Fluid, Electrolyte, and Acid-Base Balance 3

Question 1

venipuncture is:

Answer 1

a technique in which a vein is punctured through the skin by a sharp rigid stylet

Question 2

Electronic infusion pumps are necessary for:

Answer 2

IV pumps or infusion pumps, deliver an accurate hourly infusion rate

Question 3

Line maintenance involves:

Answer 3

A keeping the system sterile and intact
B changing the IV fluid containers, tubing, and contaminated site dressings
c assisting a pt with selfcare activities so as not to disrupt the system
D monitoring for complications of IV therapy

Question 4

The objectives for blood transfusions are:

Answer 4

a increasing circulation blood volume after surgery, trauma, or hemorrhage
b increasing the number of RBCs and maintaining hemoglobin levels in pts with severe anemia’s
c. providing selected cellular components as replacement therapy

Question 5

The ABO system includes:

Answer 5

identifies A, B, O, and AB blood

Question 6

The universal blood donor is:

Answer 6

type O blood

Question 7

The universal blood recipient is:

Answer 7

AB blood

Question 8

autologous transfusion

Answer 8

Is the collection and reinfusion of a pts own blood

Question 9

Acute intravascular hemolytic cause -

Answer 9

infusion of ABO incompatible whole blood, RBC’s or components containing 10 mL more of RBC; antibodies in recipient’s plasma attach to antigens on transfused RBC causing RBC destruction

Question 10

Acute intravascular hemolytic Clinical Manifestations -

Answer 10

chills, fever, low back pain, flushing, tachycardia, tachypnea, hypotension, hemoglobinuria, hemoglobinemia, sudden oliguria, circulatory shock, cardiac arrest, death

Question 11

Febrile, nonhemolytic causes -

Answer 11

antibodies against donor WBC

Question 12

Febrile, nonhemolytic Clinical Manifestations -

Answer 12

sudden shaking chills, fever, headache, flushing, anxiety, muscle pain

Question 13

Mild allergic causes

Answer 13

antibodies against donor plasma cells

Question 14

Mild allergic Clinical Manifestations

Answer 14

flushing, itching, urticaria (hives)

Question 15

Anaphylactic causes

Answer 15

antibodies to donor plasma, especially anti-IgA

Question 16

Anaphylactic Clinical Manifestations

Answer 16

anxiety, urticaria, dyspnea, wheezing, progressing to cyanosis, severe hypotension, circulatory shock, possible cardiac arrest

Question 17

Circulatory overload causes

Answer 17

blood administered faster than circulation can accumulate

Question 18

Circulatory overload Clinical Manifestations

Answer 18

dyspnea, cough, crackles, or rales in dependent portions of lungs; distended neck veins when upright

Question 19

Sepsis causes -

Answer 19

bacterial contamination of transfused blood components

Question 20

Sepsis Clinical Manifestations -

Answer 20

rapid onset of chills, high fever, severe hypotension and circulatory shock ( may occur: vomiting, diarrhea, sudden oliguria, DIC)

Question 21

List potential or actual nursing diagnoses for a patient with fluid, electrolyte, or acid-base imbalances.

Answer 21

decreased cardiac output, acute confusion, risk for electrolyte imbalance, deficient fluid volume, excess fluid volume, impaired gags exchange, risk for injury, deficient knowledge regarding disease management, impaired skin integrity, ineffective tissue perfusion

37. Restriction of fluids:
    pts who have hyponatremia usually require restricted water intake. Pt who have a very severe ECV excess sometimes have both sodium and fluid restrictions

Question 22

List three goals that are appropriate for a patient with deficient fluid volume.

Answer 22

a. the pt will be free of complications associated with the IV device throughout the duration of IV therapy
b. the pt will demonstrate balanced I&O measurements within 48 hours
c. the pt will have serum electrolytes within the normal range within 48 hours

Question 23

Enteral replacement of fluids:

Answer 23

oral replacement of fluids & electrolytes is appropriate as long as the patient is not so physiologically unstable that oral fluids cannot be replaced rapidly

Question 24

Restriction of fluids:

Answer 24

pts who have hyponatremia usually require restricted water intake. Pt who have a very severe ECV excess sometimes have both sodium and fluid restrictions

Question 25

Parenteral replacement of fluids and electrolytes:

Answer 25

fluid & electrolytes may be replaced through infusion of fluids directly into veins rather than via the digestive system

Question 26

Total parenteral nutrition:

Answer 26

: IV administration of a complex, highly concentrated solution containing nutrients and electrolytes that is formulated to meet a pts needs

Question 27

Intravenous (IV) therapy:

Answer 27

goal to correct or prevent fluid and electrolyte disturbances. It allows for direct access to the vascular system, permitting the continuous infusion of fluids over a period of time

Question 28

Vascular access devices:

Answer 28

cathetors or infusion ports designed for repeated access to the vascular system

Question 29

isotonic example

Answer 29

dextrose 5% in water, 0.9% sodium chloride, lactated ringer’s

Question 30

hypotonic example

Answer 30

0.225% sodium chloride, 0.45% sodium chloride

Question 31

hypertonic example

Answer 31

dextrose 10% in water, 3 or 5% sodium chloride, dextrose 5% in 0.45%NaCl, dextrose 5% in 0.9% NaCl, dextrose 5% in lactated ringers

Question 32

List the steps the nurse should follow if a transfusion reaction is suspected.

Answer 32

Stop infusion immediately. Keep IV line open by replacint IV tubing. Do not turn off the blood and simply turn on the normal saline. Immediately notify the MD. Remain with pt observing them. Prepare to administer emergency drugs. Prepare to perform CPR. Obtain blood and urine specimens.