Fundamentals Chapter 40 Electrolytes
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
A
A nurse must administer an isotonic intravenous solution to a client who has lost fluid. Which fluids are isotonic? Select all that apply. Lactated Ringer's solution 0.9% NaCl (normal saline) 0.33% NaCl (1/3-strength normal saline) 0.45% NaCl (½-strength saline) 5% dextrose in lactated Ringer's solution
A,B
A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which statements accurately describe this process? Select all that apply. The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. The thyroid gland secretes aldosterone, a mineralocorticoid hormone that helps the body conserve sodium, helps save chloride and water, and causes potassium to be excreted. The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. Thyroxine, released by the adrenal glands, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output. The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.
A,B,D,F
x A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which action should the nurse perform? Weigh the volume of IV fluid before instilling. Weigh the client's wet linen or dressing. Weigh the client without soiled incontinence pads. Weigh the client before and after meals.
B 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. The nurse does not weigh the client without soiled incontinence pads. The nurse does not weigh the client before and after meals to obtain an accurate assessment of the fluid output.
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? hypertonic colloid isotonic hypotonic
C Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.
A physician 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
D The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.
The process of filtration begins at the: glomerulus. Loop of Henle. Bowman's capsule. collecting ducts.
A
Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing? febrile reaction allergic reaction hemolytic reaction circulatory overload
A Febrile reaction to blood components can occur because of the recipient's hypersensitivity to the donor's white blood cells. In this reaction, the client develops a fever and chills and may complain of a headache and malaise.
The nurse has received the arterial blood gas (ABG) results. The ABG was drawn on a client who has been receiving oxygen via partial rebreather mask. Which assessment findings could indicate oxygen toxicity? Select all that apply. headache sore throat fatigue nasal flaring tachycardia
A,B,C
A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the physician to order? Whole blood Packed cells White blood cells Platelets D5W 1000 mL
B
A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells? albumin plasma granulocytes normal saline solution
B The infusion of plasma helps restore and replace the clotting factors that are lost with the infusion of large amounts of packed red blood cells. Albumin pulls third-spaced fluid by increasing colloidal osmotic pressure but does not restore clotting factors. The infusion of granulocytes improves the ability of the body to overcome infection. Normal saline is an isotonic solution that replaces fluid loss but does not replace clotting factors.
A decrease in arterial blood pressure will result in the release of: protein. thrombus. renin. insulin.
C
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
C Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.
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
A Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.
x A client is scheduled for insertion of a peripherally inserted central catheter. When assisting with the procedure, the nurse would expect that which site would most likely be used? Basilic vein Cephalic vein Median cubital vein Scalp vein
A The basilic vein is used most often, but the median cubital and cephalic veins in the antecubital area also can be used. Scalp veins are appropriate for peripheral venous access in infants under 9 months of age.
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? The client has a decreased sensation of thirst. The renal system retains more water. Urine becomes more diluted. The frequency of voiding increases.
B
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? Calcium Chloride Phosphorous Potassium
D
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: hypocalcemia. hypothyroidism. hypoglycemia. hypokalemia.
D
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
B
Which nursing actions would be performed when preparing an IV solution and tubing to initiate intravenous therapy? Select all that apply. Maintain aseptic technique when opening sterile packages and IV solution. Clamp tubing, uncap spike, and insert into entry site on bag as manufacturer directs. Squeeze drip chamber and allow it to fill one-quarter full. Remove cap at end of tubing, release clamp, and allow fluid to move through tubing. Allow fluid to flow and cap at end of tubing before all air bubbles have disappeared. Apply label to tubing reflecting the day/ date for next set change, per facility guidelines.
A,B,D,F
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
B
A client with dehydration will have an increase in: albumin potassium glucose aldosterone
D The rennin-angiotensin-aldosterone and natriuretic peptide hormone systems regulate the volume within narrow limits by adjusting fluid intake and the urinary excretion of sodium, chloride, and water.
A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant? weight gain of 0.75 kg in a day increased blood pressure bounding pulse slightly distended neck veins
A Although increased blood pressure, bounding pulse, and distended neck veins are signs of ECF volume excess, rapid weight gain (more than 0.5 kg per day) is the most significant symptom indicating ECF volume excess. A weight gain of 1 kg reflects retention of 1 L of ECF. Additionally, because the veins are very distensible, large volumes of fluid can be retained without any increase in blood pressure or changes in pulse or neck veins
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.
B
The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? interstitial extracellular intracellular intravascular
C
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.
D Generally, IV tubing is changed every 72 to 96 hours. Changing the tubing helps to prevent contamination and bacterial growth.
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: low potassium. low calcium. high sodium. high magnesium.
B
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). Sodium is regulated by the renin-angiotensin-aldosterone system. If sodium is low, it means that there is not enough water. Sodium is not regulated by natriuretic peptides.
B 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.
When providing chemotherapeutic agents, which catheter is accessed with a non-coring needle? Hickman catheter Groshong catheter Implanted venous access catheter Peripheral central catheter
C Implanted venous access catheters are accessed with a non-coring needle such as a Huber point needle.
A nurse is obtaining an arterial blood specimen from a client to assess acid-base status. Which value is expected for a client with normal status? pH: 6.45 PaCO2: 48 mm Hg (6.38 kPa) HCO3: 25 mEq/L (25 mmol/L) SaO2: 89%
C Normal values include: HCO3: 22 to 26 mEq/L; pH: 7.35 to 7.45; PaCO2: 35; and SaO2: oxygen saturation greater than 95%.
A client suffers from a genetic bleeding deficiency involving a deficit in factor VIII. Which blood product will the nurse most likely administer? Whole blood Albumin Platelets Cryoprecipitate
D Cryoprecipitate may be pooled from several units of blood and administered to clients with fibrinogen deficiencies who are predisposed to bleeding problems; genetically, these clients lack Factor VIII. Platelets, albumin and whole blood do not include sufficient quantities of this clotting factor.
Total parenteral nutrition is hypertonic. What is the percentage of dextrose in these solutions? 2.5% dextrose 5% dextrose 10% dextrose 50% dextrose
D Total parenteral nutrition (TPN) is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.
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.
A
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? Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. Flush the IV with 3 mL of normal saline. Change from infusion with an electronic pump to infusion by gravity. Flush the IV with 2 mL of 100 U/mL heparin.
B
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
B
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."
C
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.
A
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
B
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? excessive use of laxatives diaphoresis renal failure increased cardiac output
C
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? every 12 hours every 24 hours every 36 hours every 72 hours
D
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.
A
The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? calcium and phosphorus potassium and sodium chloride and magnesium potassium and chloride
A The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance.
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
B
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply. clients who have not eaten for a day clients with major trauma or burns clients with liver and renal failure clients who are recovering from cataract surgery clients with inflammatory bowel disease
B,C,E The nurse knows that clients with major trauma or burns, clients with liver and renal failure, and clients with inflammatory bowel disease are likely candidates for TPN. Clients who have not eaten for a day or clients recovering from cataract surgery are not likely candidates for TPN. Clients who have not eaten for 5 days and are not likely to eat during the next week are considered for TPN.
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
A
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.
D
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.
A
A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? Stop the transfusion and infuse normal saline using a new administration set. Check the client's vital signs. Stop the transfusion and infuse normal saline using the blood tubing. Notify the health care provider of the client's response.
A
A nurse is assessing for the presence of edema in a client who is confined to bed and who often lies supine. The nurse would pay particular attention to which area? Sacral area Face Hands Abdomen
A
A nurse is providing care to a client who is on fluid restriction. Which action by the nurse would be most appropriate? Offer the client sugar-free candy to help combat thirst. Give the client a fluid containing additional sodium to enhance the feeling of fullness. Have the client use an alcohol-based mouthwash every 2 hours to reduce the thirst sensation. Apply a petroleum-based gel to the client's lips to prevent cracking.
A
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump? The pump will continue to infuse fluid even when the needle is displaced. The pump stops pushing the fluid in the client's vein when the needle is displaced. The pump compresses the tubing to infuse the solution at a precise, preset rate. The pump will sound an audible and visual alarm warning the nurse of the situation.
A
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? Tighten the roller clamp to stop the infusion. Twist the tubing around a pencil. Tap the tubing below the air bubbles. Milk the air in the direction of the drip chamber.
A
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. Ask client to perform Valsalva maneuver. Instruct client to remain flat for 30 minutes. Apply petroleum-based ointment and sterile occlusive dressing.
A
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.
A
A client with stage III breast cancer has been prescribed 10 weeks of chemotherapy. Which intravenous (IV) access does the nurse anticipate will be needed? Groshong catheter tunneled into the subclavian vein PICC catheter inserted in the axillary vein 18 gauge peripheral IV port in the left forearm percutaneous catheter in the jugular vein
A A Groshong catheter is a tunneled catheter that is frequently used for extended therapy. The tunneling helps to secure the catheter, as well as reduce the potential for infection. The other catheter choices are not appropriate at this time.
Arterial blood gases reveal that a client's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance? increased respiratory rate renal retention of H ions hypoventilation increased excretion of bicarbonate ions by the kidneys
A Hyperventilation results in increased CO exhalation and a consequent increase in pH, with the goal of attaining the ideal of 7.35 to 7.45. Retention of hydrogen ions, increased excretion of bicarbonate ions, and hypoventilation are all processes that contribute to decreased pH and an exacerbation of acidosis.
A client is receiving IV fluids. The solution has an osmolarity of 280 mOsm/L. The nurse would expect which event to occur with the body's fluids? No shifting of fluids occurs. Fluids move into the cells. Fluids move into the interstitial space. Intracellular fluid moves to the intravascular space.
A Isotonic fluids have an osmolarity of 250 to 375 mOsm per liter, which is the same osmotic pressure as that found within the cell. Isotonic fluids are used to expand the intravascular compartment and thus increase circulating volume. Because these solutions do not alter serum osmolarity, interstitial and intracellular compartments remain unchanged and no fluid shifts occur. Hypotonic fluids have an osmolarity lower osmotic pressure than the cell. When a hypotonic solution is infused, it lowers serum osmolarity, causing body fluids to shift out of the blood vessels and into the cells and interstitial space. Hypertonic fluids have an osmolarity higher and a greater osmotic pressure than the cell. When a hypertonic solution is infused, serum osmolarity is increased, pulling fluid from the cells and the interstitial tissues into the vascular space.
x The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mm Hg (6.52 kPa) and an HCO3 level of 28 mEq/L (28 mmol/L), the nurse suspects the client is most likely experiencing which condition? Metabolic alkalosis Metabolic acidosis Respiratory acidosis Respiratory alkalosis
A Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as "contraction alkalosis"). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. The loss of stomach acid or taking in of base causes H+ shifts in the blood, and pH increases.
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.
A,B,C A pounding headache, fainting, rapid pulse rate, increased blood pressure, chills, back pains, and dyspnea occur when fluids are administered too rapidly (speed shock). Bleeding at the IV site indicates the need for additional pressure to be applied to the site. This can occur if the client is taking anticoagulants or has a bleeding disorder. Engorged neck veins, increased blood pressure, and dyspnea occur when fluid overload has occurred.
Which client(s) would be an appropriate candidate for total parenteral nutrition (TPN)? Select all that apply. client who has full-thickness (third-degree) burns over 40% of the body client with peptic ulcer disease client who had gastric surgery and is unable to eat for a few weeks client with anorexia nervosa client who has cholelithiasis
A,C,D
A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply. blood pressure 100/48 mmHg crackles in the lungs distended neck veins poor skin turgor heart rate 128/bpm
A,D,E 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.
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
All A PaCO2 level above 45 mm Hg is in the abnormal range. The PaCO2 level is influenced almost entirely by respiratory activity, with a disease such as chronic obstructive pulmonary disease resulting from abnormal results. The nurse will auscultate lung sounds and monitor oxygen saturation. The nurse will give oxygen as prescribed and needed. The nurse will need to be careful about turning off the client's desire to breathe by giving too much O2. As a general rule, clients with emphysema should be kept around 88% to 92%. The health care provider may prescribe breathing treatments and medications such as beta-agonists, anticholinergics and corticosteroids. Elevating the head of the bed can help the client to breath more easily.
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
B
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? hypervolemia hypovolemia edema circulatory overload
B
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."
B
A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed? Isotonic Hypertonic Hypotonic Osmolar
B A hypertonic solution has a greater osmolarity than plasma, which causes water to move out of the cells and be drawn into the intravascular compartment. A hypotonic solution has a lower osmolarity than plasma; therefore, fluid would move out of the intravascular space rather than pulling fluids from the tissues into the vascular space. An isotonic fluid remains in the intravascular compartment without any net flow across the semipermeable membrane. The concentration of particles in a solution is referred to as the osmolarity of a solution.
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 pretransfusion vital signs with the exception of a 1°F (0.5°C) increase in the oral temperature. The client denies other symptoms and is not in distress. What is the nurse's most appropriate action? Call the blood bank and obtain diagnostic tubes. Administer acetaminophen as prescribed. Discontinue transfusion immediately, and infuse normal saline with new tubing. Promptly discontinue the transfusion, and remove the client's IV.
B If the client's only sign or symptom is an increase in temperature, which is less than 2°F (1°C), there is no need to wholly discontinue the transfusion. The health care provider should be informed, however; and the client may receive acetaminophen or an antihistamine, as prescribed. A febrile reaction includes a fever of 2°F (1°C) or higher, tachycardia, and presence of headaches or backache.
A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action? to prevent pain and discomfort to prevent compromising circulation to reduce the potential for blood clots to avoid restriction of mobility
B The nurse looks for a large vein when using a needle with a large gauge to prevent compromising circulation. To reduce the potential for blood clots and restrict a client's mobility, the nurse does not use foot or leg veins. The nurse avoids using veins on the inner surface of the wrist to prevent pain and discomfort.
A client has been admitted with fluid volume excess related to right-sided heart failure. Which assessment data would the nurse expect related to the fluid volume excess? Select all that apply. blood pressure 100/48 mm Hg crackles in the lungs distended neck veins poor skin turgor excessive urination
B,C Right-sided heart failure leads to a back up of volume which is unable to effectively flow back to the left side of the heart. The result is fluid volume excess in the peripheral circulation which eventually leads to fluid overload. Fluid excess or hypervolemia will manifest in clinical symptoms that lead the nurse to hear crackles in the lungs upon chest auscultation. Fluid volume excess leads to translocation of large volumes of intravascular fluid to the interstitial compartment or to areas with only potential spaces such as the peritoneal cavity, pericardium, and pleural space such as in the lungs. Circulatory overload from fluid volume excess will lead to the client having distended neck veins. Fluid volume deficit causes low blood pressure whereas a volume excess would result in the client becoming hypertensive. Poor skin turgor is often seen in clients with fluid volume deficits or in dehydration. A client with a fluid volume excess would more likely have edema. A client who is hypervolemic is retaining fluid in the intravascular space preventing urinary elimination from occurring. Urinary retention rather than excessive elimination would be seen in this case.
A client is preparing for discharge to home following a diagnosis of hypoparathyroidism with associated low parathyroid hormone. Which food(s) will the nurse include when creating a diet-based teaching plan for the client? Select all that apply. peanuts yogurt broccoli tofu peaches bananas
B,C,D The parathyroid produces the hormone parathormone (PTH), which regulates serum calcium levels. A low level of PTH results in hypocalcemia. The nurse's diet-based teaching plan should include foods that include high levels of calcium, such as dairy products like yogurt and cheese. Dark green vegetables like broccoli, spinach, or greens are important sources of calcium. Oysters, salmon, and sardines are also great sources of calcium. Peanuts will help raise the levels of sodium, but not calcium. Other sources of sodium are bouillon, canned soups, and snack foods. A client can increase their levels of potassium by eating fruits such as peaches and other fruits, vegetables, or juices like orange and tomato juices. Bananas are excellent sources of magnesium, as well as potassium. Other sources of magnesium include eggs, milk, and whole grains.
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
C
A client has the following arterial blood gas results:pH: 7.33PaCO2: 42 mm HgHCO3: 19 mEq/L (19 mmol/L)PaO2: 95 mm HgWhich imbalance would the nurse suspect? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
C The results reveal metabolic acidosis, which is characterized by a pH lower than 7.35 and a plasma HCO3 concentration lower than 22 mEq/L (22 mmol/L). Respiratory acidosis is indicated by a low pH accompanied by an increased arterial concentration of carbon dioxide, which often is clinically defined as a PaCO2 of greater than 45 mm Hg. Respiratory alkalosis is present when a high pH is accompanied by a blood carbon dioxide concentration lower than 35 mm Hg. Metabolic alkalosis is characterized by a pH higher than 7.45 and a plasma HCO3 concentration above 26 mEq/L (26 mmol/L).
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
D
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? Wearing gloves when preforming the intervention Using a 10 ml syringe to introduce the flushing solution Aspirating to determine positive blood return Anchoring extension tubing near entry site with tape
D
The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction? "The lungs remove water though exhalation." "The heart circulates water and nutrients through the body." "The lungs regulate metabolic acid-base disturbances by controlling carbon dioxide." "The kidneys store and release antidiuretic hormone to increase water retention."
D
The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system? Abdominal distention Vomiting Paralytic ileus Diarrhea
D The client with hyperkalemia would experience diarrhea. Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia.
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
A
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? 30 drops/mL 60 drops/mL 90 drops/mL 120 drops/mL
B
Which client would be a candidate for total parenteral nutrition? a client with diabetic ketoacidosis a postoperative appendectomy client a client with colitis and bloody diarrhea a client receiving intravenous antibiotics
C
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
A
The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. Rate of the IV solution Manufacturer of the IV catheter Location of the IV catheter access Client's reaction to the procedure Type of IV solution Gauge and length of the IV catheter
A,C,D,E,F
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
C
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? Stop the transfusion immediately. Infuse saline at a rapid rate. Prepare to give an antihistamine. Administer oxygen.
A The nurse needs to stop the transfusion immediately. The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility.
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? The client has anti-A antibodies. The client has anti-B antibodies. The client has both anti-A and anti-B antibodies. The client is a universal donor.
A
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
A
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 maintenance of blood volume transportation of nutrients removal of waste
A 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
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: cellular hydration. volume expander. total parenteral nutrition. blood transfusion therapy.
C
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. Hypervolemia management Fluid restriction Intravenous therapy Electrolyte management Monitoring edema Nutrition management
C,D,F
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? platelets granulocytes albumin cryoprecipitate
A
The nurse is determining a site for an IV infusion. What guideline should the nurse consider? Scalp veins should be selected for infants because of their accessibility. Antecubital veins should be used for long-term infusions. Veins in the leg should be used to keep the arms free for the client's use. Veins in surgical areas should be used to increase the potency of medication.
A
A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is most appropriate? Avoid use of a tourniquet. Select a large-gauge needle. Consider venipuncture in the foot where veins are less visible. Use the client's nondominant hand to hold the vein in place.
A Use of a tourniquet may result in bursting the vein, sometimes referred to as "blowing the vein," when it is punctured with a needle. Using a large-gauge needle may also "blow" the vein. A small gauge or butterfly should be used. Using veins in the foot is not appropriate nor is attempting to hold the vein in place.
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.
B
The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to: increase in muscle mass. smaller stomach capacity. decreased skin area. increase in fat cells.
D The decreasing percentage of body fluid in older adults is related to an increase in fat cells. In addition, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults. Older adults do not have an increase muscle mass, smaller stomach capacity, or decrease skin area.
The nurse is caring for a client diagnosed with an acute myocardial infarction requiring strict monitoring of intake and output. Calculate the intake for the shift. Record your answer using a whole number rounded to the nearest 10 mL. 550 mL of urine ¼ cup of grapes 200 mL of liquid stool 4 oz of Jell-O 250 mL of IV normal saline 1 cup of apple juice
The nurse would include all items that are liquid or turn to liquid at room temperature in the calculation. Jello, IV normal saline, and apple juice are calculated as intake. Urine and stool are calculated as output. Grapes will not be included as intake. Convert all units to mL, rounded to the nearest 10 mL: 4 oz of Jello = 120 mL 1 cup of apple juice = 240 mL 120 mL + 250 mL IV fluid +240 mL = 610 mL
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.
B
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? Transparent semipermeable membrane dressing Occlusive dressing Sealed IV dressing Gauze dressing
D
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
B
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.
B
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)
B
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.
B
A nurse is preparing to insert an intravenous (IV) catheter into a client's arm. At which angle relative to the client's skin should the catheter be inserted? 30- to 35-degree angle 20- to 25-degree angle 10- to 15-degree angle 40- to 45-degree angle
C
The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? isotonic hypotonic hypertonic hypotonic, followed by isotonic
C A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.
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? "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)." "We do not record fluids absorbed into undergarments." :If the undergarment is soiled, document this fact but do not estimate its contents." "You only record urine output in an adult undergarment; you do not record diarrhea output."
A
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
B 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
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
C
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? Fully open the roller clamp on the infusion set and infuse the remaining PRBCs as rapidly as possible. Continue to infuse the PRBCs until they are completely infused. Insert a larger gauge IV catheter and transfer the infusion to the new insertion site. Discontinue the infusion and record the volume left in the blood bag.
D
What commonly used intravenous solution is hypotonic? 0.45% NaCl 0.9% NaCl lactated Ringer's 10% dextrose in water
A Half-strength saline (0.45% NaCl) is hypotonic. Normal saline (0.9% NaCl) and lactated Ringer's are isotonic. 10% dextrose in water (D10W) is hypertonic.
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.
B,C,D
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
D
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 hypotonic solution isotonic solution colloid solution
A 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. 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.
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
A Infants have a far greater volume of total fluid as a percentage of body weight than other children . However, this high percentage of fluid does not give infants a greater reserve against fluid deficit. Instead, it creates a vulnerability to fluid deficit due to the high percentage of fluid required for homeostasis. In addition, kidney immaturity and increased body surface area in relation to body size place infants at greater risk than older children or adults for fluid and electrolyte imbalances.
A client is experiencing withdrawal from alcohol and admitted to the behavioral health unit. The client begins to have muscle weakness, tremors, hyperactive deep tendon reflexes, and a change in mental status. What should the nurse prepare to replace in this client? Magnesium Chloride Potassium Phosphorus
A Magnesium deficit may lead to muscle weakness, tremors, tetany, seizures, heart block, change in mental status, hyperactive deep tendon reflexes (DTRs), and respiratory paralysis. This may occur with the client that is withdrawing from alcohol. Deficits in phosphorus may cause irritability, fatigue, weakness, paresthesias, confusion, seizures, and coma. Signs and symptoms of chloride deficiency include tachypnea, weakness, lethargy, diminished cognitive ability, hypertension, decreased cardiac output, dysrhythmias, and coma. Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias.
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.
A The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. To compensate for respiratory alkalosis, the kidneys increase the excretion of HCO3− to the urine. Kidneys compensate for respiratory acidosis by increasing the excretion of H+ ion into the urine. The kidneys respond to metabolic alkalosis by retaining acid and excreting HCO3−.
A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address? increased hydrostatic pressure decreased colloid oncotic pressure blockage of the lymph nodes increased capillary permeability
A The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.
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? Bowel motility will be restored within 24 hours after beginning supplemental K+. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.
B If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.
The primary extracellular electrolytes are: potassium, phosphate, and sulfate. magnesium, sulfate, and carbon. sodium, chloride, and bicarbonate. phosphorous, calcium, and phosphate.
C
The student nurse asks, "What is intravascular 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."
D Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). 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).
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? muscle cramping and tetany nausea, vomiting, and constipation diminished cognitive ability and hypertension muscle weakness, fatigue, and constipation
A Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.
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
A The parathyroid gland regulates calcium levels, and partial removal can cause hypocalcemia. Hypocalcemia is manifested by numbness and tingling as well as tetany. The signs and symptoms do not relate to altered magnesium or potassium levels. Calcium and phosphorus have an inverse relationship, so with low calcium, the nurse will expect a high, not a low, phosphorus level.
The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply. 100 ml from melted ice chips serving of jello bowl of chili infusion of intravenous solution barbecue sandwich cup of ice cream
A,B,D,F
The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by the 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 react to hypovolemia by stimulating fluid retention." "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."
A,C,D,E
A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I was breathing so fast because I was so anxious and in so much pain." "I've been taking antacids almost every 2 hours over the past several days." "I've had a fever for the past 3 days that just doesn't seem to go away." "I've had a GI virus for the past 3 days with severe diarrhea."
B
Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease? The secretion of aldosterone and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess. Increased plasma levels of antidiuretic hormone lead to water excess. There may be an abnormal loss or accumulation of sodium, chloride, potassium, and fluid in the body, resulting in extracellular fluid and water excesses or deficits. Hyperkalemia and hypocalcemia are common, and metabolic acidosis occurs in this disease's final stage. A disruption of acid-base balance occurs. A disruption in this organ's ability to excrete carbon dioxide causes the pH of the person's blood to fall.
B In addition to increased plasma levels of antidiuretic hormones, plasma levels of albumin decrease, so that the distribution of extracellular fluid changes, vascular volume decreases, and interstitial volume increases. Complications often lead to ascites. Complications from cardiac failure can be described as the secretion of aldosterone, and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess. Hyperkalemia and hypocalcemia are common, and metabolic acidosis occurs with renal failure. Complications associated to respiratory failure include a disruption of acid-base balance and a disruption in this organ's ability to excrete carbon dioxide; this causes the pH of the person's blood to fall.
Which finding best indicates to the nurse that the client has a therapeutic outcome from a recent blood transfusion? Steady gait while ambulating Blood pressure increases to 90/48 mm Hg No signs of chills, fever, or shortness of breath Slight flushing of the face
C
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
C 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 nurse is calculating the output of a client with renal failure and takes into account all modes of fluid loss. When addressing the client's insensible fluid loss via respiration, which amount would the nurse anticipate as the usual average? 100 to 200 mL/day 200 mL/day 300 mL/day 1500 mL/day
C Insensible losses cannot be measured or seen. They occur when water molecules move from an area of higher concentration (the body) to an area of lower concentration (the atmosphere), and include fluid lost from evaporation through the skin and as water vapor from the lungs during respiration. Insensible water loss differs from perspiration, during which sweat glands actively expel water through the skin. The loss of water through respiration is approximately 300 mL/day.
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? allergic reaction: allergy to transfused blood febrile reaction: fever develops during infusion hemolytic transfusion reaction: incompatibility of blood product bacterial reaction: bacteria present in the blood
C 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.
