Fluid Electrolyte and Acid Base Balance (Pearson)_Key highlights

Question 1

The nurse is caring for a patient who has overdosed on narcotics. Which intervention should be performed to ensure this patient’s acid–base balance?

Answer 1

Insert an artificial airway. (Because respiratory acidosis can be caused by an overdose of narcotics, an artificial airway should be inserted to prevent the compromise of oxygenation. )

Question 2

The nurse prepares teaching materials for a community health fair.

Which information should be included about obesity?

Answer 2

An individual who is obese has less body water than a lean individual. (Because fat tissue is essentially free of water, whereas lean tissue contains a significant amount of water, individuals who are obese have less body water than those who are lean.)

Question 3

The nurse is preparing a blood product to transfuse into a patient.

Which action should the nurse take after priming the tubing?

Answer 3

Start the saline solution. (After priming the tubing, the saline solution should be started to clear the intravenous catheter of incompatible solutions or medications. )

Question 4

A patient who is dehydrated is prescribed an intravenous infusion of 5% dextrose and lactated Ringer’s solution.

Which action should the nurse take?

Answer 4

Question the prescription.

Question 5

A patient experiences hemolysis of red blood cells caused by a blood transfusion. Which information should the nurse expect to be documented in the patient’s medical record?

Answer 5

The patient is Rh negative and received Rh positive blood.

Question 6

The nurse assesses a patient with a fluid and electrolyte imbalance.

For which health problem should the nurse provide frequent mouth care?

Answer 6

Fluid volume deficit (Frequent mouth care should be provided to a patient with a fluid volume deficit since dehydration can cause drying and stickiness of the oral mucous membranes)

Question 7

A patient is diagnosed with hyponatremia.

Which finding should the nurse expect when assessing this patient?

Answer 7

Muscle twitching (Hyponatremia, or a sodium deficit, causes muscle twitching because sodium is required for muscle contraction)

Question 8

The nurse evaluates serum potassium levels for assigned patients.

Which value should the nurse report to the healthcare provider?

Answer 8

2.5 mEq/L
(potassium level of 2.5 mEq/L indicates hypokalemia and should be reported to the healthcare provider.)

Question 9

A patient is prescribed to receive a blood product.

For which reason should the nurse begin the transfusion at a rate of 2 mL/min?

Answer 9

Monitor for an adverse reaction

Question 10

A patient is receiving an infusion of normal saline after receiving a blood product.

For which potential health problem should the patient be monitored?

Answer 10

Delayed infusion reaction (Normal saline is often infused while the patient is monitored for a delayed reaction to the blood)

Question 11

The nurse is asked to explain fluid balance.

Which concept should be included in the response?

Answer 11

Intracellular fluid maintains cell metabolism. (Intracellular fluid provides a medium in which metabolic processes of the cell take place. )

Question 12

A patient receives a blood product.

Which action should the nurse take when monitoring the patient for a delayed transfusion reaction?

Answer 12

Infuse normal saline.

Question 13

For which reason should a patient be denied donating blood?

Answer 13

Low body weight

Question 14

The nurse is creating a plan of care for a patient with hypomagnesemia.

Which food should the nurse encourage in the patient’s diet?

Answer 14

Tuna (Tuna is high in magnesium and should be encouraged in a patient with a magnesium deficiency.)

Question 15

The nurse assists with the insertion of a central vascular access device into a patient.

Which information should be included in the documentation?

Answer 15

Device brand (The brand of the device should be documented in case the patient experiences future problems. )

Question 16

A patient is receiving an intravenous infusion of lactated Ringer’s. For which symptoms should the patient be monitored?

Answer 16

Bounding pulse and shortness of breath
An isotonic solution such as lactated Ringer’s remains in the vascular compartment, expanding vascular volume. (SOB/ pallor = sign of fluid overload)

Question 17

A patient is prescribed phenhydramine when receiving a blood product.

At which time should the nurse administer the medication?

Answer 17

30 minutes prior

Premedication prescribed by the healthcare provider, such as phenhydramine, should be administered 30 minutes prior to the transfusion.

Question 18

The skin on a patient’s sternum remains tented for several seconds after being lightly pinched.

Which additional assessment finding should the nurse expect?

Answer 18

Dry mucous membranes

Question 19

The nurse is caring for a patient with a traumatic brain injury. Which type of solution should be avoided?

Answer 19

Dextrose 5% and water (D5W)

D5W is avoided in a patient at risk for increased intracranial pressure (IICP) because it can increase cerebral edema.

Question 20

A patient has a blood type that does not have antigens on the red blood cells. For which blood type should the nurse prepare teaching for this patient?

Answer 20

Type O

Question 21

A patient needs an intravenous access device inserted.

Which veins should be avoided?

Answer 21

Highly visible
Highly visible veins tend to roll away from the needle and should be avoided when inserting an intravenous access device.

Question 22

The nurse reviews daily urine output values for assigned patients.

For which patient output should oral fluids be encouraged?

Answer 22

1200 mL

Question 23

A patient is prescribed a potassium-sparing diuretic.

Which food should be removed from the patient’s meal tray?

Answer 23

Banana

Bananas are high in potassium and should be avoided when taking a potassium-sparing diuretic

Question 24

A patient is prescribed to receive a blood product STAT.

Which size of peripheral catheter should be inserted for this transfusion?

Answer 24

14-gauge

When rapid transfusion is required, a #14- to #18-gauge peripheral catheter is recommended

Question 25

A patient is experiencing excessive sweating, fever, and polyuria.

Which action should the nurse take?

Answer 25

Provide frequent mouth care.

Excessive sweating, fever, and polyuria can cause a fluid volume deficit. Frequent mouth care should be provided since dehydration can cause drying and stickiness of the oral mucous membranes.

Question 26

The nurse is reviewing a patient’s fluid intake.

Which food should the nurse include as part of fluid intake?

Answer 26

Ice cream

Question 27

A patient has a daily urine output of 1000 mL. Which action should the nurse take?

Answer 27

Encourage oral fluids.

Question 28

Which electrolyte is the biggest indicator of fluid change?

Answer 28

Sodium

Question 29

Which fluids are unbalanced?

Answer 29

Hypotonic and hypertonic

Question 30

Which fluid is balanced?

Answer 30

Isotonic

Question 31

HypOtonic fluid moves ____ of the cell

Answer 31

out

Question 32

HypErtonic fluid moves ___ the cell

Answer 32

into
(enters)

Question 33

How often do you change the dressing for an IV?

Answer 33

q24H (looking for phlebitis and infiltration)

Question 34

d5W is an isotonic solution that metabolizes in the body and turns into a _______ solution

Answer 34

hypotonic

Question 35

3% NS is which type of solution and given to which type of pts?

Answer 35

Hypertonic
Pts with low sodium (hyponatremia)

Question 36

1.5 NS or d5//1.5NS is which type of solution and is given to which type of pts?

Answer 36

Hypotonic
Pts with hypernatremia

Question 37

Pts with kidney or liver problems should not receive this solution

Answer 37

Lactated ringers (pt cannot break down lactate)