prep u 41 fluids & electrolytes

The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?

Verify the prescription for type of solution and amount of infusion.

A client's blood pressure has dropped from 146/92 mm Hg to 107/68 mm Hg over the course of several minutes. Increased levels of which substance will be released into the client's bloodstream?

renin

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action?

Remove the IV.

A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with fluid volume deficit. The nurse knows that the client needs restoration of which substance?

electrolytes

A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert?

muscle weakness, fatigue, and arrythmias

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

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, “I would like to give my own blood to be used in case I need it during surgery.” What is the appropriate nursing response?

“Let me refer you to the blood bank so they can provide you with information.”

A client'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 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

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

What is the lab test commonly used in the assessment and treatment of acid–base balance?

Arterial blood gas

The nurse is assisting with a client's blood transfusion. What type of reactions may occur during this procedure? Select all that apply.

• Hives, itching, and anaphylaxis may occur during an allergic reaction.

• Fever, chills, headache and malaise may occur during a febrile reaction.

• Facial flushing, fever, chills, headache, low back pain, and shock may occur during a hemolytic transfusion reaction.

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.

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

The student nurse asks, “What is interstitial fluid?” What is the appropriate nursing response?

“Fluid in the tissue space between and around cells.”

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be:

gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr

100 gtt/min

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

A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells?

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

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 the expected color and consistency.

The nurse is monitoring fluid intake and output (I&O) for a client who has diarrhea. What will the nurse document as input on the record? Select all that apply.

• 100 ml from melted ice chips

• serving of jello

• infusion of intravenous solution

• cup of ice cream

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

total parenteral nutrition.

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

2,500 mL/day

A nurse is preparing to administer cefazolin 1 gram in 50 ml of normal saline via IV piggyback over 30 minutes. The nurse should set the pump to deliver how many mL/hr?

100

A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse’s responsibilities related to this therapy? Select all that apply.

• Deciding the location of the IV catheter.

• Deciding the size of the IV catheter.

• Administering the IV solution.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene?

placing the tourniquet on the upper arm for 2 minutes

A client with type AB blood has experienced a precipitous drop in hemoglobin levels due to a gastrointestinal bleed and now requires a blood transfusion. Which blood types may this client safely receive? Select all that apply.

• A

• B

• AB

• O

The nurse is preparing to perform venipuncture. Which item(s) will the nurse plan to gather? Select all that apply.

• clean gloves

• tourniquet

• antiseptic swabs

• transparent dressing

• adhesive tape

The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate?

83 mL/hr

The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers as well as showing signs of tetany. Which imbalance does the nurse suspect?

hypocalcemia

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min?

83 gtt/min

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)?

metabolic alkalosis

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

platelets

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor?

decreased blood volume and intracellular dehydration

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

Which client(s) would be an appropriate candidate for total parenteral nutrition (TPN)? Select all that apply.

• client who has full-thickness (third-degree) burns over 40% of the body

• client who had gastric surgery and is unable to eat for a few weeks

• client with anorexia nervosa

A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which statements accurately describe this process? Select all that apply.

• The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs.

• The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body.

• The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid–base balance.

• The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.

The nurse is preparing to initiate an infusion of packed red blood cells (PRBCs). While observing the information on the blood bag, it is essential to verify which information with another nurse? Select all that apply.

• number on client’s identification band

• name on client’s identification band

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 winged infusion needle.

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

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs?

An implanted central venous access device (CVAD)

A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism will nurse likely address?

increased hydrostatic pressure

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible?

hypovolemia

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 with protracted nausea and vomiting has been receiving intravenous solution at 125 ml/h for the past several hours. The administration of this solution has resulted in an increase in blood pressure because the water in the solution has passed through the semipermeable membrane of blood cells, causing them to swell. What type of solution has the client been receiving?

A hypotonic solution

The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply.

• facilitates cellular metabolism

• helps maintain normal body temperature

• acts as a solvent for electrolytes

A client sustained severe trauma in a motor vehicle accident and has had 26 units of packed red blood cells infused since admission 2 days previously. What does the nurse predict will be prescribed to replace the clotting factors lost with the infusion of large amounts of packed red blood cells?

plasma

A client is to receive a blood transfusion. Immediately after initiating the transfusion, the nurse suspects that the client is experiencing a hemolytic reaction based on which finding? Select all that apply.

• Fever

• Facial flushing

• Low back pain

• Hematuria

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 (1.98 mmol/l); and magnesium, 1.9 mg/dl (0.78 mmol/l). The nurse should notify the health care provider of what abnormal value?

low calcium

A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed?

hypertonic

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?

Apply pressure to insertion site for at least 3 minutes.

A nurse is monitoring a client's IV infusion and auscultates the client's lung sounds. The nurse detects crackles in the bases of the lungs, which were previously clear. What is the appropriate intervention in this situation?

Notify the health care provider immediately for possible fluid overload.

A client with chronic anemia is admitted for the administration of blood. What would the nurse expect the health care provider to order?

packed cells

A nurse is obtaining an arterial blood specimen from a client to assess acid–base status. Which value is expected for a client with normal status?

HCO₃: 25 mEq/L (25 mmol/L)

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean?

The client has anti-A antibodies.

The 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 arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.