Nursing Fluid & Electrolyte
magnesium - green leafy vegetables, legumes, citrus fruit, peanut butter, and chocolate
A child is eating a peanut butter sandwich. He is ingesting an excellent source of
Aldosterone
A client with dehydration will have an increase in
sacral when determining the presence of edema. Edema is most noticeable in dependent areas of the body. When the client is sitting or standing, the edema can be assessed in the legs. The edema cannot be assessed in the hands and abdomen, as these are not dependent areas
A nurse is assessing for the presence of edema in a client who is confined to bed after fracturing her femur. The nurse would pay particular attention to which area?
300 to 400 mL/day
A nurse is calculating the output of a client with renal failure and takes into account all fluid loss. What amount would the nurse anticipate as the usual average?
Hyperactive deep tendon reflexes (DTRs)
A nurse suspects a patient with electrolyte imbalances is experiencing hypomagnesemia. What nursing assessment may indicate hypo-magnesemia?
Total parenteral nutrition - 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
increased respiratory rate - hyperventilation results in increased CO exhalation and increase pH, the goal is 7.35 to 7.45
Arterial blood gases reveal that a patient's pH is 7.20. What physiologic process will contribute to a restoration of correct acid-base balance?
Hemolytic transfusion reaction: incompatibility of blood product
During a blood transfusion, a patient displays signs of facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?
Hypovolemia also known as dehydration includes mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine, dry mucous membranes; warm skin
During an assessment of an elderly 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. The nurse recognizes that what medical diagnosis may be responsible?
Hyponatremia - low concentration of sodium in the blood
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?
muscle weakness, fatigue, & dysrhythmias (3.5 - 5)
Hypokalemia patient lab result show a serum potassium of 3.2 mEq/L. For what should you be alert?
Aldosterone - enhances renal secretion of potassium
Major control over the extracellular concentration of potassium within the human body is exerted by insulin and
normal cardiac & muscle function
Potassium is needed for neural, muscle, and
Colloid osmotic pressure
The nurse is administering albumin to a patient to promote movement of fluid into the capillaries. What is the "pulling force" of fluid by use of a protein such as albumin known as?
A newly admitted 88-year-old with a two-day history of vomiting and loose stools
The oncoming nurse is assigned to the following patients. Which patient should the nurse assess first?
electively reabsorb or secrete substance to maintain fluids and electrolytes
The passageways of the kidney permit the urine to flow to the bladder and
sodium, chloride, and bicarbonate
The primary extracellular electrolytes:
Glomerulus
The process of filtration begins at the
Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, pus, warmth, induration, and pain
Upon assessment of a patient's peripheral intravenous site, the nurse notices the area is red and warm. The patient complains of pain when the nurse gently palpates the area. What are these signs and symptoms indicative of?
Extracellular volume excess related to heart failure as evidence by edema and & orthopnea
What is an appropriate nursing diagnosis for an 80 yr old with the diagnosis of congestive heart failure with symptoms of edema, orthopnea & confusion?
Arterial Blood Gas (ABG) - assess acid base balance
What is the lab test used in the assessment and treatment of acid base balance?
excretion of potassium and magnesium from the body, increases the risk for fluid and electrolyte deficits
When an 80-year-old client who takes diuretics for hypertension informs the nurse she take laxatives daily for bowel movements, the nurse assesses the client for possible symptoms of
5% NaCl
Which of the following fluids should be administered slowly to prevent circulatory overload?
Isotonic
Which of the following solutions 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?
the system is accessed with a noncoring needle and patency is maintained by periodic flushing
Which of the following statements accurately describes a guideline when using a venous access?
Water moves from an area of lower solute concentration to an area of higher solute concentration.
Which of the following statements most accurately describes the process of osmosis?
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
Which patient is at a greater risk for fluid volume deficit related to the loss of total body fluid and extracellular fluid?
Cardiac dysrhythmias
A client has a diagnosis of heart failure, lab results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level?
replace fluid and electrolytes
A client has a physician's order for NPO following abdominal surgery. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy to
Filtered tubing
A client has been admitted to the health agency with symptoms of malnutrition. The nurse needs to administer a solution of nutrients to meet the caloric and nutritional needs of the client. The nutrient solution is packaged in a glass container and needs to be administered at a rate of 60 drops/mL. What type of tubing should the nurse use in this case?
Bedrest will cause a breakdown of bone and an increase in serum calcium
A client is placed on bedrest. Which of the following factors will occur?
Decreased potassium levels - diuretics such as Lasix are potassium wasting
A client is taking a diuretic such as Lasix. When implementing client teaching, what information should be included?
Diuretics, given for high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes - POTASSIUM, calcium, and magnesium
A client with hypertension is treated with a diuretic. The client complains of muscle weakness and falls easily. The nurse should assess which electrolyte?
place the fluid on an electronic devise
A client with renal disease requires IV fluids. It is important for the nurse to
Renin
A decrease in arterial blood will result in the release of
Fluid volume excess and acidosis. Fluid volume excess can be caused by malfunction of the kidneys (i.e., renal failure
A dialysis unit nurse caring for a patient with renal failure will expect the patient to exhibit which fluid and electrolyte imbalances?
Maintenance of cell size
A group of nursing students are 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?
Infiltration - escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall - swelling, pallor, coldness, or pain around infusion site & decrease in flow rate
A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe?
aspirate and attempt to flush the line again
A nurse flushing a capped peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation?
when a PICC line is not all the way out, the nurse should notify the physician. The physician will most likely order a chest x-ray to determine where the end of the PICC line is. A dressing should be reapplied to prevent further dislodgement.
A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation?
• Skin turgor over sternum • Decreased blood pressure • Low urine output
A nurse is caring for a client with dehydration. Which of the following signs are observed in a client with dehydration? Select all that apply
Discontinue the IV
A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which of the following actions should the nurse perform to avoid further complications and provide relief to the client?
Lactated Ringer's solution, it is used in treatment of burns, and fluid lost as bile or diarrhea
A nurse is caring for a patient who has burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this patient?
Apply chlorhexidine using a back and forth friction scrub for at least 30 seconds.
A nurse is changing a peripheral venous access dressing for a patient. Which of the following is a recommended step in this procedure?
• Cephalic vein • Metacarpal • Basilic veins • Superficial veins on the dorsal aspect of the hand
A nurse is choosing a vein to start an IV infusion in a patient. Which of the following are recommended veins to use when initiating an IV infusion?
2,600 mL
A nurse is measuring the intake and output of a patient who is dehydrated. What is the average adult daily fluid intake in milliliters that the nurse would use as a comparison?
initiate venipuncture at least 2 inches above the crease of the wrist in an adult
A nurse is preparing to start an intravenous infusion for a patient after a mastectomy. Which of the following accurately describes an assessment that should be made before starting the infusion?
inspect the container and determine that the solution is clear and transparent, expiration date, no leaks, 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 required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV?
Filtered tubing is generally used when infusing IV solutions to pediatric clients, as it removes air bubbles as well as undissolved drugs, bacteria, and large substance
A nurse is using an in-line filter when administering a prescribed dosage of IV fluid to a client. The nurse knows that an in-line filter is specifically used in which of the following situations?
weighs wet linens, pads, or dressings and subtracts the weight of a similar dry item
A nurse needs to get an accurate fluid output assessment of a client with severe diarrhea. Which of the following actions should the nurse perform?
to prevent compromising circulation
A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. Which of the following reasons explains the nurse's action?
The pump will continue to infuse fluid even when the needle is displaced
A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump?
ongoing verification of the IV solution and the infusion rate with the physician's order.
A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?
daily weights are considered one of the more accurate measures of fluid balance.
A patient has been admitted to the hospital with a diagnosis of acute renal failure, a health problem that necessitates monitoring of the patient's fluid. What is the most accurate way that the care team can achieve this assessment goal?
Implanted CVADs - ideal for long-term uses such as chemotherapy
A patient 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 patient's needs?
Respiratory alkalosis with compensation A pH of 7.52 constitutes alkalosis and the decreased PaCOindicates a respiratory etiology. When compensation occurs, PaCOand HCO- trend in the same direction.
A patient's most recent arterial blood gases indicate a pH of 7.52 with decreased PaCO and decreased HCO-. What is this patient experiencing?
Cardiac irregularities, hyperkalemia - too much potassium in blood
A patient's most recent blood work indicates a K+ level of 7.2 mEq/L, a finding that constitutes hyperkalemia. What signs and symptoms should the nurse vigilantly monitor for?
Every 72 hours
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client?
• Tunneled • Peripherally • Implanted
An obese client with lung cancer needs intermittent infusion of IV solution and medication for several months. Which of the following central venous catheters is most suitable for long-term access in a cancer client without the catheter protruding from the skin?
The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion
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 of the following interventions should the nurse perform for this client?
Hemolytic transfusion reaction: incompatibility of blood product
During a blood transfusion, a patient displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?
that the fluid is infusing too rapidly
Mr Powell, a dehydrated 35 year old has intravenous fluid running at 250 cc/h. for rapid rehydration. He is complaining of burning at the site. You see no redness, swelling, heat, or coolness upon inspection. You suspect
Muscle cramping and tetany, include numbness and tingling of fingers, mouth, or feet
Mr. Jones is admitted to your unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL. For what assessment findings will you be looking?
fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body.
Mr. Smith is admitted to your unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is
Metabolic alkalosis - excessive loss of body acids or with unusual intake of alkaline substances
The client's arterial blood gas results reveals a pH of 7.52, a PaO2 level of 49 mmHg and an HCO3 level of 28 mEq/L, the client is most likely experiencing what condition?
increase in fat cells, older adults lose muscle mass as a part of aging. The combined increase of fat and loss of muscle results in reduced total body water; after the age of 60, total body water is about 45% of a person's body weight. This decrease in water increases the risk for fluid imbalance in older adults
The nurse is caring for Mrs. Roberts, an 86-year-old patient, who fell at home and was not found for two days. Mrs. Roberts is severely dehydrated. The nurse is aware that elderly people are at increased risk for fluid imbalance for which of the following reasons?
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
The nurse is caring for a patient who had a parathyroidectomy. Upon evaluation of the patient's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland?
Diarrhea
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?
Intracellular
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 of the following fluid compartments?
1 unit over 2 to 3 hours, no longer than 4 hours
What is the rate of administration for packed red blood cells?
to overcome the pressure in vein
When administering an IV solution, the solution is placed at least 18 to 24 inches above the site of the infusion. Why?
Fluid overload - occur when blood components are infused too quickly or too voluminously
When an elderly client receiving a blood transfusion with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing
thrombus
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. What is the most likely complication that has occurred?
change the site every 3 to 4 days
When providing care for a patient who has a peripheral intravenous catheter in situ
Low calcium - normal total serum calcium levels range 8.9 - 10.1 mg/dL.
When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L; calcium 7.9 mg/dL, and magnesium 1.9 mg/dL; the nurse should notify the physician of the client's
Newborns
Which client has more extracellular fluid?
women have lower fluid because they have more adipose then men.
Which client will have more adipose tissue and less fluid?
client with colitis & bloody diarrhea, TTN is needed when there is an interference with nutrient absorption from the GI, or when complete bowel rest is necessary for healing
Which client would be a candidate for total parenteral nutrition?
0.45% NaCl
Which of the following commonly used intravenous solutions is hypotonic?
the renal tubules become permeable to water
Which of the following statements accurately describes the role of antidiuretic hormone in the regulation of body fluids? When antidiuretic hormone is present,
sodium deficit in ECF caused by a loss of sodium or gain of water
Which one of the following electrolyte imbalances occurs due to a sodium deficit in ECF caused by a loss of sodium or gain of water?
Women and obese people have less body water
Who has the least volume of body water?
febrile reaction - because of the recipient's hypersensitivity to the donor's white blood cells
Within 15 minutes after the start of a blood transfusion, the client complains of chills and headache. During frequent vital signs, the nurse begins to see an elevation in the temperature. What condition is the client experiencing?
