Question 1

Which assessment finding should cause a nurse to question administering a sodium-containing isotonic IV fluid?

Accepted Answer

Pitting edema indicates that the patient may be retaining excess extracellular fluid,and the nurse should question the order for solution meant to rehydrate the patient.All other options are consistent with ECV deficit,in which case the patient would benefit from a sodium-containing isotonic solution that expands ECV.

Question 2

A nurse is caring for a patient with diabetes who has a bowel obstruction and has orders to ensure that the volume of intake matches the output.In the past 4 hours,the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips.The patient also has a nasogastric suction tube set to low continuous suction,which yielded an output of 300 mL.The patient has voided 400 mL of urine.After reporting these values to the physician,what orders does the nurse anticipate?

Accepted Answer

The total fluid intake and output equals 700 mL,which meets the provider goals.The nurse should record half the volume of ice chips when calculating intake.Patients with nasogastric suctioning are at risk for potassium deficit,so the nurse would anticipate a potassium supplement to correct this condition.The other measures would be unnecessary because the net fluid volume is equal.

Question 3

The nurse would select the dorsal venous plexus of the foot as an IV site for which patient?

Accepted Answer

Use of the foot as an IV site is common in children but is avoided in adults because of the risk for thrombophlebitis.

Question 4

The nurse knows that IV fluid therapy has been effective for a patient with hypernatremia when what happens?

Accepted Answer

Hypernatremia is a condition of elevated serum sodium concentration.Blood pressure is not an accurate indicator of hypernatremia.Emesis and diarrhea will not stop because of IV therapy.Urine output is influenced by many factors,including ECV.A large dilute urine output can cause further hypernatremia.

Question 5

A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed.The patient is afebrile and dyspneic.The nurse auscultates crackles in both lung bases and sees jugular vein distension.The nurse recognizes that the patient is experiencing which transfusion complication?

Accepted Answer

The signs and symptoms are consistent with fluid volume overload.Anaphylactic shock would have manifested with urticaria,dyspnea,and hypotension.Septicemia would include a fever.A hemolytic reaction would consist of flank pain,chills,and fever.

Question 6

A patient informs the nurse that he has the type of diabetes that does not have to do with "blood sugar." The nurse advises the patient to make which dietary change?

Accepted Answer

The patient is indicating that he has diabetes insipidus,which places him at risk for dehydration and hypernatremia.To prevent dehydration,the patient should drink plenty of fluids to replace the extra water excreted in the urine.Foods high in acid should be avoided by a patient with gastroesophageal reflux disease (GERD).A reduction in carbohydrates applies to patients with type 2 diabetes mellitus.Calcium-rich dairy products would be recommended for a patient with hypocalcemia.

Question 7

A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours.The nurse anticipates which fluid therapy initially?

Accepted Answer

Patients with prolonged vomiting and diarrhea become hypovolemic.The best solution to replace ECV is 0.9% sodium chloride,which is an isotonic solution.Dextrose 10% in water,dextrose 5% in water,and 0.45% sodium chloride act as hypotonic solutions in the body.The first consideration is replacing ECV to oxygenate tissues.

Question 8

Which fluid order should the nurse question for a patient with a traumatic brain injury?

Accepted Answer

A fluid of 0.45% sodium chloride is a hypotonic solution,and hypotonic solutions cause cells to swell,which can cause increased intracranial pressure.This can be life-threatening for a patient with a traumatic brain injury.The other solutions are physiologically isotonic sodium-containing solutions that expand ECV but do not cause cell swelling.In the fluid container,dextrose 5% in 0.9% sodium chloride is hypertonic,but the dextrose enters cells rapidly,leaving isotonic 0.9% sodium chloride.

Question 9

The physician asks the nurse to monitor the fluid volume statuses of a patient with heart failure and a patient at risk for clinical dehydration.What is the most effective nursing intervention for monitoring both of these patients?

Accepted Answer

An effective measure of fluid retention or loss is daily weights;each kilogram (2.2 pounds)gained or lost is equivalent to 1 litre of fluid gained or lost.This measurement should be performed at the same time every day with the same scale and the same amount of clothing.Although intake and output records are important assessment measures,some patients are not able to keep their own records themselves.Blood pressure can decrease with ECV deficit but does not necessarily increase with recent ECV excess (heart failure patient).Edema occurs with ECV excess but not with clinical dehydration.

Question 10

A patient was admitted for hypovolemia and has IV fluid running at 250 mL/hr.The patient complains of burning at the IV insertion site.Upon assessment,the nurse does not find redness,swelling,heat,or coolness.The nurse suspects which of the following?

Accepted Answer

The infusion may be flowing faster than the vein can handle,which causes discomfort.The nurse should slow down the infusion.With infiltration,the skin around the IV insertion site becomes blanched,cool,and edematous.Pain,warmth,erythema,and a palpable venous cord are all symptoms of phlebitis.Allergic response to the fluid could involve a combination of itching,flushing,hypotension,and dyspnea,depending on the severity.

Question 11

A nurse is caring for a patient with cancer who presents with anorexia,blood pressure of 100/60,elevated white blood cell count,and oral candidiasis.The nurse knows that the purpose of starting total parenteral nutrition (TPN)is what?

Accepted Answer

TPN is an intravenous (IV)solution composed of nutrients and electrolytes to replace the ones the patient is not eating.TPN does not stimulate the appetite,and it does not contain blood pressure medication or antibiotics.

Question 12

A patient had an acute intravascular hemolytic reaction during a blood transfusion.After discontinuing the blood transfusion,what is the nurse's next action?

Accepted Answer

The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open,in case any sorts of medications need to be delivered through that IV site.The existing tubing should not be used because that would infuse the blood in the tubing into the patient.It is necessary to preserve the IV catheter in place for IV access to treat the patient.After the patient has been assessed and stabilized,the blood can be returned to the blood bank.

Question 13

A nurse is caring for a patient who is in hypertensive crisis.When the nurse is flushing the patient's peripheral IV line,the patient complains of pain.Upon assessment,the nurse notices a red streak near the IV site that is warm to the touch.What is the nurse's initial action?

Accepted Answer

The IV site is phlebitic.The nurse should start a new IV infusion before discontinuing the old one because it is important to always have an IV access site in a patient who is in hypertensive crisis.Then the physician can be notified.Pain medication may or may not need to be administered.

Question 14

A patient with a lower respiratory infection has a pH of 7.25,a PaCO₂ of 55 mm Hg,and a HCO₃^- level of 20 mmol/L (20 mEq/L).The physician has been notified.Which is the priority nursing intervention for this patient?

Accepted Answer

The patient has respiratory acidosis from CO₂ retention.Increasing rate and depth of respiration enables the patient to blow off excess carbon dioxide,and this will begin to correct the imbalance.Checking the urine colour is not a necessary assessment.Trendelenburg position would probably make it more difficult for the patient to breathe and should be avoided.High Fowler's position may be more comfortable for the patient,but it is not necessary.

Question 15

A nurse begins infusing a 250-mL bag of IV fluid at 1845 hours on Monday and programs the pump to infuse at 20 mL/hr.At what time should the infusion be completed?

Accepted Answer

This answer would be calculated as follows:
• 250 mL divided by 20 mL/hr = 12.5 hr
• 0.5 hr × 60 min = 30 min
• 1845 + 12 hr 30 min = 3115,which would be 0715 on Tuesday,the following day.

Question 16

The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has which of the following?

Accepted Answer

All blood transfusions must have a filter to prevent microemboli from being administered to the patient.The patient's blood should not be aspirated to mix with the infusion blood.The blood should not have air bubbles to vent;if a bag of blood does have bubbles,the nurse should promptly return the blood to the blood bank.The only substance compatible with blood is normal saline;no additives should be mixed with the infusing blood.

Question 17

A patient has the following laboratory values: sodium level,145 mmol/L (145 mEq/L);potassium level,4.5 mmol/L (4.5 mEq/L);calcium level,1.05 mmol/L (4.5 mg/dL).What would the nurse expect to find in the assessment?

Accepted Answer

This patient has hypocalcemia;the normal calcium range is 2.25 to 2.75 mmol/L (8.4 to 10.5 mg/dL).Sodium and potassium values are within their normal ranges (sodium,135 to 145 mmol/L [135 to 145 mEq/L];potassium,3.5 to 5.0 mmol/L [3.5 to 5.0 mEq/L]).Hypocalcemia causes muscle tetany,Trousseau's sign,and tingling of the extremities.Lightheadedness when a patient stands up is a manifestation of ECV deficit or sometimes hypokalemia.Weak quadriceps muscles are associated with potassium imbalances.Decreased deep tendon reflexes are related to hypercalcemia or hypermagnesemia.

Question 18

The nurse is caring for a patient with hyperkalemia.Which body system would be most important for the nurse plan to monitor closely?

Accepted Answer

Potassium balance is necessary for cardiac function.Hyperkalemia places the patient at risk for potentially serious dysrhythmias.Monitoring of gastrointestinal,neurological,and respiratory systems would be indicated for other electrolyte imbalances.

Question 19

The nurse is caring for a patient with sepsis.The plan of care for the patient is to administer antibiotics three times a day for 4 weeks.What device will be used to administer these antibiotics?

Accepted Answer

A PICC line is a type of central venous device that can be introduced into a peripheral vein for administration of IV antibiotics for an extended period,over the course of several weeks.A continuous infusion would not be appropriate if the patient were to receive antibiotics only three times daily.A peripheral catheter would not be necessary or have a heparin lock.An implanted port catheter is intended for long-term use of venous access over months,or even years.

Question 20

A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr.The nurse is using microdrip gravity drip tubing.What is the minute flow rate (drops per minute)?

Accepted Answer

Microdrip tubing delivers 60 gtt/mL.To obtain a rate of 125 mL/hr with microdrip tubing,the calculation is 125 mL/hr × 60 gtt/mL ¸ 60 min = 125 gtt/min.

Quiz 40: Fluid, electrolyte, and Acid-base Balances

Which assessment finding should cause a nurse to question administering a sodium-containing isotonic IV fluid?

The nurse would select the dorsal venous plexus of the foot as an IV site for which patient?

The nurse knows that IV fluid therapy has been effective for a patient with hypernatremia when what happens?

A patient informs the nurse that he has the type of diabetes that does not have to do with "blood sugar." The nurse advises the patient to make which dietary change?

A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours.The nurse anticipates which fluid therapy initially?

Which fluid order should the nurse question for a patient with a traumatic brain injury?

The physician asks the nurse to monitor the fluid volume statuses of a patient with heart failure and a patient at risk for clinical dehydration.What is the most effective nursing intervention for monitoring both of these patients?

A patient was admitted for hypovolemia and has IV fluid running at 250 mL/hr.The patient complains of burning at the IV insertion site.Upon assessment,the nurse does not find redness,swelling,heat,or coolness.The nurse suspects which of the following?

A nurse is caring for a patient with cancer who presents with anorexia,blood pressure of 100/60,elevated white blood cell count,and oral candidiasis.The nurse knows that the purpose of starting total parenteral nutrition (TPN) is what?

A patient had an acute intravascular hemolytic reaction during a blood transfusion.After discontinuing the blood transfusion,what is the nurse's next action?

A nurse is caring for a patient who is in hypertensive crisis.When the nurse is flushing the patient's peripheral IV line,the patient complains of pain.Upon assessment,the nurse notices a red streak near the IV site that is warm to the touch.What is the nurse's initial action?

A patient with a lower respiratory infection has a pH of 7.25,a PaCO₂ of 55 mm Hg,and a HCO₃^- level of 20 mmol/L (20 mEq/L) .The physician has been notified.Which is the priority nursing intervention for this patient?

A nurse begins infusing a 250-mL bag of IV fluid at 1845 hours on Monday and programs the pump to infuse at 20 mL/hr.At what time should the infusion be completed?

The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has which of the following?

A patient has the following laboratory values: sodium level,145 mmol/L (145 mEq/L) ;potassium level,4.5 mmol/L (4.5 mEq/L) ;calcium level,1.05 mmol/L (4.5 mg/dL) .What would the nurse expect to find in the assessment?

The nurse is caring for a patient with hyperkalemia.Which body system would be most important for the nurse plan to monitor closely?

The nurse is caring for a patient with sepsis.The plan of care for the patient is to administer antibiotics three times a day for 4 weeks.What device will be used to administer these antibiotics?

A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr.The nurse is using microdrip gravity drip tubing.What is the minute flow rate (drops per minute) ?

Quiz 40: Fluid, electrolyte, and Acid-base Balances

Which assessment finding should cause a nurse to question administering a sodium-containing isotonic IV fluid?

The nurse would select the dorsal venous plexus of the foot as an IV site for which patient?

The nurse knows that IV fluid therapy has been effective for a patient with hypernatremia when what happens?

A patient informs the nurse that he has the type of diabetes that does not have to do with "blood sugar." The nurse advises the patient to make which dietary change?

A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours.The nurse anticipates which fluid therapy initially?

Which fluid order should the nurse question for a patient with a traumatic brain injury?

The physician asks the nurse to monitor the fluid volume statuses of a patient with heart failure and a patient at risk for clinical dehydration.What is the most effective nursing intervention for monitoring both of these patients?

A patient was admitted for hypovolemia and has IV fluid running at 250 mL/hr.The patient complains of burning at the IV insertion site.Upon assessment,the nurse does not find redness,swelling,heat,or coolness.The nurse suspects which of the following?

A nurse is caring for a patient with cancer who presents with anorexia,blood pressure of 100/60,elevated white blood cell count,and oral candidiasis.The nurse knows that the purpose of starting total parenteral nutrition (TPN) is what?

A patient had an acute intravascular hemolytic reaction during a blood transfusion.After discontinuing the blood transfusion,what is the nurse's next action?

A nurse is caring for a patient who is in hypertensive crisis.When the nurse is flushing the patient's peripheral IV line,the patient complains of pain.Upon assessment,the nurse notices a red streak near the IV site that is warm to the touch.What is the nurse's initial action?

A patient with a lower respiratory infection has a pH of 7.25,a PaCO2 of 55 mm Hg,and a HCO3- level of 20 mmol/L (20 mEq/L) .The physician has been notified.Which is the priority nursing intervention for this patient?

A nurse begins infusing a 250-mL bag of IV fluid at 1845 hours on Monday and programs the pump to infuse at 20 mL/hr.At what time should the infusion be completed?

The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has which of the following?

A patient has the following laboratory values: sodium level,145 mmol/L (145 mEq/L) ;potassium level,4.5 mmol/L (4.5 mEq/L) ;calcium level,1.05 mmol/L (4.5 mg/dL) .What would the nurse expect to find in the assessment?

The nurse is caring for a patient with hyperkalemia.Which body system would be most important for the nurse plan to monitor closely?

The nurse is caring for a patient with sepsis.The plan of care for the patient is to administer antibiotics three times a day for 4 weeks.What device will be used to administer these antibiotics?

A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr.The nurse is using microdrip gravity drip tubing.What is the minute flow rate (drops per minute) ?

A patient with a lower respiratory infection has a pH of 7.25,a PaCO₂ of 55 mm Hg,and a HCO₃^- level of 20 mmol/L (20 mEq/L) .The physician has been notified.Which is the priority nursing intervention for this patient?