Chapter 42: Fluid, Electrolyte, and Acid-Base BalanceA patient has dehydration. While planning care, the nurse considers that the majority of the
... [Show More] patient’s total water volume exists in with compartment?The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing?The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient’s edema?The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift?A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access deviceThe nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant in the blood?The nurse receives the patient’s most recent blood work results. Which laboratory value is of greatest concern?The nurse observes that the patient’s calcium is elevated. When checking the phosphate level, what does the nurse expect to see?Four patients arrive at the emergency department at the same time. Which patient will the nurse see first?The patient has an intravenous (IV) line, and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve.A 2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child?A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect?In which patient will the nurse expect to see a positive Chvostek sign?A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient?A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel?The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis?The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first?A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is mostappropriate?The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients?A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan?A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare?A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching?The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement?The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient’s medical record?A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit?A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)?A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed?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 health care provider, which order does the nurse anticipate?A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient’s peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse’s initial action?.A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)?The nurse is caring for a group of patients. Which patient will the nurse see first?A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately?A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse?A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse’s next action?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. On which transfusion complication will the nurse focus interventions?A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain?The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient’s dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.Which assessments will alert the nurse that a patient IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touchA nurse is discontinuing a patient’s peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal. [Show Less]