfusion for a pt following surgery. during the transfusion, the pt displays signs of dyspnea, dry cough, and pulmonary edema. what would be the nurses PRIORIRY action related to these symptoms?
put on gloves, remove the catheter
nurse is initiating a peripheral venous access IV infusion for a pt. 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 touch. what would be the nurse's NEXT action related to these findings?
moist crackles heard upon auscultation
nurse is performing physical assessment for pts with fluid imbalance which finding indicated a fluid volume excess?
Hives, itching, and anaphylaxis
occur in allergic reactions;
Phlebitis Grade 4
palpable venous cord, more than 1" with purulent drainage
interventions for an allergic reaction
stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider STAT, administer antihistamine parenterally as needed
febrile reaction
stop the transfusion immediately and keep the vein open with normal saline, notify the health care provider and treat symptoms
interventions for a bacterial reaction
stop the transfusion immediately, obtain a culture of pt blood, monitor vital signs, notify health care provider, administer antibiotics STAT
For clients with chlorhexidine allergies,
the nurse would use povidone-iodine swabs, using an expanding circular motion, allowing one minute contact time and removing the povidone-iodine with an alcohol pad.
Hypotonic solutions are administered
to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Isotonic solution is generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period.
Colloid solutions are used
to replace circulating blood volume because the suspended molecules pull fluid from other compartments. However, these solutions are not related to clients with cerebral edema.
Fluid overload can occur
when blood components are infused too quickly or too voluminously. Symptoms include increased venous pressure, distended neck veins, dyspnea, coughing, and abnormal breath sounds.