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Foundations Ch 40 Fluid/Electrolyte/Acid-Base
Terms in this set (72)
a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain.
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
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. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.
Apricots are a rich source of
Dairy products are rich sources of
Processed meat and bread products provide
A woman aged 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 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.
Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation?
Discontinue the IV and relocate it to another spot.
The nurse should inspect the IV site for presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted.
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
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.
Chloride is a common anion, which is a
negatively charged ion
. Magnesium, potassium, and calcium are cations, or
positively charged ions.
A nurse is assessing clients across the lifespan for fluid and electrolyte balance. Which age group would the nurse identify as having the greatest risk for these imbalances?
Infants have a far greater volume of total fluid as a percentage of body weight than other children . However, this high percentage of fluid does not give infants a greater reserve against fluid deficit. Instead, it creates a
vulnerability to fluid deficit due to the high percentage of fluid required for homeostasis. In addition, kidney immaturity and increased body surface area in relation to body size place infants at greater risk than older children or adults for fluid and electrolyte imbalances.
kidney immaturity and increased body surface area in relation to body size place infants at greater risk than older children or adults for
fluid and electrolyte imbalances.
A client has the following arterial blood gas results:pH: 7.33PaCO2: 42 mm HgHCO3: 19 mEq/L (19 mmol/L)PaO2: 95 mm HgWhich imbalance would the nurse suspect?
The results reveal metabolic acidosis, which is characterized by a pH lower than 7.35 and a plasma HCO3 concentration lower than 22 mEq/L (22 mmol/L).
The results reveal metabolic acidosis, which is characterized by
a pH lower than 7.35 and a plasma HCO3 concentration lower than 22 mEq/L (22 mmol/L).
Respiratory acidosis is indicated by a
low pH accompanied by an increased arterial concentration of carbon dioxide, which often is clinically defined as a PaCO2 of greater than 45 mm Hg.
Respiratory alkalosis is present when a
high pH is accompanied by a blood carbon dioxide concentration lower than 35 mm Hg
Metabolic alkalosis is characterized by a
pH higher than 7.45 and a plasma HCO3 concentration above 26 mEq/L (26 mmol/L).
Intracellular fluid (fluid inside cells) represents the
greatest proportion of water in the body.
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).
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 health care provider, not the nurse, specifies the
type of solution, additional additives, the volume (in mL), and the duration of the infusion.
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.
Rather than asking older adults if they would like a drink, it is important to
identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs
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
The tourniquet should not be applied for longer than
1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client.
A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What is the nurse's most appropriate action?
Infiltration is the
escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Likely, the IV needs to be discontinued if there is a combination of swelling and pallor.
A registered nurse is overseeing the care of numerous clients on a busy acute medicine unit. Which task would be most safe to delegate to a licensed practical nurse (LPN)?
Changing the dressing on a client's peripheral IV site
Changing a peripheral IV dressing poses a lower risk to the client's safety than the other listed nursing actions and this would be the safest task to delegate. It would be inappropriate to delegate a blood transfusion, deaccess an implanted port, or remove a PICC to an LPN.
Right-sided heart failure leads to a
back up of volume which is unable to effectively flow back to the left side of the heart. The result is fluid volume excess in the peripheral circulation which eventually leads to fluid overload.
Fluid excess or hypervolemia will manifest in clinical symptoms that lead the nurse to
hear crackles in the lungs upon chest auscultation.
Fluid volume excess leads to
translocation of large volumes of intravascular fluid to the interstitial compartment or to areas with only potential spaces such as the peritoneal cavity, pericardium, and pleural space such as in the lungs
Circulatory overload from fluid volume excess will lead to the client having
distended neck veins.
Fluid volume deficit causes low blood pressure whereas a volume excess would result in the client becoming
hypertensive. Poor skin turgor is often seen in clients with fluid volume deficits or in dehydration
A client who is hypervolemic is retaining fluid in the
intravascular space preventing urinary elimination from occurring. Urinary retention rather than excessive elimination would be seen in this case.
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 likely to find?
Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in
metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an extracellular fluid (ECF) volume deficit and hypokalemia.
Intestinal contents also are rich in
sodium, chloride, water, and potassium
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?
The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility.
Before preparing the solution, the nurse should
inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached
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
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 fluids have an osmolarity of
250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.
The primary extracellular electrolytes are:
sodium, chloride, and bicarbonate.
How is control over the extracellular concentration of potassium within the human body is exerted?
Aldosterone exerts major control over the extracellular concentration of
potassium. It also enhances renal secretion of potassium
The flow rate (gtt/min) equals the
volume (mL) times the drop factor (gtt/mL) divided by the time in minutes.
What is the lab test commonly used in the assessment and treatment of acid-base balance?
Arterial blood gas
Basic metabolic panel (BMP) assess kidney
function (BUN and creatinine), sodium and potassium levels, and blood glucose level.
Edema happens when there is which fluid volume imbalance?
extracellular fluid volume excess
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 nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration?
"I should drink 2,500 mL/day of fluid."
In healthy adults, fluid intake generally averages approximately
2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss
Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by
local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site.
. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by
respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.
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 nurse is reviewing the client's serum electrolyte levels which are as follows:Sodium: 138 mEq/L (138 mmol/L)Potassium: 3.2 mEq/L (3.2 mmol/L)Calcium: 10.0 mg/dL (2.5 mmol/L)Magnesium: 2.0 mEq/L (1.0 mmol/L)Chloride: 100 mEq/L (100 mmol/L)Phosphate: 4.5 mg/dL (2.6 mEq/L)Based on these levels, the nurse would identify which imbalance?
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?
A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/ml What is the flow rate?
Metabolic alkalosis is associated with an excess
of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition.
Metabolic acidosis is a proportionate deficit of
bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea.
Respiratory acidosis is when the
carbon dioxide level is high and the ph is low
. Respiratory alkalosis is when the
carbon dioxide level is low and the ph is high.
A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
distended neck veins
A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant?
weight gain of 0.75 kg in a day
milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr
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?
The nurse is performing an assessment of a client with hypocalcemia who has been admitted to the acute care facility. Which symptom(s) does the nurse document that correlates with the admitting diagnosis? Select all that apply.
Report of muscle cramps
Report of numbness and tingling of the mouth
Which finding best indicates to the nurse that the client has a therapeutic outcome from a recent blood transfusion?
No signs of chills, fever, or shortness of breath
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