Fluid and Electrolyte
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas
A nurse is caring for a patient who is on a TPN. Which of the following clients are candidates for TPN
Major trauma or burns liver or renal failure inflammatory bowel diseas.
A decrease in arterial blood pressure will result in the release of
Renin
Phlebitis
inflammation of the vein
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?
+1 The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.
What is the rate of administration for packed red blood cells?
1 unit over 2 to 3 hours, no longer than 4 hours
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Acute Confusion related to cerebral edema
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) Correct Explanation: Implanted CVADs are ideal for long-term uses such as chemotherapy.
The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level?
Cardiac dysrhythmias
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
Cardiac irregularites
A client's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor?
Cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials.
The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?
Cardiac volume intolerance Explanation: The elderly patient is more likely to experience cardiac volume intolerance related to the heart having less efficient pumping ability.
A nurse is choosing a vein to start an IV infusion in a patient. Which of the following are recommended veins to use when initiating an IV infusion? Select all that apply.
Cephalic metacarpal basilic superficial veins on dorsal aspect of the hand
The nurse is caring for a patient with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?
ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other potassium rich foods from diet
A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV?
Ensure that the prescribed solution is clear and transparent.
A nurse is caring for a patient who has a PICC line. Which nursing action is recommended
Flush using normal saline and or heparin, according to facility policy.
When a 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 what?
Hypokalemia
Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. What is this electrolyte imbalance known as?
Hyponatremia Explanation: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water.
The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mmHg and an HCO3 level of 28 mEq/L, the nurse suspects the client is most likely experiencing which of the following conditions?
Metabolic Alkalosis
Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L. For what manifestations will you be alert?
Muscle weakness, fatigue, and dysrhythmias
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation?
Notify the primary care provider immediately for possible fluid overload.
The nurse is determining a site for an IV infusion. What guideline should the nurse consider?
Scalp veins should be selected for infacts because of thei accessibility
The primary extracellular electrolytes are
Sodium, chloride, and bicarbonate
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as
Total parenteral nutrition Explanation: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.
An IV hypertonic solution containing dextrose, proteins, vitamins and minerals is known as
Total parenteral nutriton.
A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which of the following actions should the nurse perform?
Weigh the client's wet linen or dressing. Explanation: In cases in which accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, or dressings and subtracts the weight of a similar dry item.
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 a(an)
Winged infusion needle Explanation: Winged infusion needles are short, beveled needles with plastic flaps or wings. They may be used for short-term therapy or when therapy is given to a child or infant.
Which of the following clients would be a candidate for total parenteral nutrition?
a client with colitis and bloddy diaherra
Which actions would a nurse perform after selecting a site and palpating accessible veins in order to start an IV infusion?
~Advance the needle or catheter into the vein. A sensation of "give" can be felt when the needle enters the vein. • When blood returns through the lumen of the needle or the flashback chamber of the catheter, advance device into the vein until the hub is at the venipuncture site. • Release the tourniquet, quickly remove the protective cap from the IV tubing, and attach the tubing to the catheter or needle.
The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which of the following statements made by 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 kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." • The adrenal glands regulate blood volume by secreting aldosterone." • "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst."
The student nurse asks the instructor how buffer systems work in the body to maintain the pH of the blood. The instructor explains each of the buffer systems to the students. Which of the following are buffer systems that will be discussed by the instructor? Select all that apply.
• Carbonic acid-sodium bicarbonate buffer system • Phosphate buffer system • Protein buffer system
What nursing actions would be performed when preparing an IV solution and tubing when starting an IV infusion?
• Maintain aseptic technique when opening sterile packages and IV solution. • Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. • Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. • Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.
The nurse is teaching a patient about the function of sodium in the body. What teaching points would the nurse make?
• Sodium is the primary regulator of ECF volume • Sodium is normally maintained in the body within a relatively narrow range, and deviations quickly result in serious health problems. • Sodium participates in the generation and transmission of nerve impulses.
