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Fluid and Electrolyte Kaplan Review
Terms in this set (28)
The nurse determines the client has a deep partial thickness burn injury of the back. Which is the best initial nursing action?
Gently clean the area and then leave it alone.
Rationale: For a deep partial thickness burn, gently clean away debris and dirt; blisters form a protective cover, so leave intact, without applying sterile gauze
Which lab finding does the nurse expect if the client is diagnosed with a fluid volume deficit?
Specific gravity 1.034
Rationale: Specific gravity greater than 1.030 indicates fluid volume deficit; other symptoms include increased temp, rapid, weak pulse, poor skin turgor, hypotension, dry eye sockets, dry mouth and mucous membranes; nursing considerations: force fluids, provide isotonic IV fluids, daily weights
The client has a major burn injury. The nurse knows medication is best absorbed by which route?
Rationale: Fluid shift during emergent post-burn phase causes limited absorption from subcutaneous and IM spaces; administer medication prior to painful procedures; keep environment warm to prevent shivering
When measuring the central venous pressure, it is most important for the nurse to take which action?
Place the manometer at the level of the right atrium.
Rationale: By placing the level of the manometer at the right atrium, the pressure reading will be equal to the pressure in the right atrium; if the manometer is higher or lower, the reading will be inaccurate; client should lie flat and breathe normally; reading should be taken at the highest level of fluctuation seen during repspiration
The nurse identifies which group of symptoms is indicative of a hemolytic transfusion reaction?
Kidney pain, hematuria, cyanosis
The nurse assesses a client who sustained a burn injury. The nurse is most concerned if which observation is made?
The client has singed nasal hair.
The nurse evaluates a client's fluid balance. Which finding most likely requires an intervention?
Output is 800 ml less than intake
The nurse identifies which sign or symptom as an early indication of fluid volume excess?
The nurse notices than an IV infusion reaction is not running. Which action should the nurse take initially?
Check the site.
The adult client has a hx of diabetes insipidus. The nurse identifies which imbalance is most likely to develop if this medical problem recurs?
Rationale: Diabetes insipidus is a disorder of water metabolism caused by a deficiency of ADH; large amounts of water are lost from the body causing a buidlup of sodium in the body, leading to hypernatremia; sodium greater than 145 mEq/L; symptoms include excessive urine output, chronic, severe dehydration, excessive thirst, weakness; record intake and output, monitor urine specific gravity, condition of skin, VS, administer vasopressin
The nurse cares for a client receiving a blood transfusion. The nurse observes which symptoms if fluid overload occurs during the trasnfusion?
Increased pulse, increase BP, increased respirations
A client received mag sulfate IV for treatment of preeclampsia. The nurse knows it is the most important to have which interventions at the bedside?
Reflex hammer and calcium gluconate
The nurse identifies NG drainage, vomiting, diarrhea and the use of diuretics likely cause which electrolyte imbalance?
The nurse instructs a client with a full thickness burn injury of the legs about an appropriate diet. The nurse determines teaching is successful if the client selects which menu?
Meat and orange juice
Following the transfusion of one unit of packed RBCs, the nurse prepares to administer another unit. Which action is most important for the nurse to take initially?
Check the type and cross-match with another nurse
The nurse understands fatigue, weakness, and nausea and vomiting are signs of which symptom?
A central venous pressure line is inserted in the client. Following catheter insertion, the client reports dyspnea, shortness of breath, and chest pain. The nurse understands the most probable cause of theses symptoms is which reason?
The nurse cares for the older client admitted to the hospital for persistent vomiting and abdominal pain. A NG tube is inserted and connected to suction. An IV infusion of 1,000 ml of D5W with 20 mEq of potassium chloride is started at 100 ml per hour. The nurse understands potassium chloride has been added to the infusion for which reason?
Replaces the potassium lost in the gastric fluid.
The nurse knows which client is most likely to manifest symptoms of fluid volume deficit?
A client diagnosed with Addison's disease
The client has a transfusion reaction. Which is the nurse's first action?
Stop the transfusion.
The nurse monitors a client receiving a blood transfusion. The nurse should intervene if which is observed?
The blood infuses at 10 ml/min for the first 15 min.
The ED nurse knows which cause most frequently is associated with tetany?
A nurse assesses a client who sustained a burn injury. The burn area is blistered and painful. Which classification best describes the burned area?
Deep partial thickness
The nurse cares for a client diagnosed with a fractured right hip. The client's lab values are: Hgb 15 g/dL, Hct 46%, sodium 140 mEq/L, potassium 6.2 mEq/L, and chloride 100 mEq/L. The nurse is most concerned if which finding is observed?
An episode of ventricular fibrillation.
The nurse cares for a client receiving a blood transfusion. The nurse is most concerned if which observation is made?
The nurse identifies which CVP reading indicates fluid overload?
Rationale: A CVP reading measures effective blood volume and efficiency of cardiac pumping; the normal range is 2-8 mmHg; a CVP reading of 8 mmHg is WNL
The client suffers a full thickness burn injury. The nurse cares for the client during the shock phase. The nurse understands which finding is expected during this phase?
Decreased urine output
The nurse observes a student nurse begin an IV on an elderly client. The nurse should intervene if which action is observed?
The student nurse marks the time on the IV bag with a permanent marker.
Rationale: Can contaminate the solution; use time taping
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