PrepU chapter 39: Fluid, electrolyte, and acid-base balance

The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction?

"The kidneys store and release antidiuretic hormone to increase water retention."

What commonly used intravenous solution is hypotonic?

0.45% NaCl

Which IV solutions would the nurse expect to be ordered for a client who has hypovolemia? Select all that apply.

0.9% NaCl (normal saline) Lactated Ringer's solution 5% dextrose in 0.9% NaCl

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

1+

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend?

2,500 mL/day

The physician writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse?

25

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?

3,000

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?

55-year old with congestive heart failure on furosemide

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?

60 drops/mL

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?

Apricots

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.

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.

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

The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients?

Cardiac volume intolerance

The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply.

Diarrhea Cardiac dysrhythmia

A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded?

Fruit consumption

A nurse is reading a journal article about fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?

Infants

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?

Intracellular

What nursing interventions would be appropriate for a patient diagnosed with deficient fluid volume? (Select all that apply.)

Intravenous therapy Electrolyte management Nutrition management

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

Because metabolism continually produces acids, maintenance of pH within these incredibly narrow limits depends on two processes: buffering and compensation. Which statement describes a function of buffering?

It helps to prevent large changes in pH by absorbing or releasing H+ ions.

A nurse is assessing a client's fluid balance status. The nurse understands that which organ plays the major role in regulating fluid balance?

Kidneys

A client has the following arterial blood gas results: pH: 7.33 PaCO2: 42 mm Hg HCO3: 19 mEq/L 919 mmol/L) PaO2: 95 mm Hg Which imbalance would the nurse suspect?

Metabolic acidosis

A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing?

Metabolic alkalosis

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.

Metabolic alkalosis Hypokalemia

Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium?

Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L).

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

A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply.

Pulse rate 90 bpm Blood pressure 104/68 mm Hg

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.

The nurse is determining a site for an IV infusion. What guideline should the nurse consider?

Scalp veins should be selected for infants because of their accessibility.

Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium?

Sodium is regulated by the renin-angiotensin-aldosterone system.

A client's atrial pressure is known to be increased. What effect will this ultimately have on the client's sodium levels?

Sodium levels will decrease.

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.

Which is not true regarding magnesium?

The liver regulates magnesium levels by breaking down the ion when serum levels are low.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?

The renal system retains more water.

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.

Which client would be a candidate for total parenteral nutrition?

a client with colitis and bloody diarrhea

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

A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? (Select all that apply.)

blood pressure 100/48 mm Hg poor skin turgor heart rate 128/bpm

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

A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status?

daily weights

When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing:

fluid overload.

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?

hypertonic

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

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.

The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to:

increase in fat cells.

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 client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client?

platelets

Which is a common anion?

Chloride

Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease?

Increased plasma levels of antidiuretic hormone lead to water excess.

Miss Roberts is admitted to the unit with a diagnosis of three days of continuous vomiting. You would suspect which of the following acid/base imbalances related to the loss of stomach acid?

Metabolic alkalosis

When educating a client about foods that affect fluid balance, the nurse would advise the client to decrease:

Na+

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 client has a physician's order for n.p.o (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?

replace fluid and electrolytes

Which client has more extracellular fluid?

Newborn

A nurse is educating a group of adults on dietary requirements. What food should the nurse recommend as a significant source of phosphorous?

Steak

Major control over the extracellular concentration of potassium within the human body is exerted by:

aldosterone.

A student has joined the marching band at his high school. The band begins practicing outside in August. This student and other band members need to be instructed that:

the band members should drink large amounts of water.

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 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

The nurse is caring for a client who was found after spending 2 days without food or water in the desert and was admitted through the emergency department. The client is severely dehydrated. What are reasons why the human body requires fluid? Select all that apply.

facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the physician of the client's:

low calcium.

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 contains lipids or fat to provide extra calories."

The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate?

"Granulocytes are a type of white blood cell that can help fight infection."

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client?

O negative

Calcium is important for which functions? Select all that apply.

wound healing synaptic transmission in nervous tissue membrane excitability blood clotting

An older adult client with dehydration repeatedly tells the nurse, "I am just not thirsty. I don't want anything to drink." Which nursing actions are appropriate? (Select all that apply.)

Identify fluid preferences. Offer fluids at times other than meals. Offer small amounts of preferred liquids frequently.

The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action?

Tighten the roller clamp to stop the infusion.

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

The process of filtration begins at the:

glomerulus.

The nurse is caring for a client who has had severe diarrhea for 24 hours. Which fluid does the nurse anticipate infusing?

hypotonic

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?

ordering type of solution, additive, amount of infusion, and duration

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?

300 to 400 mL/day

The nurse is calculating the infusion rate for the following order: Infuse 1000 ml of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtts/min. What is the infusion rate?

42 gtts/min

A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? (Select all that apply.)

Clients with major trauma or burns Clients with liver and renal failure Clients with inflammatory bowel disease

The primary extracellular electrolytes are:

sodium, chloride, and bicarbonate.

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?

thrombus

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 a(an)

Winged infusion needle

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

The nurse is instructed by the physician that the client needs an intravenous fluid that is not likely to pull fluids into the vascular space. The nurse recognizes that the physician is suggesting which kind of fluid?

Hypotonic

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.

The nurse is preparing to hang a Nitroglycerin drip in a glass bottle for a client with chest pain. Which tubing selection by the nurse is appropriate?

primary vented tubing

A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply.

respiratory muscle weakness confusion ventricular dysrhythmia

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?

Stop the transfusion.

Potassium is needed for neural, muscle, and:

cardiac function.

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?

Apply a warm compress.

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate?

50 gtt/min

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

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included?

Decreased potassium levels

A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance?

Hyperphosphatemia

A nurse is teaching a client about his newly prescribed diuretic and how it affects his fluid and electrolyte balance. In addition to water, the nurse would explain that the drug also affects which electrolyte? Select all that apply.

Sodium Chloride Potassium Magnesium

A nurse is teaching a client about total parenteral nutrition. What should the nurse teach the client regarding the substances within total parenteral nutrition? (Select all that apply.)

proteins carbohydrates fats vitamins minerals

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as:

total parenteral nutrition.

What is the rate of administration for packed red blood cells?

1 unit over 2 to 3 hours, no longer than 4 hours

Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. The client's health record indicates that he is taking diuretics. Which nursing diagnosis would be most appropriate for the client?

ECF Deficient Fluid Volume

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase, which may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate?

Hypertonic

The nursing instructor is discussing fluid and electrolyte balance with a group of students. One of the students asks the instructor how fluids move to maintain homeostasis. The instructor formulates her response based on her knowledge that fluid homeostasis can be maintained by which of the following? Select all that apply.

Osmosis Filtration Diffusion Active transport

A nurse is caring for a client with dehydration. Which sign is observed in a client with dehydration? Select all that apply.

decreased skin turgor over sternum decreased blood pressure low urine output increased pulse

Edema happens when there is which fluid volume imbalance?

extracellular fluid volume excess

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: 7.60; PaCO2: 64; HCO3: 42

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 indicative of:

phlebitis.

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:

replacement of fluids for those lost from vomiting and diarrhea.

The student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response?

"Fluid in the tissue space between and around cells."

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?

"I should drink 2500 mL/day of fluid."

A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find?

Hypokalemia

A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse?

Spinach

A decrease in arterial blood pressure will result in the release of:

renin.

A client is diagnosed with body fluid hypoosmolality. Treatment involves restricting his intake of free water. Which fluids would the nurse most likely restrict? Select all that apply.

Apple juice Tea

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea

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?

Muscle weakness, fatigue, and dysrhythmias

A nurse monitoring an IV infusion notes the signs and symptoms of a thrombus. What nursing interventions would the nurse perform? (Select all that apply.)

Stop the infusion immediately. Apply warm compresses as ordered by the primary care provider. Restart the IV at another site.

A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. The nurse looks for a large vein when using a needle with a large gauge. What explains the nurse's action?

To prevent compromising circulation

A child is eating a peanut butter sandwich. He is ingesting an excellent source of:

magnesium.

A client with renal disease requires IV fluids. It is important for the nurse to:

place the fluids on an electronic device.

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 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

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)

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

The nurse is caring for a client with severe edema. Which intervention will the nurse choose to restore fluid balance? (Select all that apply.)

Ask provider to order a low-salt diet. Administer furosemide as ordered. Reduce infusing fluid volume as ordered. Treat the underlying condition that contributes to increased fluid volume.

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 urination vomiting infusion of intravenous solution

During a blood transfusion, a client displays signs of immediate onset facial flushing, fever, chills, headache, low back pain, and shock. Which transfusion reaction should the nurse suspect?

hemolytic transfusion reaction: incompatibility of blood product

The passageways of the kidney permit the urine to flow to the bladder and:

selectively reabsorb or secrete substance to maintain fluids and electrolytes.

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."

Which client will have more adipose tissue and less fluid?

A woman

Which statement accurately describes a guideline when using an implanted port venous access device?

The system is accessed with a noncoring needle and patency is maintained by periodic flushing.

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome?

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.

What food would the nurse provide for a client who has hypokalemia?

Bananas

The nurse is providing care to a client who has been experiencing emesis for 24 hours. Which fluid should the nurse anticipate incorporating into the client's plan of care?

hypotonic