Chapter 41: Fluid, Electrolyte, and Acid-Base Balance MeaganNicole Quizlet Flashcards

(52 cards)

1
Q
A 2-year-old child was 
brought into the 
emergency 
department after 
ingesting several 
morphine tablets 
from a bottle in his 
mother's purse. The 
nurse knows that the 
child is at greatest 
risk for which acid- 
base imbalance? 
a. Respiratory 
acidosis 
b. Respiratory 
alkalosis 
c. Metabolic acidosis 
d. Metabolic alkalosis
A
ANS: A 
Morphine overdose can cause 
respiratory depression and 
hypoventilation. Hypoventilation 
results in retention of CO2 and 
respiratory acidosis. Respiratory 
alkalosis would result from hy- 
perventilation, causing a decrease in 
CO2 levels. Metabolic acid-base 
imbalance would be a result of 
kidney dysfunction, vomiting, 
diarrhea, or other conditions that 
affect metabolic acids.
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2
Q
Approximately two 
thirds of the body's 
total water volume 
exists in the \_\_\_\_\_ 
fluid. 
a. Intracellular 
b. Interstitial 
c. Intravascular 
d. Transcellular
A
ANS: A 
Intracellular fluid accounts for 
approximately two thirds of the 
fluids in the body—about 42% of 
total body weight. Interstitial fluid, 
intravascular fluid, and transcellular 
fluid constitute extra-cellular fluid, 
which is the fluid outside a cell.
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3
Q
A chemotherapy 
patient has gained 5 
pounds in 2 days. 
Which assessment 
question by the nurse 
is most appropriate? 
a. "Are you having 
difficulty sleeping at 
night?" 
b. "How many 
calories a day do you 
con-sume?" 
c. "Do you have dry 
mouth or feel 
thirsty?" 
d. "How many times a 
day do you urinate?"
A
ANS: D 
A rapid gain in weight usually 
indicates ECV excess if the person 
began with normal ECV. Asking the 
patient about urination habits will 
illuminate whether the body is trying 
to excrete the excess fluid, or if renal 
dysfunction is contributing to ECV 
excess. Difficulty sleeping at night 
can occur if the body builds up 
excessive fluid in the lungs; however, 
it could also mean that the patient is 
getting up frequently to urinate, so 
the question is not specific enough. 
Caloric intake does not account for 
rapid weight changes. Dry mouth 
and thirst accompany ECV deficit, 
which would be associated with 
rapid weight loss.
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4
Q
In which patient 
would the nurse 
expect to see a 
positive Chvostek 
sign? 
a. A 7-year-old child 
admitted for severe 
burns 
b. A 24-year-old adult 
admitted for chronic 
alcohol abuse 
c. A 50-year-old 
patient admitted for 
an acute exacerbation 
of 
hyperparathyroidism 
d. A 75-year-old 
patient admitted for a 
bro-ken hip related to 
osteoporosis
A
ANS: B 
A positive Chvostek sign is 
representative of hypocalcemia or 
hypomagnesemia. Hypomag- 
nesemia is common with alcohol 
abuse. Hypocalcemia can be brought 
on by alcohol abuse and pancreatitis 
(which also can be affected by 
alcohol consumption). Burn patients 
frequently expe-rience ECV deficit. 
Hyperparathyroidism causes 
hypercalcemia. Immobility is 
associated with hypercalcemia.
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5
Q
A nurse begins 
infusing a 250-mL 
bag of IV fluid at 1845 
on Monday and 
programs the pump 
to infuse at 20 mL/hr. 
At what time should 
the infusion be 
completed? 
a. 0645 Tuesday 
b. 0675 Tuesday 
c. 0715 Tuesday 
d. 0735 Tuesday
A
ANS: C 
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.
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6
Q
The nurse is assessing a patient 
and finds crackles in the lung 
bases and neck vein distention. 
The nurse gives the patient a 
diuretic. What electrolyte 
imbalance is the nurse most 
concerned about? 
a. Potassium imbalance 
b. Sodium imbalance 
c. Calcium imbalance 
d. Phosphate imbalance
A
ANS: A 
Using a diuretic can 
cause excess excretion 
of potassium, unless it 
is a potassium-sparing 
diuretic. The other 
electrolytes are not 
excreted in the same 
way with diuretics.
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7
Q
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 distention. The 
nurse recognizes that the patient 
is experiencing which 
transfusion complication? 
a. Anaphylactic shock 
b. Septicemia 
c. Fluid volume overload 
d. Hemolytic reaction
A
ANS: C 
The signs and 
symptoms are 
concurrent with fluid 
volume overload. 
Anaphylactic shock 
would have presented 
with urticaria, dyspnea, 
and hypotension. 
Septicemia would 
include a fever. A 
hemolytic reaction 
would consist of flank 
pain, chills, and fever.
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8
Q
A nurse is caring for a cancer 
patient who presents with 
anorexia, blood pressure 100/60, 
elevated white blood cell count, 
and oral candidiasis. The nurse 
knows that the purpose of 
starting total parenteral 
nutrition (TPN) is to 
a. Replace fluid, electrolytes, and 
nutrients in the patient. 
b. Stimulate the patient's 
appetite to eat. 
c. Provide medication to raise 
the patient's blood pressure. 
d. Deliver antibiotics to fight off 
infection.
A
ANS: A 
Total parenteral 
nutrition is an 
intravenous solution 
composed of nutrients 
and electrolytes to 
replace the ones the 
patient is not eating. 
TPN does not stimulate 
the appetite. TPN does 
not contain blood 
pressure medication or 
antibiotics.
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9
Q
The nurse is caring for a diabetic 
patient in renal failure. Which 
laboratory findings would the 
nurse expect? 
a. pH 7.3, PaCO2 36 mm Hg, 
HCO3- 19 mEq/L 
b. pH 7.5, PaCO2 35 mm Hg, 
HCO3- 35 mEq/L 
c. pH 7.3, PaCO2 47 mm Hg, 
HCO3- 23 mEq/L 
d. pH 7.35, PaCO2 40 mm Hg, 
HCO3- 25 mEq/L
A
ANS: A 
Patients in renal 
failure develop 
metabolic acidosis. 
The laboratory values 
that reflect this are pH 
7.3, PaCO2 36 mm 
Hg, HCO3- 19 mEq/L. 
A laboratory finding of 
pH 7.5, PaCO2 35 mm 
Hg, HCO3- 35 mEq/L 
is metabolic alkalosis. 
pH 7.3, PaCO2 47 mm 
Hg, HCO3- 23 mEq/L 
is respira-tory 
acidosis. pH 7.35, 
PaCO2 40 mm Hg, 
HCO3- 25 mEq/L 
values are within 
normal range.
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10
Q
A nurse is caring for a diabetic 
patient with 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 4 mL/hr and has 
eaten 200 mL of ice chips. The 
patient also has an NG suction 
tube set to low continuous 
suction that had 300 mL output. 
The patient has voided 400 mL of 
urine. After reporting these 
values to the physician, what 
orders does the nurse 
anticipate? 
a. Add a potassium supplement 
to replace loss from output. 
b. Decrease the rate of 
intravenous fluids to 100 mL/hr. 
c. Discontinue the nasogastric 
suctioning. 
d. Administer a diuretic to 
prevent fluid volume excess.
A
ANS: A 
The total fluid intake 
and output equals 700 
mL, which meets the 
provider goals. 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.
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11
Q
A nurse is caring for a 
patient who is in 
hypertensive crisis. When 
the nurse is flushing the 
patient's peripheral IV, the 
patient complains of pain. 
Upon assessment, the 
nurse notices a red streak 
that is warm to the touch. 
What is the nurse's initial 
action? 
a. Notify the physician. 
b. Administer pain 
medication. 
c. Discontinue the IV. 
d. Start a new IV line.
A
ANS: D 
The IV site has phlebitis. The 
nurse should start a new IV 
before discontinuing the old 
one be-cause 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
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12
Q
A nurse is caring for a 
patient whose ECG 
presents with changes 
characteristic of 
hypokalemia. Which 
assessment finding would 
the nurse expect? 
a. Thready peripheral 
pulses 
b. Abdominal distention 
c. Dry mucous membranes 
d. Flushed skin
A
ANS: B 
Signs and symptoms of 
hypokalemia are muscle 
weakness and fatigue, 
abdominal distention, 
decreased bowel sounds, and 
cardiac dysrhythmias. 
Thready peripheral pulses 
indicate hypovolemia. Dry 
mucous membranes and 
flushed skin are indicative of 
dehydration and hyper- 
natremia.
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13
Q
The nurse is caring for a 
patient with hyperkalemia. 
Which body system would 
be most important for the 
nurse plan to monitor 
closely? 
a. Gastrointestinal 
b. Neurological 
c. Cardiac 
d. Respiratory
A
ANS: C 
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.
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14
Q
The nurse is caring for a patient with sepsis. The plan 
of care for the patient is to administer antibiotics 3 
times a day for 4 weeks. What device will be 
used to administer these antibiotics? 
a. A continuous 
infusion 
b. A heparin 
locked 
peripheral 
catheter 
c. A PICC line 
d. An implanted 
port catheter
A

ANS: C
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 take place if
the patient received antibiotics only 3 times daily. A pe-ripheral catheter would not be necessary or heparin locked. An implanted port catheter is in-tended for long-term use of venous access over months, or even years.

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15
Q
A nurse is preparing to administer a blood 
transfusion. Which assessment finding would the nurse report immediately? 
a. Blood 
pressure 120/60 
b. Temperature 
101.3° F 
c. Poor skin 
turgor and pallor 
d. Heart rate of 
100 beats per 
minute
A
ANS: B 
A fever should be reported immediately, 
and the blood transfusion may be 
postponed. All other assessment findings 
are acceptable before starting a blood 
transfusion.
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16
Q
The nurse knows 
that an 
imbalance of 
which ion causes 
acid-base 
impairment? 
a. Hydrogen 
b. Calcium 
c. Magnesium 
d. Sodium
A
ANS: A 
The concentration of hydrogen ions 
determines pH. Low pH designates an 
acidic environment. High pH designates 
an alkaline environment. Calcium, 
magnesium, and sodium are ions, but 
their imbalances are not direct acid-base 
impairments.
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17
Q
The nurse knows 
that edema in a 
patient who has 
venous congestion 
from right heart 
failure is 
facilitated by an 
imbalance with 
regard to \_\_\_\_\_ 
pressure. 
a. Hydrostatic 
b. Osmotic 
c. Oncotic 
d. Concentration
A
ANS: A 
Venous congestion increases capillary 
hydrostatic pressure. Increased 
hydrostatic pressure causes edema by 
causing increased movement of fluid 
into the interstitial area. Osmotic and 
oncotic pressures involve the 
concentrations of solutes and can 
contribute to edema in other situations. 
Concentration pressure is not a nursing 
term.
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18
Q
The nurse knows 
that intravenous 
fluid therapy has 
been effective for a 
patient with 
hypernatremia 
when 
a. Serum sodium 
concentration 
returns to normal. 
b. Systolic and 
diastolic blood 
pressure 
decrease. 
c. Large amounts 
of emesis and 
diarrhea 
decrease. 
d. Urine output 
increases to 150 
mL/hr.
A
ANS: A 
Hypernatremia is diagnosed by elevated 
serum sodium concentration. Blood 
pressure is not an accurate indicator of 
hypernatremia. Emesis and diarrhea 
will not stop because of intravenous 
therapy. Urine output is influenced by 
many factors, including extracellular 
fluid volume. A large dilute urine output 
can cause further hypernatremia.
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19
Q
The nurse knows 
that the most 
abundant cation 
in the blood is 
a. Sodium. 
b. Potassium. 
c. Chloride. 
d. Magnesium.
A
ANS: A 
Sodium is the most abundant cation in 
the blood. Potassium is the 
predominant intracellular cat-ion. 
Chloride is an anion (negatively 
charged) rather then a cation (positively 
charged). Magne-sium is found 
predominantly inside cells and in bone.
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20
Q
The nurse receives the patient's most recent blood 
work results. Which laboratory value is of greatest 
concern? 
a. Sodium of 145 
mEq/L 
b. Calcium of 17.5 
mg/dL 
c. Potassium of 
3.5 mEq/L 
d. Chloride of 
100 mEq/L
A
ANS: B 
Normal calcium range is 8.5 mg/dL to 
10.5 mg/dL; therefore, a value of 17.5 
mg/dL is abnor-mally high and of 
concern. The rest of the laboratory values 
are within their normal ranges: so-dium 
135 to 145 mEq/L; potassium 3.5 to 5.0 
mEq/L; chloride 98 to 106 mEq/L.
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21
Q
The nurse selects appropriate tubing for a blood 
transfusion by ensuring that the tubing has:
a. Two-way 
valves to allow 
the patient's 
blood to mix 
and warm the 
blood 
transfusing. 
b. An injection 
port to mix 
additional 
electrolytes 
into the blood. 
c. An air vent 
to let bubbles 
in the blood 
escape. 
d. A filter to 
ensure that 
clots do not 
enter the 
patient.
A

ANS: D
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.

22
Q
The nurse understands that administering a hypertonic 
solution to a patient will shift water 
from the \_\_\_\_\_ to the \_\_\_\_\_ space. 
a. 
Intracellular; 
extracellular 
b. 
Extracellular; 
intracellular 
c. 
Intravascular; 
intracellular 
d. 
Intravascular; 
interstitial
A

ANS: A
A hypertonic solution has a concentration
greater than normal body fluids, so water
will shift out of cells because of the osmotic
pull of the extra particles. Movement of
water into cells occurs when hypotonic
fluids are administered. Distribution of fluid
between intravascular and intersti-tial
spaces occurs by filtration, the net sum of
hydrostatic and osmotic pressures.

23
Q
The nurse would expect a patient with increased levels of 
serum calcium to also have 
\_\_\_\_\_ levels. 
a. Increased potassium 
b. Decreased phosphate 
c. Decreased sodium 
d. Increased magnesium
A

ANS: B
Serum calcium and phosphate have an inverse relationship. When one is elevated, the other de-creases, except in some patients with end-stage renal disease. Increased
serum calcium would not necessarily cause changes in levels of potassium, sodium, or magnesium.

24
Q
The nurse would expect a patient with respiratory 
acidosis to have an excessive amount of 
a. Carbon dioxide. 
b. Bicarbonate. 
c. Oxygen. 
d. Phosphate.
A

ANS: A
Respiratory acidosis occurs when the lungs are not able to excrete enough carbon dioxide. Carbon dioxide and water create carbonic acid. A buildup of carbonic acid causes the ECF to be-come more acidic, decreasing the pH. Bicarbonate is normal with uncompensated respiratory acidosis or elevated with compensated respiratory acidosis. Excessive oxygen and phosphate are not characteristic of respiratory acidosis.

25
The nurse would not expect full compensation to occur for which acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
ANS: B Usually the cause of respiratory alkalosis is a temporary event (e.g., an asthma or anxiety attack). The kidneys take about 24 hours to compensate for an event, so it is unlikely to see much if any compensation for respiratory alkalosis. Respiratory acidosis usually results from longer-term conditions such as chronic lung disease, narcotic overdose, or another event that causes respira-tory depression. The kidneys still do not respond for about 24 hours, but usually the event is still occurring. For both metabolic imbalances, the respiratory system is quick to attempt to compen-sate: however, it may have difficulty sustaining that compensation.
26
The nurse would select the dorsal venous plexus of the foot as an IV site for which patient? a. A 2-year-old child b. A 22-year- old adult c. A 50-year- old patient d. An 80-year- old patient
ANS: A | Use of the foot as an IV site is common in children but is avoided in adults because of the risk for thrombophlebitis.
27
A patient had an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, what is the nurse's next action? a. Run normal saline through the existing tubing. b. Start normal saline at TKO rate using new tubing. c. Discontinue the IV catheter. d. Return the blood to the blood bank.
ANS: B 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 exist-ing 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 pa-tient has been assessed and stabilized, the blood can be returned to the blood bank.
28
A patient informs the nurse that he has the type of diabetes that does not require insulin. The nurse advises the patient to make which dietary change? a. Drink plenty of fluids throughout the day to stay hydrated. b. Avoid food high in acid to avoid metabolic acidosis. c. Reduce the quantity of carbohydrates ingested to lower blood sugar. d. Include a serving of dairy in each meal to elevate calcium levels.
ANS: A The patient is indicating that he has diabetes insipidus, which places him at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid should be avoided in a patient with GERD. A reduction in carbohydrates applies to type 2 diabetes mellitus patients. Calcium-rich dairy products would be recommended for a hypocalcemic patient.
29
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. 12 gtt/min b. 24 gtt/min c. 125 gtt/min d. 150 gtt/min
ANS: C Microdrip tubing delivers 60 gtt/mL. Calculation for a rate of 125 mL/hr using microdrip tubing: (125 mL/1 hr)(60 gtt/1 mL)(1 hr/60 min) = 125 gtt/min.
30
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? a. 0.9% sodium chloride b. Dextrose 10% in water c. Dextrose 5% in water d. 0.45% sodium chloride
ANS: A Patients with prolonged vomiting and diarrhea become hypovolemic. The best solution to replace extracellular volume 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 extracellular volume to oxygenate tissues.
31
``` A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values? a. pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.52, PaCO2 48 mm Hg, HCO3- 28 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L ```
ANS: B Compensated metabolic alkalosis should show alkalosis pH and HCO3- (metabolic) values, with a slightly acidic CO2 (compensatory respiratory acidosis). In this case, pH 7.52 is alkaline (normal = 7.35 to 7.45), PaCO2 is acidic (normal 35 to 45 mm Hg), and HCO3- is elevated (normal = 22 to 26 mEq/L). A result of pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L is uncompensated metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L is within normal limits. pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L is compensated respiratory acidosis.
32
A patient was admitted for hypovolemia and has intravenous 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 that the a. IV has infiltrated. b. IV has caused phlebitis. c. Fluid is infusing too quickly. d. Patient is allergic to the fluid.
ANS: C The infusion may be flowing faster than the vein can handle, causing discomfort. The nurse should slow down the infusion. Infiltration results in skin that is blanched, cool, and edematous around the IV insertion site. 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.
33
A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 55 mm Hg, and HCO3- of 20 mEq/L. The physician has been notified. Which is the priority nursing intervention for this patient? a. Check the color of the patient's urine output. b. Place the patient in Trendelenburg position. c. Encourage the patient to increase respirations. d. Place the patient in high Fowler's position.
ANS: C The patient has respiratory acidosis from CO2 retention. Increasing rate and depth of respiration will allow the patient to blow off excess carbon dioxide, and this will begin to correct the imbalance. Checking the urine color is not a necessary assessment. The Trendelenburg position likely would make it more difficult for the patient to breathe and should be avoided. Placing the patient in high Fowler's position may make the patient more comfortable, but it is not necessary.
34
The physician asks the nurse to monitor the fluid volume status of a congestive heart failure patient and a patient at risk for clinical dehydration. What is the most effective nursing intervention for monitoring both of these patients? a. Weigh the patients every morning before breakfast. b. Ask the patients to record their intake and output. c. Measure the patients' blood pressure every 4 hours. d. Assess the patients for edema in extremities.
ANS: A An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using 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 will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration.
35
The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as a. Hydrolysis. b. Osmosis. c. Filtration. d. Active transport.
ANS: B The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Hydrolysis is not a term related to fluid and electrolyte balance. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Active transport requires metabolic activity and is not passive.
36
When discontinuing a peripheral IV access, the nurse should (Select all that apply.) a. Use scissors to remove the IV site dressing and tape. b. Keep the catheter parallel to the skin while removing it. c. Apply firm pressure with sterile gauze during removal. d. Stop the infusion before removing the IV catheter. e. Wear sterile gloves and a mask. f. Apply pressure to the site for 2 to 3 minutes after removal.
ANS: B, D, F The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the patient's skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicated to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile.
37
When selecting a site to insert an intravenous catheter on an adult, the nurse should (Select all that apply.) a. Start proximally and move distally on the arm. b. Choose a vein with minimal curvature. c. Choose the patient's dominant arm. d. Check for contraindications to the extremity. e. Select a vein that is rigid. f. Avoid areas of flexion.
ANS: B, D, F The nurse should start distally and move proximally, choosing the nondominant arm if possible. The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such mastectomy, AV fistula, and central line in the extremity. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage.
38
Which assessment finding should cause a nurse to question administering a sodium containing isotonic intravenous fluid? a. Blood pressure 102/58 b. Dry mucous membranes c. Poor skin turgor d. Pitting edema
ANS: D Pitting edema indicates that the patient may be retaining excess extracellular fluid, and the nurse should question the type of solution meant to rehydrate the patient. All other options are consistent with ECV deficit, and the patient would benefit from a sodium-containing isotonic solution that expands extracellular volume
39
Which assessment finding would the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Lightheadedness when standing up b. Weak quadriceps muscles c. Tingling of the extremities and tetany d. Decreased deep tendon reflexes
``` ANS: C This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Hypocalcemia causes muscle tetany, positive Trousseau's sign, and tingling of the extremities. Lightheadedness when standing 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. ```
40
``` Which fluid order should the nurse question for a patient with a traumatic brain injury? a. 0.45% sodium chloride b. 0.9% sodium chloride c. Lactated Ringer's d. Dextrose 5% in 0.9% sodium chloride ```
``` ANS: A 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 solu-tions that will expand ECV but will 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. ```
41
Which laboratory value should the nurse examine when evaluating uncompensated respiratory alkalosis? a. PaO2 b. Anion gap c. PaCO2 d. HCO3-
ANS: C Uncompensated respiratory imbalances are seen in the PaCO2 levels. PaO2 indicates oxygen sta-tus. Anion gap is used for metabolic acidosis. HCO3- is used to evaluate compensation for respiratory imbalances or uncompensated metabolic imbalances.
42
____ is released from pituitary gland in response to ↑ blood osmolality
ADH
43
Aldosterone released by adrenal cortex in response to ___ or ___ in plasma
↑K+ or ↓Na Note: ↑reabsorption of Na & excretion of K+ & H+ ↑Na will retain water
44
Renin - enzyme secreted by kidneys in response to ____ ____ cause by _____
↓ renal perfusion | ↓ECF
45
_____ produces angiotensin I→ angiotensin II causes _____ ______, redirects blood flow to kidneys
Renin | peripheral vasoconstriction
46
____ _____ becomes more permeable & returns more water to circulation
Renal tubule
47
______ is the loss of pure water alone without losing Na
Dehydration
48
____ ____ ____ includes the loss of body fluids and electrolytes. Fluid loss is often ____.
Fluid Volume Deficit (FVD) isotonic Can occur with: Loss of body fluids due to diarrhea, fistula drainage, hemorrhage, polyuria Inadequate intake Shift of fluid from plasma to interstitial space
49
What is too much fluid in vascular space
FVE = fluid volume excess
50
What is insufficient fluid volume in vascular space
FVD = fluid volume deficit
51
Fluid deficit due to loss of:
Vomiting, diarrhea, fistula, GI suction, sweating, 3rd spacing (burns), diuretics, hemorrhage
52
Fluid deficit due to decreased intake:
Nausea, anorexia, inability to drink, water not available