NUR 108 Ch40: Fluid, Electrolyte, and Acid-Base Balance

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

Potassium Explanation: 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.

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

Sacral area Explanation: The nurse should assess the sacral area in the client when determining the presence of edema. Edema is most noticeable in dependent areas of the body. The edema cannot be assessed in the face, hands and abdomen, as these are not dependent areas.

The primary extracellular electrolytes are: potassium, phosphate, and sulfate. magnesium, sulfate, and carbon. sodium, chloride, and bicarbonate. phosphorous, calcium, and phosphate.

sodium, chloride, and bicarbonate. Explanation: The primary extracellular electrolytes are sodium, chloride, and bicarbonate.

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

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

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.

Offer small amounts of preferred beverage frequently. Explanation: Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

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

hemolytic transfusion reaction: incompatibility of blood product Explanation: 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.

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

isotonic Explanation: Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

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

1 unit over 2 to 3 hours, no longer than 4 hours Explanation: Packed red blood cells are administered 1 unit over 2 to 3 hours for no longer than 4 hours.

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

3.5 cm H2O Explanation: 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 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, which amount would the nurse anticipate as the usual average? 100 to 200 mL/day 200 mL/day 300 to 400 mL/day 1500 mL/day

300 to 400 mL/day Explanation: The fluid lost through insensible loss is about 300 to 400 mL/day. Insensible water loss occurs when water molecules move from an area of higher concentration, such as the body, to an area of lower concentration, like the atmosphere. Loss of fluid through the skin as perspiration accounts for an average daily loss of 100 to 200 mL of fluid. Loss of fluid through the gastrointestinal system in the form of feces is approximately 200 mL. Normal urine output for 24 hours is approximately 1500 mL if intake is normal.

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

50 gtt/min Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 40: Fluid, Electrolyte, and Acid-Base Balance, p. 1627.

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

An implanted central venous access device (CVAD) Explanation: Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.

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. Apply a warm compress. Position the client on the left side. Apply antiseptic and a dressing.

Apply a warm compress. Explanation: 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.

A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? Dairy products Apricots Processed meat Bread products

Apricots Explanation: Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

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.

Avoid use of a tourniquet. Explanation: It may be possible and advantageous to avoid using a tourniquet when accessing a vein that is visually prominent on an older adult. 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.

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 (3,2 mmol/L). For what complications should the nurse be aware, related to the potassium level? Fluid volume excess Pulmonary embolus Cardiac dysrhythmias Tetany

Cardiac dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. Pulmonary emboli and fluid volume excess are not related to a low potassium level. Tetany can be a result of low calcium or high phosphorus but is not related to potassium levels.

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)? Changing the dressing on a client's peripheral IV site Initiating a client's transfusion of packed red blood cells Deaccessing a client's implanted port Removing a client's PICC in anticipation of the client's discharge

Changing the dressing on a client's peripheral IV site Explanation: Changing a peripheral IV dressing poses a lower risk to the client's safety than the other listed nursing actions and this would be the safest task to delegate. It would be inappropriate to delegate a blood transfusion, deaccess an implanted port, or remove a PICC to an LPN.

The nurse is instructing a young woman on her dietary needs for calcium in the prevention of osteoporosis. What food supplies the greatest amount of calcium? Cheese Meat Cauliflower Salad

Cheese Explanation: Dairy products are excellent sources of calcium.

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.

Deciding the location of the IV catheter. Deciding the size of the IV catheter. Administering the IV solution. Explanation: 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.

A nurse is caring for four different pediatric clients, all of whom require insertion of an intravenous (IV) catheter. For which client would it be appropriate to insert the IV into the foot? Preschool-aged child School-aged child Toddler Infant

Infant Explanation: The foot is a potential IV insertion site for neonates and infants, but it should not be used once a child can walk.

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

Intravenous therapy Electrolyte management Nutrition management Explanation: 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.

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

Lactated Ringer's solution 0.9% NaCl (normal saline) Explanation: The following IV fluids are isotonic: 0.9% NaCl (normal saline) and lactated Ringer's solution (LR). The IV fluids 0.45% NaCl (½ strength saline) 0.33% NaCl (1/3 strength normal saline) are hypotonic. The IV fluids 5% dextrose in 0.45% NaCl and 5% dextrose in lactated Ringer's solution are hypertonic.

As observed the nurse changing a peripheral venous access site dressing is idemonstrating inappropriate technique by implementing which action? Not preforming the intervention under sterile conditions Not wearing gloves when preforming the intervention By applying stablizing pressure to the catherter By pulling the dressing toward the insertion site

Not wearing gloves when preforming the intervention Explanation: The changing of a peripheral venous access site dressing requires the use of clean gloves to minimize the transmission of microorganisms during the procedure and to prevent the nurse from coming into contact with blood. The intervention does not require sterile precautions. The mammer in which the nurse is applying stablizing pressure to the catherter and pulling the adhered dressing toward the insertion site demonstrates appropriate technique.

The nurse is changing a client's peripherally-inserted central catheter (PICC) dressing. What is the nurse's best action?

PICC's should be covered with a transparent dressing that allows for easy inspection. Opaque gauze or mepore dressings are not transparent and cannot be used.

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? Reassure the client that the feelings are associated with anxiety, and will pass. Confirm the shortness of breath by listening to the client's lungs. Stop the transfusion. Increase rate of infusion to restore blood volume more quickly.

Stop the transfusion. Explanation: Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. Reassuring the client will not help if the client is experiencing a blood reaction. Increasing the rate of the administration will make the potential reaction worse, if this is a transfusion reaction. Listening to the client's lungs is not the priority action.

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.

Water moves from an area of lower solute concentration to an area of higher solute concentration. Explanation: 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.

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 devic

a 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.

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

cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosophorus. Increased intracraniel pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

Which is a common anion? magnesium potassium chloride calcium

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

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

decreased blood volume and intracellular dehydration Explanation: 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.

Edema happens when there is which fluid volume imbalance? extracellular fluid volume deficit water deficit water excess extracellular fluid volume excess

extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

The process of filtration begins at the: glomerulus. Loop of Henle. Bowman's capsule. collecting ducts.

glomerulus. Explanation: The process of filtration begins at the glomerulus.

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

hypovolemia Explanation: 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.

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? platelets granulocytes albumin cryoprecipitate

platelets Explanation: Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third-spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: cellular hydration. volume expander. total parenteral nutrition. blood transfusion therapy.

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 intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: cellular hydration. volume expander. total parenteral nutrition. blood transfusion therapy.

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.

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

83 mL/hr Explanation: When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (8). This is 83 mL/hr. Other options are incorrect.

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.

The client has anti-A antibodies. Explanation: Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction. Clients with type O blood are universal donors.

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I need to drink no more than 1,000 mL/day" "I should drink 1,500 mL/day of fluid." "I should drink 2,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid."

"I should drink 2,500 mL/day of fluid." Explanation: 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.

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

2,500 mL/day Explanation: 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 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

3,000 Explanation: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

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.

Avoid salty or excessively sweet fluids. Explanation: 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.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he 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

Banana Explanation: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? Select a primary tubing of about 37 inches (94 cm) long. Ensure that the prescribed solution is clear and transparent. Use half-instilled IV solutions before infusing a new one. Avoid replacing IV solutions every 24 hours.

Ensure that the prescribed solution is clear and transparent. Explanation: Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

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

Gauze dressing Explanation: A gauze dressing is recommended if the client is diaphoretic or if the site is bleeding or oozing. However, the gauze dressing should be replaced with a transparent semipermeable membrane once this is resolved. Transparent semipermeable membranes are a type of sealed IV dressing. Occlusive dressings would not be appropriate.

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.

Stop the transfusion immediately. Explanation: 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 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.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? To assure the IV solution is approprate for this administration To assure effective administration of the prescribed IV solution To provide for effective time management in the administration of the prescribed IV solution To demonstrate effective nursing care in the administration of the prescribed IV solution

To assure the IV solution is approprate for this administration Explanation: The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is approprate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.

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

hypertonic Explanation: 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.

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.

hypokalemia. Explanation: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

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: an access route to administer medications intravenously. replacement of fluids for those lost from vomiting and diarrhea. an access route to replace fluids in combination with blood products. intravenous fluids to be administered on an outpatient basis.

replacement of fluids for those lost from vomiting and diarrhea. Explanation: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.

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

distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

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."

"Let me refer you to the blood bank so they can provide you with information." Explanation: Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be reinfused.

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

60 drops/mL Explanation: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

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

Arterial blood gas Explanation: 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.

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

Metabolic alkalosis Explanation: Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high.

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

Rate of the IV solution Location of the IV catheter access Client's reaction to the procedure Type of IV solution Gauge and length of the IV catheter Explanation: The nurse should document the location where the IV access was placed, as well as the size of the IV catheter or needle, the type of IV solution, the rate of the IV infusion, and the use of a securing or stabilization device. Additionally, document the condition of the site. Record the client's reaction to the procedure and pertinent client teaching, such as asking the client to alert the nurse if the client experiences any pain from the IV or notices any swelling at the site. Document the IV fluid solution on the intake and output record.

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

a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Explanation: Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).

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 age 4 months Explanation: 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 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

calcium and phosphorus Explanation: 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 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

hypertonic solution Explanation: 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.

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

intracellular Explanation: Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment.

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

maintenance of cell size Explanation: 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.

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. Explanation: 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.