Fluid Electrolyte and Acid Base Balance (Pearson)_Key highlights Flashcards
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?
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. )
The nurse prepares teaching materials for a community health fair.
Which information should be included about obesity?
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.)
The nurse is preparing a blood product to transfuse into a patient.
Which action should the nurse take after priming the tubing?
Start the saline solution. (After priming the tubing, the saline solution should be started to clear the intravenous catheter of incompatible solutions or medications. )
A patient who is dehydrated is prescribed an intravenous infusion of 5% dextrose and lactated Ringer’s solution.
Which action should the nurse take?
Question the prescription.
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?
The patient is Rh negative and received Rh positive blood.
The nurse assesses a patient with a fluid and electrolyte imbalance.
For which health problem should the nurse provide frequent mouth care?
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)
A patient is diagnosed with hyponatremia.
Which finding should the nurse expect when assessing this patient?
Muscle twitching (Hyponatremia, or a sodium deficit, causes muscle twitching because sodium is required for muscle contraction)
The nurse evaluates serum potassium levels for assigned patients.
Which value should the nurse report to the healthcare provider?
2.5 mEq/L
(potassium level of 2.5 mEq/L indicates hypokalemia and should be reported to the healthcare provider.)
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?
Monitor for an adverse reaction
A patient is receiving an infusion of normal saline after receiving a blood product.
For which potential health problem should the patient be monitored?
Delayed infusion reaction (Normal saline is often infused while the patient is monitored for a delayed reaction to the blood)
The nurse is asked to explain fluid balance.
Which concept should be included in the response?
Intracellular fluid maintains cell metabolism. (Intracellular fluid provides a medium in which metabolic processes of the cell take place. )
A patient receives a blood product.
Which action should the nurse take when monitoring the patient for a delayed transfusion reaction?
Infuse normal saline.
For which reason should a patient be denied donating blood?
Low body weight
The nurse is creating a plan of care for a patient with hypomagnesemia.
Which food should the nurse encourage in the patient’s diet?
Tuna (Tuna is high in magnesium and should be encouraged in a patient with a magnesium deficiency.)
The nurse assists with the insertion of a central vascular access device into a patient.
Which information should be included in the documentation?
Device brand (The brand of the device should be documented in case the patient experiences future problems. )
A patient is receiving an intravenous infusion of lactated Ringer’s. For which symptoms should the patient be monitored?
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)
A patient is prescribed phenhydramine when receiving a blood product.
At which time should the nurse administer the medication?
30 minutes prior
Premedication prescribed by the healthcare provider, such as phenhydramine, should be administered 30 minutes prior to the transfusion.
The skin on a patient’s sternum remains tented for several seconds after being lightly pinched.
Which additional assessment finding should the nurse expect?
Dry mucous membranes
The nurse is caring for a patient with a traumatic brain injury. Which type of solution should be avoided?
Dextrose 5% and water (D5W)
D5W is avoided in a patient at risk for increased intracranial pressure (IICP) because it can increase cerebral edema.
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?
Type O
A patient needs an intravenous access device inserted.
Which veins should be avoided?
Highly visible
Highly visible veins tend to roll away from the needle and should be avoided when inserting an intravenous access device.
The nurse reviews daily urine output values for assigned patients.
For which patient output should oral fluids be encouraged?
1200 mL
A patient is prescribed a potassium-sparing diuretic.
Which food should be removed from the patient’s meal tray?
Banana
Bananas are high in potassium and should be avoided when taking a potassium-sparing diuretic
A patient is prescribed to receive a blood product STAT.
Which size of peripheral catheter should be inserted for this transfusion?
14-gauge
When rapid transfusion is required, a #14- to #18-gauge peripheral catheter is recommended
A patient is experiencing excessive sweating, fever, and polyuria.
Which action should the nurse take?
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.
The nurse is reviewing a patient’s fluid intake.
Which food should the nurse include as part of fluid intake?
Ice cream
A patient has a daily urine output of 1000 mL. Which action should the nurse take?
Encourage oral fluids.
Which electrolyte is the biggest indicator of fluid change?
Sodium
Which fluids are unbalanced?
Hypotonic and hypertonic
Which fluid is balanced?
Isotonic
HypOtonic fluid moves ____ of the cell
out
HypErtonic fluid moves ___ the cell
into
(enters)
How often do you change the dressing for an IV?
q24H (looking for phlebitis and infiltration)
d5W is an isotonic solution that metabolizes in the body and turns into a _______ solution
hypotonic
3% NS is which type of solution and given to which type of pts?
Hypertonic
Pts with low sodium (hyponatremia)
1.5 NS or d5//1.5NS is which type of solution and is given to which type of pts?
Hypotonic
Pts with hypernatremia
Pts with kidney or liver problems should not receive this solution
Lactated ringers (pt cannot break down lactate)
