Fluid and Electro PrepU

The nurse is caring for a client who has had severe diarrhea for 24 hours. Which fluid does the nurse anticipate infusing? isotonic hypotonic hypertonic hypertonic, followed by isotonic

A hypotonic solution contains fewer dissolved substances than normally found in plasma. It is administered to clients with fluid losses in excess of fluid intake, such as those who have diarrhea or vomiting. Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. The water also passes through capillary walls and becomes distributed within other body cells and the interstitial spaces. Hypotonic solutions, therefore, are an effective way to rehydrate clients experiencing fluid deficits.

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

ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level.

The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O? 23-year-old with ulnar and radial fracture 34-year-old whose urinary catheter was discontinued yesterday 48-year-old who has had a bowel movement after surgery 55-year-old with congestive heart failure on furosemide

Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O.

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? an infant age 4 months an adolescent age 17 years a woman age 45 years a man age 50 years

An infant has considerably more total body fluid and extracellular fluid (ECF) than does an adult. Because ECF is more easily lost from the body than intracellular fluid, infants are more prone to fluid volume deficits. An adolescent at 17 years is considered to have an adultlike body system similar to the 45-and 50-year-old.

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? isotonic hypotonic hypertonic plasma

Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.

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

Because hypotonic solutions are dilute, the water in the solution passes through the semipermeable membrane of blood cells, causing them to swell. This temporarily increases blood pressure as it expands the circulating volume. Hypertonic solutions draw water out of body cells while isotonic solutions have little effect on the distribution of body fluids. Blood transfusions do not cause the entry of water into body cells.

Which is a common anion? magnesium potassium chloride calcium

Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

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? Sodium Chloride Phosphorous Potassium

Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium.

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

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

A 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 alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Endocrine disorders and ingestion of large amounts of antacids cause metabolic alkalosis.

A client has been admitted with fluid volume excess related to left-sided heart failure. Which assessment data would the nurse document related to the fluid volume excess? Select all that apply. blood pressure 100/48 mmHg crackles in the lungs distended neck veins poor skin turgor excessive urination

Fluid volume deficit causes a low BP (100/48 mmHg), poor skin turgor, and an elevated heart rate (128/bpm). Fluid excess can cause crackles and distended neck veins as well as decreased urine output.

The nurse is preparing to change the IV tubing of a client receiving a peripheral venous IV infusion 5% dextrose and water based on the understanding that IV tubing is generally changed at which interval? Every 24 hours. Every 36 hours. Every 60 hours. Every 96 hours.

Generally, IV tubing is changed every 72 to 96 hours. Changing the tubing helps to prevent contamination and bacterial growth.

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

In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. 1,000 mL/day and 1,500 mL/day are too low, and 3,500 mL/day is too high.

A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate? "Infiltration is the inflammation of the vein, while phlebitis is a localized irritation." "Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein." "Infiltration is a localized blood clot, and phlebitis occurs when an IV is improperly placed." "Infiltration occurs when an IV is improperly placed, and phlebitis indicates circulatory overload."

Infiltration is the escape of IV fluid into the tissue, and phlebitis is the inflammation of a vein. All other options are incorrect.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Increased sodium levels Increased potassium levels Decreased potassium levels Decreased oxygen levels

Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

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.

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.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: phlebitis. an infiltration. a systemic blood infection. rapid fluid administration.

Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.

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? Sepsis Phlebitis Infiltration Air embolism

Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.

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

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles.

A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse? Eggs Chicken Apples Spinach

Sardines, whole grains, and green leafy vegetables also provide calcium.

The client has a sodium level of 131 mEq/L and has been placed on fluid restrictions of 1,000 mL per day. What interventions would the nurse include in the plan of care to assist the client in adhering to the fluid restriction? Select all that apply. Offer the client fluids in small containers. Provide a moisturizer for the lips and mouth. Provide hard candies for the client to suck on. Remove the water pitcher from the client's bedside. Limit frequent oral hygiene for the client.

The client has hyponatremia and is on fluid restriction. The nurse offers fluid in small containers. This action makes the container appear to have more fluid than it actually does. The nurse provides a lubricant or moisturizer for the lips and mouth, as the client with hyponatremia typically experiences dry mouth. The nurse removes the water pitcher from the client's bedside to remove a visual reminder of fluid and to limit fluid intake. Hard candy increases the client's thirst. Frequent oral hygiene will assist in keeping the client's mouth moist.

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.

The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

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

The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min

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? 3.5 cm H2O 5 cm H2O 9.5 cm H2O 12 cm H2O

The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? Discontinue the IV and relocate it to another site. Call the primary care provider to see whether anti-inflammatory drugs should be administered. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site.

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

A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? 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.

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