Question 1

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?

Accepted Answer

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.

Question 2

A patient had an acute intravascular hemolytic reaction to a blood transfusion.After discontinuing the blood transfusion,what is the nurse's next action?

Accepted Answer

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 existing 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 patient has been assessed and stabilized,the blood can be returned to the blood bank.

Question 3

A nurse has just received a bag of packed red blood cells.The nurse knows that the blood must not remain at room temperature for longer than

Accepted Answer

Blood should be allowed to sit at room temperature for a maximum of 4 hours.After 4 hours,risk of bacterial contamination of the blood is increased.

Question 4

A nurse is preparing to administer a blood transfusion.Which assessment finding would the nurse report immediately?

Accepted Answer

A fever should be reported immediately,and the blood transfusion may be postponed.All other assessment findings are acceptable before starting a blood transfusion.

Question 5

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 150 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?

Accepted Answer

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.

Question 6

The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has

Accepted Answer

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.

Question 7

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?

Accepted Answer

The IV site has phlebitis.The nurse should start a new IV before discontinuing the old one because 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.

Question 8

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?

Accepted Answer

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 peripheral catheter would not be necessary or heparin locked.An implanted port catheter is intended for long-term use of venous access over months,or even years.

Question 9

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?

Accepted Answer

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.

Question 10

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?

Accepted Answer

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.

Question 11

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

Accepted Answer

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.

Question 12

The nurse is caring for a patient with hyperkalemia.Which body system would be most important for the nurse plan to monitor closely?

Accepted Answer

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.

Question 13

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

Accepted Answer

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.

Question 14

The nurse knows that intravenous fluid therapy has been effective for a patient with hypernatremia when

Accepted Answer

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.

Question 15

Which assessment finding should cause a nurse to question administering a sodium-containing isotonic intravenous fluid?

Accepted Answer

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.

Question 16

The nurse would select the dorsal venous plexus of the foot as an IV site for which patient?

Accepted Answer

Use of the foot as an IV site is common in children but is avoided in adults because of the risk for thrombophlebitis.

Question 17

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?

Accepted Answer

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.

Question 18

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)?

Accepted Answer

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.

Question 19

Which fluid order should the nurse question for a patient with a traumatic brain injury?

Accepted Answer

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 solutions 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.

Question 20

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?

Accepted Answer

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.

Quiz 89: Fluid, electrolyte, and Acid-Base Balance