NUR 303 - Adaptive Quiz Ch 40: Fluid, Electrolyte, and Acid-Base Balance
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?
1 unit over 2 to 3 hours, no longer than 4 hours
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? 1) "I have never given blood before" 2) "I received a blood transfusion in the United Kingdom."
2) "I received a blood transfusion in the United Kingdom."
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)
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas
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.
What food supplies the greatest amount of calcium?
Cheese
A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action?
Discontinue the IV.
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?
Distended neck veins
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?
Infant
As observed the nurse changing a peripheral venous access site dressing is idemonstrating inappropriate technique by implementing which action?
Not wearing gloves when preforming the intervention
A nurse is caring for a client who is prescribed a peripheral intravenous (IV) infusion. After reviewing the image, which action is most important for the nurse to take?
Obtain new intravenous tubing and spike the infusion bag without touching the tip of the tubing
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?
a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
Potassium is needed for neural, muscle, and:
cardiac function
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
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:
hypokalemia
a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as:
hyponatremia
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
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
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume?
isotonic
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
The primary extracellular electrolytes are
sodium, chloride, and bicarbonate.
The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response?
"Fluid in the tissue space between and around cells."
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?
Cardiac dysrhythmias
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
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.
A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV?
Ensure that the prescribed solution is clear and transparent.
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation?
Notify the primary care provider immediately for possible fluid overload.
The nurse is caring for a client whose blood type is B negative. Which donor blood type does the nurse confirm as compatible for this client?
O negative
An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations?
Offer small amounts of preferred beverage frequently
What is the physiologic process that drives the thirst factor?
decreased blood volume and intracellular dehydration
A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of:
electrolytes
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
A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply.
orthostatic hypotension decreased urine output slow-filling peripheral veins
A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?
placing the tourniquet on the upper arm for 2 minutes
A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?
platelets
A decrease in arterial blood pressure will result in the release of:
renin
When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which complication has most likely occurred?
thrombus
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:
total parenteral nutrition.
A nursing instructor is explaining the difference between infiltration and phlebitis to a student. Which statement is most appropriate?
"Infiltration occurs when IV fluid escapes into the tissue, while phlebitis is inflammation of the vein."
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?
"Let me refer you to the blood bank so they can provide you with information."
A client has been prescribed 2 units of packed red blood cells. A type and cross-match has been performed and the first unit has arrived on the floor from the blood bank. When administering this client's blood transfusion, the nurse should perform which actions? Select all that apply.
1) Ask another nurse to assist with confirming the order, blood group, and other vital information. 2) Start the administration slowly for the first 15 minutes of the transfusion.
A nurse is preparing the site for insertion of a peripheral venous catheter using chlorhexidine. Which actions would be appropriate for the nurse to do? Select all that apply.
1) rub in a side to side motion 2) use a back and forth motion
How much average daily intake does the nurse recommend?
2,500 mL/day
A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply.
A B AB O
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning?
Acute Confusion related to cerebral edema
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?
Phlebitis
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?
Remove the IV.
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
he nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention?
"I received a blood transfusion in the United Kingdom."
A nurse is preparing to resite a client's IV during the client's hospital stay following a mastectomy. What accurately describes an assessment that should be made before starting the infusion?
The nurse should assess the preferred site, ideally the dorsal and ventral surfaces of the upper extremities.
Which is a common anion?
chloride
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 siderail. 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 action is mostappropriate?
Remove the IV catheter and reinsert another in a different location.
