Question 1

Cross-matching of blood is ordered for a client before major surgery. What does this process do?

Accepted Answer

The process of cross-matching of blood determines the compatibility between blood specimens of the donor and the recipient to avoid transfusion reactions during the surgery. It involves mixing a sample of the recipient's blood with a sample of the donor's blood and checking for any reactions that may occur. This helps to ensure that the blood transfused during the surgery is safe and well-tolerated by the recipient.

Question 2

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?

Accepted Answer

The diuretic is likely causing the client to produce an increased amount of urine, which may lead to a decrease in fluid volume, potentially putting the client at risk for deficient fluid volume. Therefore, an appropriate nursing diagnosis would be Risk for Deficient Fluid Volume, and an educational plan could be created to address strategies for maintaining adequate hydration while taking the diuretic.

Question 3

A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this?

Accepted Answer

An autologous transfusion involves the client donating their own blood prior to surgery to be used for the transfusion during or after the surgery. This can help reduce the risk of blood-borne infections and can also help ensure compatibility with the client's blood type.

Question 4

A client's PaCO₂is abnormal on an ABG report. Which of is the most likely be the medical diagnosis?

Accepted Answer

PaCO2 (carbon dioxide pressure in arterial blood) is one of the measures used to evaluate respiratory function. An abnormal PaCO2 can indicate respiratory acidosis, which can be caused by chronic obstructive pulmonary disease (COPD) among other respiratory disorders. Rheumatoid arthritis and sexually transmitted infections would not commonly result in abnormal ABG results, and an infection of the bladder and ureters would not affect PaCO2.

Question 5

A specially trained nurse has inserted a PICC line. What would be done next?

Accepted Answer

After inserting a PICC line, it is standard procedure to send the client to the radiology department for an X-ray to confirm the correct placement of the line before using it for any administration of fluids or medications. This ensures that the line is in the correct position and reduces the risk of complications.

Question 6

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

Accepted Answer

Intracellular fluid (ICF) is the fluid contained within the cells and constitutes around 70% of the total body water. Extracellular fluid (ECF) is the fluid outside the cells, which includes intravascular fluid (blood plasma), interstitial fluid (fluid surrounding the cells), and other fluids in specialized compartments such as cerebrospinal fluid and synovial fluid.

Question 7

A nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body fluid is lost via the gastrointestinal tract?

Accepted Answer

Normally, the body loses about 300 mL of fluid daily via the gastrointestinal tract as part of the digestive process. This amount can increase significantly in conditions like severe diarrhea.

Question 8

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?

Accepted Answer

Comparing the total intake and output of fluids for the 24 hours is essential for accurately assessing a client's fluid status, as it helps in identifying any imbalances that may need intervention.

Question 9

A nurse reads the laboratory report and notes that the client has hyponatremia. What physical assessment should be made?

Accepted Answer

Hyponatremia is an electrolyte imbalance characterized by low sodium levels in the blood. GI symptoms such as nausea, vomiting, and diarrhea can occur in hyponatremia. Therefore, monitoring for GI symptoms is important in assessing a client with hyponatremia.

Question 10

A student is learning how to administer intravenous fluids, including accessing a vein. Although all of the following may occur, which is the most potentially harmful risk posed for the client when accessing the vein?

Accepted Answer

Infection is the most potentially harmful risk as it can lead to serious complications such as sepsis and long-term damage to the vein or surrounding tissues. Discomfort, pain, and minor bleeding are common side effects of accessing a vein and can be managed with proper technique and patient education.

Question 11

Which location might the nurse use to assess the condition of an insertion site for a central venous access device?

Accepted Answer

The jugular vein is a common site for the insertion of central venous access devices, making it a relevant location for a nurse to assess the condition of an insertion site.

Question 12

What is the average adult fluid intake and loss in each 24 hours?

Accepted Answer

The average adult fluid intake and loss in each 24 hours is between 1,500 to 3,500 mL, which includes fluids consumed through drinking and eating as well as fluids lost through urine, sweat, breath, and bowel movements. Therefore, option D is the best choice.

Question 13

Which question about fluid balance would be appropriate when conducting a health history for a client?

Accepted Answer

Asking about urination habits is a relevant question when assessing fluid balance as it provides information on the amount and frequency of urine production, which is an indicator of fluid intake and output.

Question 14

Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?

Accepted Answer

Infants have a higher percentage of their body weight made up of water, particularly extracellular fluid (ECF), compared to adults. This makes them more susceptible to fluid volume deficits through mechanisms such as increased insensible water loss and a higher metabolic rate.

Question 15

A physician writes an order to "force fluids." What will be the first action the nurse will take in implementing this order?

Accepted Answer

Explaining to the client why increasing fluid intake is needed is crucial for compliance and understanding, making it the first step in implementing the order to "force fluids."

Question 16

A client is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than four hours. What should the nurse do next?

Accepted Answer

Blood transfusions should not exceed four hours due to the risk of bacterial growth and potential harm to the patient. Therefore, the transfusion should be discontinued for safety.

Question 17

A client asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond?

Accepted Answer

The process of donating blood is designed to be extremely safe for the donor, with new, sterile equipment used for each donation, eliminating the risk of contracting diseases through the donation process.

Question 18

A nurse is administering a potassium supplement to a client. What will the nurse do to disguise the taste and decrease gastric irritation?

Accepted Answer

Diluting the potassium supplement can help disguise its taste and reduce gastric irritation by lessening its concentration.

Question 19

A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request?

Accepted Answer

Weakness and leg cramps are common symptoms of hypokalemia, which is a low level of potassium in the blood. Drawing blood and requesting a potassium level would help to confirm or rule out this possibility. The other options are not relevant to the client's symptoms or the rationale for the requested lab work.

Question 20

A client has an order to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem?

Accepted Answer

When a client is on a fluid restriction, they may experience dry mouth or thirst. Providing thorough and frequent oral hygiene can help alleviate dry mouth and provide some comfort to the client. Chewing gum may increase saliva production, but it may also increase thirst, so it is not an appropriate measure for someone on a fluid restriction. Back rubs and hair care do not directly address the discomfort associated with fluid restriction.

Quiz 39: Fluid, Electrolyte, and Acid-Base Balance