Prep U Fluids and Electrolytes Flashcards
The nurse should ensure _______ when the client is to receive intravascular therapy for more than 6 days?
Peripherally inserted central catheter (PICC)
When the duration of intravascular therapy is likely to be more than 6 days, a midline catheter or peripherally inserted central catheter (PICC) is preferred to a short peripheral catheter. In adult clients, use of the femoral vein for central venous access should be avoided. Steel needles should be avoided when administering fluids and medications that might cause tissue necrosis if extravasation occurs.
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when he makes which statement?
“I sleep on three pillows each night.”
Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.
A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks’ gestation tells the nurse that she takes mineral oil for occasional constipation. The nurse should instruct the client to do?
Mineral oil is a harsh laxative that is contraindicated during pregnancy because it interferes with absorption of the fat-soluble vitamins A, D, E, and K from the intestinal tract. Dietary measures, exercise, and increased fluid and fiber intake are better choices to prevent constipation. If necessary, a stool softener or mild laxative may be prescribed. Use of fruit juice is recommended for the client receiving iron supplementation to enhance its absorption. Mineral oil does not lead to vitamin C deficiency in pregnant clients. Mineral oil use is contraindicated during pregnancy and therefore should not be used. Increased fluids, fiber, and exercise are better choices to suggest for relief of constipation. (less)
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?
Lactated Ringer’s solution
with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn’t give half-normal saline solution because it’s hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic. (less)
In a client with chronic bronchitis, which sign would lead the nurse to suspect right-sided heart failure?
Leg edema:
Right-sided heart failure is characterized by signs of circulatory congestion, such as leg edema, jugular vein distention, and hepatomegaly. Left-sided heart failure is characterized by circumoral cyanosis, crackles, and a productive cough.
A client must receive a blood transfusion of packed red blood cells (RBCs) for severe anemia. What I.V. fluid should the nurse use to prime the tubing before hanging this blood product?
Normal saline solution is used for administering blood transfusions. Lactated Ringer’s solution or dextrose solutions may cause blood clotting or RBC hemolysis. Current guidelines do not indicate a “no priming” method without NSS.
Which sign suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?
Jugular vein distention
SIADH secretion causes antidiuretic hormone overproduction, which leads to fluid retention. Severe SIADH can cause such complications as vascular fluid overload, signaled by jugular vein distention. This syndrome isn’t associated with tetanic contractions. It may cause weight gain and fluid retention (secondary to oliguria).
What is the primary goal of nursing care during the emergent phase after a burn injury?
Replace lost fluids.
During the emergent phase of burn care, one of the most significant problems is hypovolemic shock. The development of hypovolemic shock can lead to impaired blood flow through the heart and kidneys, resulting in decreased cardiac output and renal ischemia. Efforts are directed toward replacing lost fluids and preventing hypovolemic shock. Preventing infection and controlling pain are important goals, but preventing circulatory collapse is a higher priority. It is too early in the stage of burn injury to promote wound healing.
A client is brought to the emergency department with abdominal trauma following an automobile accident. Vital signs are as follows: HR 132, RR 28, BP 84/58, temp 97.0 (36.1 C), and oxygen saturation of 89% on room air. Which of the following orders from the health care provider should the nurse implement first?
Administer 1 liter 0.9% saline IV.
The client is demonstrating vital signs consistent with fluid volume deficit, likely from bleeding, hypovolemic shock, or both resulting from the automobile accident.
Because cervical effacement and dilation aren’t progressing in a client in labor, the physician orders I.V. administration of oxytocin. Why must the nurse monitor the client’s fluid intake and output closely during oxytocin administration?
Oxytocin causes water intoxication.
The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death.
After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the pediatrician if the neonate exhibits which of the following?
Passage of a liquid stool with a watery ring.
The mother demonstrates understanding of the discharge instructions when she says that she should contact the pediatrician if the baby has a liquid stool with a watery ring,
The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. The nurse should tell the client to drink:
At least 3,000 mL of fluids daily.
Instructions should be as specific as possible, and the nurse should avoid general statements such as “a lot.” A specific goal is most useful
A physician orders a loop diuretic for a client. When administering this drug, the nurse anticipates that the client may develop which electrolyte imbalance?
Hypokalemia
A loop diuretic removes water and, along with it, sodium and potassium. This may result in hypokalemia, hypovolemia, and hyponatremia.
Which type of solution raises serum osmolarity and pulls fluid from the intracellular and intrastitial compartments into the intravascular compartment?
Hypertonic
The osmolarity of a hypertonic solution is higher than that of serum. A hypertonic solution draws fluid into the intravascular compartment from the intracellular and interstitial compartments. An isotonic solution’s osmolarity is about equal to that of serum. It expands the intravascular and interstitial compartments. A hypotonic solution’s osmolarity is lower than serum’s. A hypotonic solution hydrates the intracellular and interstitial compartments by shifting fluid out of the intravascular compartment.
The client is to receive antibiotic intravenous (IV) therapy in the home. The nurse should develop a teaching plan to ensure that the client and family can manage the IV fluid and infusion correctly and avoid complications. The plan should include which of the following? Select all that apply.
Report signs of redness or inflammation at the site.
• Call the health care provider for a temperature above 100 degrees F (37.8 degrees C).
• Cleanse the port with alcohol.
After a total laryngectomy, the client has a feeding tube. The feeding tube is effective if the tube feedings:
Meet the fluid and nutritional needs of the client.
The goal of postoperative care is to maintain physiologic integrity. Therefore, inserting a feeding tube is a strategy to ensure the fluid and nutritional needs of the client
Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has lasted for 2 days. On assessment, the nurse detects dry mucous membranes and lethargy. What other finding suggests a fluid volume deficit?
A sunken fontanel
In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels, increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity.
A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?
Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition
A client is receiving total parenteral nutrition (TPN), and the nurse is concerned about the complication of fluid volume overload. Which of the following nursing actions is most appropriate in the administration of TPN to prevent this complication?
a) Weigh the client every day.
b) Reduce the ordered flow rate by half.
c) Continuously monitor the infusion rate.
d) Use an infusion pump to administer the TPN solution.
Use an infusion pump to administer the TPN solution.
Complications of TPN include fluid overload, electrolyte imbalances, infection, hyperglycemia and hypoglycemia, air embolism, and pneumothorax.
Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
Auscultation of moist crackles.
An early sign of circulatory overload is moist rales or crackles heard when auscultating over the chest wall. Elevated blood pressure, engorged neck veins, a wide variation between fluid intake and output (with a higher intake than output), shortness of breath, increased respiratory rate, dyspnea, and cyanosis occur later
A nurse is caring for a 3-year-old client with a neuroblastoma who has been receiving chemotherapy for the last 4 weeks. His laboratory test results indicate a Hgb of 12.5 g/dL (125 g/l), HCT of 36.8% (0.37), WBC of 2000 mm3 (2 X 109/l), and platelet count of 150,000 ul (150 X 109/l). Based on the child’s values, what is the highest priority nursing intervention?
Encourage meticulous handwashing by client and visitors.
A WBC of 2000 mm3 (2 X 109/l) is low and increases the child’s risk for infection. Meticulous handwashing is a standard/routine precaution and the first line of defense in combating infection. A platelet count of 150,000 ul (150 X 109/l) is within normal range, so there is no need to transfuse the child with platelets. Mouth care will help decrease the risk of infection; however, handwashing is the priority because it will have the greatest effects on diminishing the risk of infection. A Hgb of 12.5 g/dL (125 g/l) and a HCT of 36.8% (0.37) are within normal range so there is no need to transfuse packed red blood cells.
The nurse assesses the child with chronic renal failure who is receiving peritoneal dialysis for edema. Which finding is expected for this child?
Pallor.
With edema, pallor can occur owing to hemodilution as intestinal fluid moves to the vascular space. The child would exhibit pulmonary crackles secondary to pulmonary congestion .
A client reports vomiting every hour for the past 8 to 10 hours. The nurse should assess the client for risk of which of the following? Select all that apply:
Metabolic alkalosis
• Hypokalemia
Gastric acid contains a substantial amount of potassium, hydrogen ions, and chloride ions. Frequent vomiting can induce an excessive loss of these acids to alkalosis.
Which of the following foods should the nurse teach a client with heart failure to limit when following a 2-g sodium diet?
Tomato juice.
Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been remove .