NUR FUND + PREP U Chapter 39 Fluid, Electrolyte, and Acid-Base Balance

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? B positive AB negative O negative A positive

A B AB O Explanation: Persons with type AB blood are often called universal recipients, a fact that is rooted in their lack of agglutinins for either A or B antigens.

What is the lab test commonly used in the assessment and treatment of acid-base balance? Complete blood count Chemistry I 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

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

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

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

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

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? Eat crackers and bread. Use an alcohol-based mouthwash to moisten your mouth. Avoid salty or excessively sweet fluids. Use regular gum and hard candy.

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.

Which client has more extracellular fluid? Adult woman Newborn Female school-age child Adolescent man

Newborn Explanation: Newborns have more extracellular fluid than intracellular fluid.

The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice? preparing solution for administration ordering type of solution, additive, amount of infusion, and duration performing venipuncture regulating the rate of administration

ordering type of solution, additive, amount of infusion, and duration Explanation: The nurse prepares the solution for administration, performs a venipuncture, regulates the rate of administration, monitors the infusion, and discontinues the administration when fluid balance is restored. The healthcare provider, not the nurse, specifies the type of solution, additional additives, the volume (in mL), and the duration of the infusion.

The student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response? "Fluid inside cells." "Fluid outside cells." "Watery plasma, or serum, portion of blood." "Fluid in the tissue space between and around cells."

"Fluid in the tissue space between and around cells." Explanation: 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).

A nurse is caring for a patient who has fluid imbalance related to the development of ascites. Which imbalances would the nurse monitor for in this patient? Select all that apply. a. Extracellular fluid volume deficit b. Protein deficit c. Metabolic alkalosis d. Sodium deficit e. Plasma-to-interstitial fluid shift f. Metabolic acidosis

Answer: a. Extracellular fluid volume deficit b. Protein deficit d. Sodium deficit e. Plasma-to-interstitial fluid shift Rationale: Patients with fluid loss due to ascites (fluid accumulation in peritoneal cavity leading to abdominal swelling) are at risk for extracellular fluid volume deficit, protein deficit, sodium deficit, and plasma-interstitial fluid shift.

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level? a. Pulmonary embolus b. Cardiac dysrhythmias c. Tetany d. Fluid volume excess

Answer: b. Cardiac dysrhythmias Rationale: 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 nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable indicator of a patient's fluid balance status? a. Recording intake and output b. Testing skin turgor c. Reviewing the complete blood count (CBC) d. Measuring weight daily

Answer: d. Measuring weight daily Rationale: Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a subjective component. Measurement of skin turbot is subjective, and the complete blood count (CBC) does not necessarily reflect fluid balance.

A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings? a. Reposition the extremity and raise the height of the IV pole. b. Apply pressure to the dressing on the IV. c. Pull the catheter out slightly and reinsert it. d. Put on gloves; remove the catheter; apply pressure with a sterile pad.

Answer: d. Put on gloves; remove the catheter; apply pressure with a sterile pad. Rationale: This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also apply pressure with a sterile gauze pad, secure the gauze with tape over the insertion site, and restart the IV in a new location.

A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded? Sips of water Frozen fluids Parenteral fluids Fruit consumption

Fruit consumption Explanation: Any water consumption must be recorded in order to closely monitor a patient who has congestive heart failure. Many of these patients are on fluid restrictions. Sips of water, parenteral fluids, and frozen fluids count as fluid intake. The amount of water in fruits cannot be measured.

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? Potassium Phosphorous Sodium Chloride

b) 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 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? muscle weakness cardiac irregularities 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.

The nurse is monitoring intake and output (I&O;) for a client who recently had surgery. Which client actions will the nurse document on the I&O;record? (Select all that apply.) drinking milk eating a sandwich infusion of intravenous solution vomiting urination

drinking milk urination vomiting infusion of intravenous solution Explanation: The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output.

A client who is receiving total parenteral nutrition and lipids asks the nurse why the solution looks like milk. What is the most appropriate nursing response? "The white milky solution is the total parenteral nutrition." "The white milky solution is medication that is mixed into the total parenteral nutrition." "The white milky solution should be discarded and replaced with a clear solution." "The white milky solution contains lipids or fat to provide extra calories."

"The white milky solution contains lipids or fat to provide extra calories." Explanation: A parenteral lipid emulsion is a mixture of water and fats in the form of soybean or safflower oil, egg yolk phospholipids, and glycerin. Lipid solutions, which look milky white, are given intermittently with TPN solutions. They provide additional calories and promote adequate blood levels of fatty acids. Lipids cannot be mixed with TPN, as the lipid molecules tend to break or separate. All other options are incorrect.

A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that apply. a. 5% dextrose in water (D5W) b. 0.9% NaCl (normal saline) c. Lactated Ringer's solution d. 0.33% NaCl (1/3-strength normal saline) e. 0.45% NaCl (1/2-strength normal saline) f. 10% dextrose in water (D10W)

Answer: a. 5% dextrose in water (D5W) d. 0.33% NaCl (1/3-strength normal saline) e. 0.45% NaCl (1/2-strength normal saline) Rationale: 5% dextrose in water (D5W), 0.33% NaCl (1/3-strength normal saline), and 0.45% NaCl (1/2-strength normal saline) are used to treat hypernatremia (high sodium). 0.9% NaCl (normal saline) is used to treat hypovolemia (low volume), metabolic alkalosis, hyponatremia (low sodium), and hypochloremia (low chloride). Lactated Ringer's solution is used in the treatment of hypovolemia (low volume), burns, and fluid lost from gastrointestinal sources. 10% dextrose in water (D10W) is used in peripheral parenteral nutrition (PPN).

Which client is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid? a. An infant age 4 months b. A man age 86 years c. A woman age 45 years d. An adolescent age 17 years

Answer: a. An infant age 4 months Rationale: 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.

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation? a. Notify the primary care provider immediately for possible fluid overload. b. Check all clamps on the tubing and check tubing for any kinking. c. No intervention is necessary as this is a normal finding with IV infusion. d. Notify the primary care provider immediately because these are signs of speed shock.

Answer: a. Notify the primary care provider immediately for possible fluid overload. Rationale: If the client's lungs sounds were previously clear, but now some crackles in the bases are auscultated, notify the primary care provider immediately. The client may be exhibiting signs of fluid overload. Be prepared to tell the health care provider what the past intake and output totals were, as well as the vital signs and pulse oximetry findings of the client.

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 what? a. Phlebitis b. Rapid fluid administration c. A systemic blood infection d. An infiltration

Answer: a. Phlebitis Rationale: Phlebitis is a local infection at the sit of an intravenous catheter. Signs and symptoms include redness, pus, 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.

A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement? a. Explaining the mechanisms involved in transporting fluid to and from intracellular compartments. b. Keeping fluids readily available for the patient. c. Emphasizing the long-term outcome of increasing fluids when the patient returns home. d. Planning to offer most daily fluids in the evening.

Answer: b. Keeping fluids readily available for the patient. Rationale: Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

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 before and after meals. Weigh the client without soiled incontinence pads. Weigh the client's wet linen or dressing.

Weigh the client's wet linen or dressing. Explanation: In cases in which accurate assessment is critical to a client's treatment, the nurse weighs wet linens, pads, or dressings and subtracts the weight of a similar dry item. 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.

A nurse is choosing a vein to start an IV infusion in a client. What are recommended veins to use when initiating an IV infusion? (Select all that apply.) metacarpal antecubital vein superficial veins on the dorsal aspect of the hand leg veins basilic veins cephalic vein

cephalic vein metacarpal basilic veins superficial veins on the dorsal aspect of the hand Explanation: The cephalic vein, accessory cephalic vein, metacarpal, and basilic vein are appropriate sites for infusion (INS, 2006). The superficial veins on the dorsal aspect of the hand can also be used successfully for some people, but can be more painful). The antecubital vein should not be used if another vein is available because flexion of the arm can displace the IV catheter over time. Leg veins should not be used unless other sites are inaccessible because of the danger of stagnation of peripheral circulation and possible serious complications.

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate? "Granulocytes help to control bleeding associated with infection." "Granulocytes are a type of white blood cell that can help fight infection." "Granulocytes replace clotting factors that are altered from infection." "Granulocytes help third spacing of fluid that occurs with infection."

"Granulocytes are a type of white blood cell that can help fight infection." Explanation: Granulocytes are a type of white blood cell that are used to fight infection. All other options are incorrect statements related to granulocytes.

What is the rate of administration for packed red blood cells? IV push over 3 minutes As fast as the patient can tolerate 1 unit over 2 to 3 hours, no longer than 4 hours 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. Answer A describes platelets, answer C represents cryoprecipitate, and answer D describes fresh-frozen plasma.

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?" Which of the following would the nurse include as a suggestion for this client? a. Avoid salty of excessively sweet fluids. b. Use regular gum and hard candy. c. Use an alcohol-based mouthwash to moisten your mouth. d. Eat crackers and bread.

Answer: a. Avoid salty of excessively sweet fluids. Rationale: 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. 15-30 minutes later, however, oral membranes may be even drier than before. Dry food, such as crackers and bread, also 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.

When providing care for a client who has a peripheral intravenous catheter in situ, the nurse should do what? a. Change the site every 3-4 days. b. Flush the catheter every six hours with hypertonic solution if the IV is not in constant use. c. Clean the insertion site daily using sterile technique. d. Insert the largest gauge possible to maximize flow and minimize the risk of occlusion.

Answer: a. Change the site every 3-4 days. Rationale: Peripheral IV site should be rotated every 72-96 hours, depending on the institutional protocol. IV insertion sites are not cleansed daily. Flushes are not necessary every six hours. Hypertonic solution is not used for IV flushes. The smallest gauge that is practical should be inserted in order to minimize trauma.

The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. Which of the following would the nurse expect to find when assessing the client's gastrointestinal system? a. Diarrhea b. Abdominal distention c. Paralytic ileus d. Vomiting

Answer: a. Diarrhea Rationale: The client with hyperkalemia would experience diarrhea. Abdominal distention, vomiting, and paralytic ileum would reflect hypokalemia.

A nurse carefully assesses the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a patient with damage to which of the following? a. Kidneys b. Lungs c. Adrenal glands d. Blood vessels

Answer: b. Lungs Rationale: The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypokalemia. His laboratory results show a serum potassium of 3.2 mEq/L (3.2 mmol/L). For what manifestations will you be alert? 1.Diminished cognitive ability and hypertension 2. Nausea, vomiting, and constipation 3. Muscle weakness, fatigue, and constipation 4. Muscle weakness, fatigue, and dysrhythmias

4. Muscle weakness, fatigue, and dysrhythmias Explanation: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and dysrhythmias. 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 works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O? 34-year old whose urinary catheter was discontinued yesterday 23-year old with ulnar and radial fracture 48-year old who has had a bowel movement after surgery 55-year old with congestive heart failure on furosemide

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

The nurse is calculating an infusion rate for the following order: Infuse 1000 ml of 0.9% Na Cl over 12 hours using an electronic infusion device. What is the infusion rate? 83 ml/hour 103 gtts/hour 100 ml/hour 13 ml/hour

83 ml/hour Explanation: When calculating the infusion rate with an electronic device, divide the total volume to be infused (1000 ml) by the total amount of time in hours (8). This is 83 ml/hour.

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).

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? A peripheral venous catheter inserted to the antecubital fossa An implanted central venous access device (CVAD) 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.

A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion rate to administer via gravity infusion.

Answer: 50 gtts/min Rationale: When administering 500mL of solution over 10 hours, and the set delivers 60 gtts/mL, the nurse would use the following formula: gtt/min = (500x60)/600 500 x 60 = 30,000/600 = 50 gtts/min

A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply. a. "Try to drink at least six to eight glasses of water each day." b. "Try to limit your fluid intake to one quart of water daily." c. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." e. "Temporarily increase food containing caffeine for their diuretic effect." f. "Weigh yourself daily and report any changes in your weight."

Answer: a. "Try to drink at least six to eight glasses of water each day." c. "Limit sugar, salt, and alcohol in your diet." d. "Report side effects of medications you are taking, especially diarrhea." f. "Weigh yourself daily and report any changes in your weight." Rationale: Generally, fluid intake and output average 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access devise is most likely to meet this client's needs? a. An implanted central venous access device (CVAD) b. A peripheral venous catheter inserted to the cephalic vein c. A peripheral venous catheter inserted to the antecubital fossa d. A midline peripheral catheter

Answer: a. An implanted central venous access device (CVAD) Rationale: 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.

A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and present with a pounding headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms? a. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. b. Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs. c. Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance. d. Discontinue the infusion immediately, apply warm, moist compresses to the site, and restart the IV at another site.

Answer: a. Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately. Rationale: The nurse is observing the signs and symptoms of speed-shock: the body's reaction to a substance that is injected into the circulatory system too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

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 which of the following? a. Electrolytes b. Non-electrolytes c. Colloid solution d. Interstitial fluid

Answer: a. Electrolytes Rationale: The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. the client does not need to have non-electrolytes, colloid solution, or interstitial fluid restored. Non-electrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolved into a true solution and do not pass through a semipermeable membrane.

The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of what? a. Fluid volume excess b. Hyponatremia c. Metabolic acidosis d. Hypovolemia

Answer: a. Fluid volume excess Rationale: Edema is a characteristic sign of fluid volume excess (hypervolemia). Metabolic acidosis and hyponatremia are not directly associated with the development of peripheral edema.

Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. What is this electrolyte imbalance known as? a. Hyponatremia b. Hyperkalemia c. Hypernatremia d. Hypokalemia

Answer: a. Hyponatremia Rationale: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

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? a. Increased respiratory rate b. Renal retention of H ions c. Hypoventilation d. Increased excretion of bicarbonate ions by the kidneys

Answer: a. Increased respiratory rate Rationale: Hyperventilation results in increased CO exhalation and a consequent increase in pH, with the goal of attaining the ideal of 7.35-7.45. Retention of hydrogen ions, increased excretion of bicarbonate ions, and hypoventilation are all processes that contribute to a decreased pH and an exacerbation of acidosis.

A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms? a. Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. b. Stop the transfusion immediately and keep the vein open with normal saline, notify the physician stat, admits antihistamine parenterally as needed. c. Stop the transfusion immediately and keep the vein open with normal saline, notify the physician, and treat symptoms. d. Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the physician, administer antibiotics stat.

Answer: a. Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent. Rationale: The client is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the nurse document. a. 1 b. 2 c. 3 d. 4

Answer: b. 2 Rationale: Grade 2 phlebitis presents with pain at access site with erythema (reddening) and/or edema. Grade 1 presents as erythema at access site with or without pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 inch and with purulent drainage.

A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient? a. Encourage foods and fluids with high sodium content. b. Administer oral K supplements as ordered. c. Caution the patient about eating foods high in potassium content. d. Discuss calcium losing aspects of nicotine and alcohol use.

Answer: b. Administer oral K supplements as ordered. Rationale: Nursing interventions for a patient with hypokalemia (low potassium) include encouraging foods high in potassium and administering oral K as ordered. Encouraging foods with high sodium content is appropriate for a patient with hyponatremia (low sodium). Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia (high potassium), and securing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia (low calcium).

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? a. Bread products b. Apricots c. Processed meat d. Dairy products

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

A woman age 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 what? a. Intravenous fluids to be administered on an outpatient basis. b. Replacement of fluids for those lost from vomiting and diarrhea. c. An access route to administer medications intravenously. d. An access route to replace fluids in combination with blood products.

Answer: b. Replacement of fluids for those lost from vomiting and diarrhea. Rationale: 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.

The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2mm and just perceptible. The nurse documents this at which grade? a. 4+ b. 3+ c. + d. 2+

Answer: c. + Rationale: The edema in the client should be graded as +, which means that the edema is just perceptible and of 2mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4-6 mm. A measurement of 4+ indicates severe edema of 8mm or more.

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6 mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented? a. 1+ pitting edema b. 2+ pitting edema c. 3+ pitting edema d. 4+ pitting edema

Answer: c. 3+ pitting edema Rationale: 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4 mm pit that lasts longer than 1+ with fairly normal contour. 4+ is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

A nurse is flushing a patient's implanted port after administering medications. The nurse observes that the port flushes, but does not have a blood return. What would be the nurse's next action based on these findings? a. Gently push down on the needle and flush it a second time. b. Stop flushing and remove the needle; notify the primary care provider. c. Ask the patient to perform a Valsalva maneuver; change the patient position. d. Close the clamp; wait 3 minutes, try flushing the port again.

Answer: c. Ask the patient to perform a Valsalva maneuver; change the patient position. Rationale: If a port flushes but does not have a blood return, the nurse should ask the patient to perform a Valsalva maneuver, have the patient change position or place the affected arm over the head, or ride or lower the head of the bed. If these measures do not work, the nurse should remove the needle and reaches the device with a new needle.

A client's most recent blood work indicated a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? a. Muscle weakness b. Increased intracranial pressure (ICP) c. Cardiac irregularities d. Metabolic acidosis

Answer: c. Cardiac irregularities Rationale: 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.

A client admitted with heart failure requires careful monitoring of his fluid status. What assessment parameter will provide the nurse with the best indication of the client's fluid status? a. Intake and output measurements b. Daily BUN and serum creatinine monitoring c. Daily weights d. Daily electrolyte monitoring

Answer: c. Daily weights Rationale: Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client's daily weight may be the more accurate measurement of a client's fluid status. Laboratory tests are helpful in assessing kidney function and electrolyte values, but do not provide the precise information on fluid losses or gains as is provided by a daily weight at the same time, using the same scale.

A client who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor? a. Increased blood volume and extracellular overhydration. b. Increased blood volume and intracellular dehydration. c. Decreased blood volume and intracellular dehydration. d. Decreased blood volume and extracellular overhydration.

Answer: c. Decreased blood volume and intracellular dehydration. Rationale: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume.

A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances? a. Fluid volume deficit and alkalosis. b. Fluid volume excess and alkalosis. c. Fluid volume excess and acidosis. d. Fluid volume deficit and acidosis.

Answer: c. Fluid volume excess and acidosis. Rationale: Fluid volume excess can be caused by malfunction of the kidneys (i.e., renal failure). The kidneys are also responsible for acid-base balance, and in the presence of renal failure, the kidneys cannot regulate hydrogen ions and bicarbonate ions, so the client develops metabolic acidosis.

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 which of the following? a. Increasing the excretion of HCO into the urine. b. Increasing the excretion of H ion into the urine. c. Increasing ventilation through the lungs. d. Preventing excretion of acids into the urine.

Answer: c. Increasing ventilation through the lungs. Rationale: 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 HCO 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 HCO.

Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg; HCO3-, 14 mEq/L? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

Answer: c. Metabolic acidosis Rationale: A low pH indicated acidosis. This, coupled with a low bicarbonate, indicated metabolic acidosis. The pH and bicarbonate would be elevated with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicated respiratory alkalosis.

Which of the following statements most accurately describes the process of osmosis? a. Solutes pass through semipermeable membranes to areas of lower concentration. b. Water shifts from high-solute areas to areas of lower solute concentration. c. Water moves from an area of lower solute concentration to an area of higher solute concentration. d. Plasma proteins facilitate the reabsorption of fluids into the capillaries.

Answer: c. Water moves from an area of lower solute concentration to an area of higher solute concentration. Rationale: 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 and plasma proteins facilitate colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.

Which of the following commonly used intravenous solutions is hypotonic? a. 5% dextrose in 0.45% NaCl b. 0.9% NaCl c. Lactated Ringer's d. 0.45% NaCl

Answer: d. 0.45% NaCl Rationale: 0.45% NaCl is hypotonic, while normal saline and Lactated Ringer's are isotonic. 5% dextrose in 0.45% NaCl is hypertonic.

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 of the following interventions should the nurse perform for this complication? a. Elevate the client's head. b. Apply antiseptic and a dressing. c. Position the client on the left side. d. Apply a warm compress.

Answer: d. Apply a warm compress. Rationale: 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.

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? a. Chloride and magnesium b. Potassium and chloride c. Potassium and sodium d. Calcium and phosphorus

Answer: d. Calcium and phosphorus Rationale: 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.

When a client age 80 years who takes diuretics for management of hypertension informs the nurse that she takes laxatives daily to promote bowel movements, the nurse assesses the client for possible symptoms of what? a. Hypoglycemia b. Hypothyroidism c. Hypocalcemia d. Hypokalemia

Answer: d. Hypokalemia Rationale: 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 nurse is providing care to a client who has been vomiting for the past 2 days. The nurse would assess this client for which imbalance? Select all that apply. Respiratory acidosis Hypernatremia Hypercalcemia Metabolic alkalosis Hypokalemia

Metabolic alkalosis Hypokalemia Explanation: If sufficient gastric juice (ECF with additional acid) is lost from the stomach, then consequently hydrogen, sodium, and chloride ions are depleted, increasing the risk of ECF volume deficit and/or metabolic alkalosis. Gastric fluid also is high in potassium, and excessive losses may contribute to hypokalemia. Respiratory acidosis would be more likely to occur with an underlying lung disorder, such as asthma or emphysema. Vomiting leads to a loss of sodium, so elevated sodium levels would be unlikely. Imbalances of calcium are not typically associated with imbalances associated with vomiting.

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 Explanation: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. B positive, A positive, and AB negative are not considered compatible in this scenario.

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? nausea and vomiting muscle twitching fingerprinting over sternum distended neck veins

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 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.

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding? pH: 7.32; PaCO2: 26; HCO3: 18 pH: 7.32; PaCO2: 28; HCO3: 24 pH: 7.28; PaCO2: 52; HCO3: 32 pH: 7.60; PaCO2: 64; HCO3: 42

pH: 7.60; PaCO2: 64; HCO3: 42 Explanation: In metabolic acidosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high HCO3, such as 64; and a high PaCO2, such as 42. The numbers correlate with metabolic alkalosis, which is indicated by the hyperventilation and the retention of CO2. The other blood gas finding do not correlate with metabolic acidosis.

A decrease in arterial blood pressure will result in the release of: protein. renin. thrombus. insulin.

renin. Explanation: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

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

total parenteral nutrition. (TPN) Explanation: Total parenteral nutrition is a hypertonic solution containing 20% to 50% dextrose, proteins, vitamins, and minerals that is administered into the venous system.