Fluid, Electrolyte, and Acid-Base Balances

1.A nurse is caring for a patient who is suffering from kidney failure and is receiving peritoneal dialysis. The nurse explains that peritoneal dialysis works by instilling a solution into the abdomen that contains dextrose that will pull extra fluid into the abdominal cavity. What is the name of this process?

a.
Diffusion
b.
Osmosis
c.
Filtration
d.
Active transport

ANS: B

Osmosis is movement of water across a semipermeable membrane from a compartment of lower particle concentration to one that has a higher particle concentration. Diffusion is passive movement of electrolytes or other particles from an area of higher concentration to an area of lower concentration. In other words, the electrolytes move down their concentration gradient until the electrolyte concentration is equal in all areas. Electrolytes cannot diffuse across cell membranes unless the membranes have proteins that serve as ion channels. Filtration is the net effect of several forces that tend to move fluid across a membrane. Active transport is the energy-requiring movement of electrolytes or other substances across cell membranes against their concentration gradient (from an area of low concentration to an area of higher concentration).

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:465

OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

2.A patient has been admitted to the postsurgical nursing unit after surgery. The health care provider has ordered the patient to have an IV of 0.9% sodium chloride. The nurse who is caring for the patient recognizes this as what type of solution?

a.
Hypotonic
b.
Isotonic
c.
Hypertonic
d.
Hypnotic

ANS: B

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:465

OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

3.The patient is in a coma after a motor vehicle accident. In addition to IV medications, the patient is receiving an isotonic IV fluid. The primary purpose for this fluid infusion is to:

a.
cause cells to shrink and reduce swelling.
b.
move fluid from intravascular space into cells.
c.
pull fluid from cells into the intravascular space.
d.
expand the body’s intravascular fluid volume.

ANS: D

Fluids that have the same osmolality as normal blood are called isotonic. Intravenous (IV) solutions are hypertonic, isotonic, or hypotonic. Isotonic solutions such as 0.9% sodium chloride (same osmolality as normal blood) expand the body’s extracellular fluid volume without causing water to shift in or out of cells. Infusion of hypertonic intravenous solutions (more concentrated than normal blood), such as 3% sodium chloride, pulls fluid from cells by osmosis, causing them to shrink. Physiologically hypotonic solutions (less concentrated than normal blood after they are infused) move water from the extracellular compartment into the cells by osmosis, causing them to swell.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:465

OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

4.Two nursing students were having pizza one evening as they were studying. One student remarked that whenever she ate pizza, she was incredibly thirsty. The second student explained that this thirst was caused by:

a.
colloid osmotic pressure.
b.
osmoreceptors.
c.
oncotic pressure.
d.
hydrostatic pressure.

ANS: B

Thirst, a conscious desire for water, regulates fluid intake when plasma osmolality increases (osmoreceptor-mediated thirst) or the blood volume decreases (baroreceptor-mediated thirst and angiotensin II–mediated thirst). The thirst-control mechanism is in the hypothalamus of the brain. Osmoreceptors there continually monitor plasma osmolality; when osmolality increases, the hypothalamus stimulates thirst. Colloid osmotic pressure (oncotic pressure) is an inward-pulling force caused by the presence of protein molecules. Hydrostatic pressure is the force of a fluid pressing outward against the walls of its container. Thus capillary hydrostatic pressure is an outward-pushing force.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:465 | 466

OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

5.A 7-year-old patient was admitted to the hospital with a high fever. The nurse caring for the child knows that the child has increased insensible water loss resulting from the fever and should receive additional water to prevent hypernatremia. Insensible water loss occurs through which organ?

a.
Kidneys
b.
GI tract
c.
Skin
d.
Stomach

ANS: C

Fluid output normally occurs through four organs: the skin, lungs, GI tract, and kidneysInsensible water loss is not visible; it is continuous and occurs through the skin and lungs. Output of insensible water also increases with fever. Visible perspiration (sweat) is secreted by the sweat glands. The GI tract plays a vital role in fluid balance. Approximately 3 to 6 L of fluid move into the GI tract daily and return again to the ECF. However, diarrhea causes a large fluid output from the GI tract. The kidneys are the major regulator of fluid output because they respond to hormones that influence urine production. When healthy people drink more water, they make a larger urine volume to maintain fluid balance. In patient situations, fluid loss occurs abnormally, such as through vomiting (stomach), wound drainage, and hemorrhage.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:466

OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

6.A patient presents to the emergency department complaining of increased urine output. The patient has been drinking alcohol and is still visibly impaired. He is aware of his condition and apologizes, stating that he has never gotten drunk before and if he survives he never will again, but he knows that if he drinks too much he will lose potassium and die. The nurse realizes that the patient is dealing with:

a.
antidiuretic hormone (ADH) suppression.
b.
ADH stimulation.
c.
insensible water loss.
d.
angiotensin II release.

ANS: A

Ethyl alcohol decreases ADH release, which is why people urinate frequently when they drink alcoholic beverages. Antidiuretic hormone acts on the kidneys, causing them to reabsorb water. With ADH stimulation a patient will experience a decrease in urinary output; volume is returned to systemic circulation, diluting the blood and decreasing osmolarity. Insensible water loss is continuous and nonperceptual. Lungs expire water daily through respiration. Angiotensin II causes vasoconstriction of many blood vessels, which helps regulate blood pressure, and it stimulates the release of aldosterone, which assists fluid homeostasis.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:466

OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

7.The body’s fluid and electrolyte balance is maintained partially by hormonal regulation. The nurse conveys an understanding of this mechanism in which statement?

a.
“The pituitary gland secretes aldosterone.”
b.
“The kidney secretes antidiuretic hormone.”
c.
“The adrenal cortex secretes antidiuretic hormone.”
d.
“The pituitary gland secretes antidiuretic hormone.”

ANS: D

The hypothalamus controls release of ADH from the posterior pituitary gland. Antidiuretic hormone circulates to the kidneys, where it acts on the collecting ducts, causing them to reabsorb water. The adrenal cortex releases aldosterone in response to increased plasma potassium concentration or as the end product of the renin-angiotensin-aldosterone system (RAAS).

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:466

OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

8.A 15-year-old patient suffered a head injury as the result of a bicycle accident. The nurse is concerned about potential fluid complications caused by the injury. What should the nurse monitor most closely?

a.
Aldosterone release
b.
Urine output
c.
Renin release
d.
Body temperature

ANS: B

Antidiuretic hormone regulates osmolality of body fluids by influencing how much water is excreted in urine. The hypothalamus controls release of ADH from the posterior pituitary gland. Head injury may cause altered urine output by injuring the hypothalamus or pituitary. A head injury would not involve the adrenal gland. The adrenal cortex releases aldosterone in response to increased plasma potassium concentration or as the end product of the renin-angiotensin-aldosterone system (RAAS). Renin, released by the kidneys, acts on the inactive protein angiotensinogen to produce angiotensin I. Other enzymes in the lung capillaries convert to angiotensin II. Again, there is no direct correlation to head injury. Body temperature does not reflect fluid imbalance directly.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:466

OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9.The patient is taking furosemide (Lasix) and has been complaining of muscle weakness. The nurse should be most concerned about which imbalance?

a.
Hyponatremia
b.
Hypokalemia
c.
Hypochloremia
d.
Hyperchloremia

ANS: B

Hypokalemia causes muscle weakness and if severe, cardiac dysrhythmias. Sodium concentration imbalances really are water imbalances. With hyponatremia, water enters cells by osmosis, causing them to swell. Signs of cerebral dysfunction occur when brain cells swell. Hypochloremia always occurs with other imbalances and has no unique signs and symptoms. Hyperchloremia is abnormally high blood chloride level, which occurs with some types of acidosis, some renal conditions, and other electrolyte imbalances. It also has no unique signs and symptoms.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:468

OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

10.The patient is on a ventilator. The health care provider has indicated concern about the patient’s acid-base status. The nurse anticipates that the health care provider will determine the acid-base levels via:

a.
PaO2 measurement.
b.
SaO2 levels.
c.
chloride levels.
d.
arterial blood gas analysis.

ANS: D

Arterial blood gas (ABG) analysis is an effective method of evaluating acid-base balance and oxygenation. PaO2 is the partial pressure of oxygen in arterial blood. When PaO2 is within normal range, it has no primary role in acid-base regulation. SaO2 is the percentage of hemoglobin molecules that are carrying as much oxygen as is possible (saturated). SaO2, however, has no direct effect on acid-base balance. Hypochloremia is abnormally low blood chloride level. Hyperchloremia is an abnormally high blood chloride level, which occurs with some types of acidosis, some renal conditions, and other electrolyte imbalances. Neither has unique signs and symptoms.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:468 | 471

OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

11.A 76-year-old patient is hospitalized with pneumonia and has become increasingly confused throughout the shift. The nurse becomes concerned about the patient’s condition and contacts the health care provider, who orders arterial blood gas analysis. The blood gas report shows a pH of 7.33, PaCO2 of 47, PaO2 of 78, and bicarbonate of 26. This indicates which imbalance?

a.
Respiratory alkalosis
b.
Respiratory acidosis
c.
Metabolic alkalosis
d.
Metabolic acidosis

ANS: B

Normal arterial blood pH value is 7.35 to 7.45 (acidic is less than 7.35, and alkalotic is greater than 7.45). Respiratory acidosis is an increased PaCO2 and an increased hydrogen ion concentration (pH below 7.35) that reflect the excess carbonic acid (H2CO3) in the blood. Hypoventilation produces respiratory acidosis, which causes the cerebrospinal fluid and brain cells to become acidic, thus decreasing the level of consciousness. Respiratory alkalosis is a decreased PaCO2 and increased pH (above 7.45) that reflect the deficit of carbonic acid (H2CO3) in the blood. Metabolic acidosis results from conditions that increase metabolic acids in the body or decrease the amount of base (bicarbonate). The bicarbonate level is always low because the bicarbonate system buffers metabolic acids. Metabolic alkalosis results from a gain of bicarbonate or excessive excretion of metabolic acid.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 468 | 471 OBJ: Describe common fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

12.A college freshman has bulimia. She vomits after eating and has recently noticed tingling of her fingers and toes and muscle cramps. Her roommate is a nursing student and is concerned about which imbalance?

a.
Respiratory acidosis
b.
Metabolic acidosis
c.
Respiratory alkalosis
d.
Metabolic alkalosis

ANS: D

Metabolic alkalosis results from acid loss from the body or an increase in levels of bicarbonate. The most common causes are vomiting and gastric suction. Respiratory acidosis results from respiratory diseases or other conditions that reduce alveolar ventilation (hypoventilation), preventing excretion of the carbonic acid continuously produced by cells. Metabolic acidosis results from conditions that increase metabolic acids in the body or decrease the amount of base (bicarbonate). Diabetic ketoacidosis is a common cause of metabolic acidosis. Hyperventilation produces respiratory alkalosis, which causes cerebrospinal fluid and brain cells to become alkalotic, decreasing the level of consciousness.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 468 | 471 OBJ: Describe common fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

13.A patient’s arterial blood gas levels indicate a pH of 7.51, PaCO2 of 40 mm Hg, PaO2 of 85 mm Hg, and HCO3 of 32 mEq/L. The patient has been vomiting. The nurse knows the patient has which imbalance?

a.
Metabolic acidosis
b.
Metabolic alkalosis
c.
Respiratory acidosis
d.
Respiratory alkalosis

ANS: B

Normal arterial blood pH value is 7.35 to 7.45 (acidic is less than 7.35, and alkalotic is greater than 7.45). Metabolic alkalosis results from acid loss from the body or an increase in levels of bicarbonate. Normal range of bicarbonate (HCO3–) is 22 to 26 mEq/L. A level above 26 mEq/L indicates metabolic alkalosis. The most common causes are vomiting and gastric suction. Metabolic acidosis results from conditions that increase metabolic acids in the body or decrease the amount of base (bicarbonate). Diabetic ketoacidosis is a common cause of metabolic acidosis. Hypoventilation produces respiratory acidosis, which causes cerebrospinal fluid and brain cells to become acidic, thus decreasing the level of consciousness. Hyperventilation produces respiratory alkalosis, which causes cerebrospinal fluid and brain cells to become alkalotic, decreasing the level of consciousness.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 468 | 471 OBJ: Describe common fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

14.Which patient has the greatest risk for ECV deficit?

a.
A 4-month-old infant with fever and vomiting
b.
A 17-year-old adolescent with acute appendicitis
c.
A 28-year-old woman with Crohn’s disease
d.
A 63-year-old man with peptic ulcer disease

ANS: A

Fever increases insensible water loss through the skin and lungs. Infants and very young children have relatively more body surface area and higher percentage of body water than older children and adults. They have greater water needs and immature kidneys. Infants are at greater risk for ECV deficit and hypernatremia because their body water loss is proportionately greater per kilogram of weight. Although acute appendicitis may cause vomiting and an active episode of Crohn’s disease may cause diarrhea, adolescents and young adults have less risk of ECV deficit than an infant. An older adult has increased risk of ECV deficit if there is a large fluid output; however, peptic ulcer disease ordinarily does not cause a large fluid output.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:473

OBJ: Discuss risk factors for fluid, electrolyte, and acid-base imbalances.

TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

15.A patient has heart failure. The patient’s medications include an angiotensin-converting enzyme (ACE) inhibitor, a beta blocker, and a diuretic. To keep the patient safe, the nurse should:

a.
weigh the patient daily using different scales for comparison.
b.
monitor daily weight, comparing with the previous day’s weight.
c.
teach that daily weights are done in hospitals, but not at home.
d.
weigh the patient at different times of the day to determine trends.

ANS: B

Daily weights are an important indicator of fluid status. Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid gained or lost. Weigh heart failure patients daily, as well as other patients who are at high risk for or actually have ECV excess. Obtain the weight at the same time each day with the same calibrated scale after a patient voids. Teach heart failure patients to take and record daily weights at home and to contact their health care provider if weight increases suddenly according to parameters their providers set. Classic research shows that heart failure patients who are hospitalized for decompensated heart failure often experience steady increases in daily weights during the week before hospitalization.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:474

OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

16.Which measurement can the nurse delegate to nursing assistive personnel?

a.
Oral fluid intake
b.
Intravenous fluid intake
c.
Tube drainage output
d.
Nasogastric tube intake

ANS: A

You can delegate portions of I&O measurement to nursing assistive personnel (NAP). In many agencies, NAP can record oral intake but not intake through tubes or IVs and can record urine, diarrhea, and vomitus output, but not drainage through tubes.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:477

OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

17.A 27-year-old patient has seen a health care provider at the local clinic because he has had diarrhea for the past week. The health care provider instructed the patient to drink plenty of fluids, and the nurse clarifies these instructions by advising him to avoid which item as long as he has diarrhea?

a.
Ice chips
b.
Pedialyte
c.
Coffee
d.
Tap water

ANS: C

When replacing fluids by mouth in a patient with ECV deficit, choose fluids that contain Na+(e.g., Pedialyte and Gastrolyte). Liquids containing lactose, caffeine, or low Na+ content are not appropriate when a patient has diarrhea. Strategies to encourage fluid intake include offering small sips of fluid frequently, popsicles, and ice chips.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:481

OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

18.A patient has recently been diagnosed with heart failure and has been put on a low sodium diet in the hospital. In addition, the patient has a fluid restriction. The nurse should suggest that half the total oral fluid allotment occur between which two times?

a.
7 AM; 7 PM
b.
3 AM; 3 PM
c.
7 AM; 3 PM
d.
3 PM; 7 AM

ANS: C

In acute care settings, fluid restrictions often allot half the oral fluids between 7 AM and 3 PM, the period when patients usually are more active, receive two meals, and take most of their oral medications. Offer the remainder of the fluid allowance during the evening and night shifts.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:482

OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

19.The patient is unable to eat and there are no bowel sounds, indicating that his bowels are not functioning. The best approach to providing nourishment would be:

a.
intravenous crystalloids.
b.
blood product administration.
c.
parenteral nutrition (PN).
d.
colloid administration.

ANS: C

Parenteral nutrition (PN) is a nutritionally adequate solution consisting of glucose, other nutrients, and electrolytes administered through a central venous catheter. This intervention meets nutritional needs when the GI tract is nonfunctional. Fluid and electrolytes may be replaced through infusion of fluids intravenously (IV), meaning directly into veins. Parenteral replacement includes PN, IV fluid and electrolyte therapy (crystalloids), and blood product (colloids) administration. The goal of IV fluid administration is to correct or prevent fluid and electrolyte disturbances.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:482

OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

20.The nurse works on the cardiac unit of a hospital. The health care provider has ordered 20 mEq of KCl per L to be added to the fluids that the patient is receiving. The patient currently has a bag of D5W IV fluid infusing. Which action is most appropriate?

a.
Administer 20 mEq KCl diluted in 5 mL of fluid by IV push in 5 minutes.
b.
Estimate the amount of fluid in the IV bag and add KCl to equal 20 mEq/L.
c.
Give the KCl undiluted by IV push in 5 minutes for the most rapid action.
d.
Check the patient’s potassium level before hanging the new IV solution.

ANS: D

Remember that failure to verify that a patient has adequate renal function and urine output before administering an IV solution containing potassium could cause hyperkalemia. Under no circumstances should KCl be given in an IV push. A direct IV infusion of KCl may be fatal. Intravenous administration of KCl requires dilution in solution and infusion slowly over a period of time. In most hospitals, nurses do not add KCl to IV bags. Usually a pharmacist prepares the solution.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:483

OBJ: Discuss appropriate nursing interventions for patients with fluid, electrolyte, and acid-base imbalances. TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

21.A 15-year-old adolescent has been recently diagnosed with cancer. The patient will be receiving IV chemotherapy for several weeks. Which vascular access device should be used for short-term administration of his IV fluid?

a.
Implanted port
b.
Peripherally placed IV catheter
c.
Central line
d.
Peripherally inserted central catheter

ANS: B

Peripheral catheters are for short-term use (e.g., to restore fluid volume). Devices for long-term use include central lines, peripherally inserted central catheters (PICCs), and implanted ports. These devices are more effective than peripheral catheters for administering PN and medications and solutions that are irritating to veins.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:482 | 483

OBJ:Describe purpose and procedures for initiation and maintenance of intravenous therapy.TOP:Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

22.The nurse is caring for an 84-year-old patient who gets hemodialysis 3 days a week. He is taking corticosteroids and has multiple bruises on his extremities. The patient needs an IV started. When starting the IV, the nurse should:

a.
attempt to start the IV in the dorsum of the patient’s hand.
b.
avoid areas of skin that are red and warm to the touch.
c.
use the arm on the side of the patient’s dialysis fistula.
d.
start the IV in the patient’s foot after patient teaching.

ANS: B

When assessing patients for potential venipuncture sites, consider conditions that exclude certain sites. For example, because older adults and patients receiving corticosteroids have fragile veins, avoid sites that are easily bumped or moved, such as the dorsal surface of the hand. Venipuncture is contraindicated in a site that has signs of inflammation, infiltration, or thrombosis. An infected site is red, tender, swollen, and possibly warm to the touch. Avoid using an extremity with a vascular (dialysis) graft or fistula or on the same side as a mastectomy (breast surgery). Intravenous insertion in a foot vein is used with children but should be avoided in adults because of the danger of thrombophlebitis.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:483 | 484

OBJ:Describe the purpose and procedures for initiation and maintenance of intravenous therapy.TOP:Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

23.A nurse is mentoring a new nurse who is learning to start IVs. The nurse tells the new nurse that in case the patient needs subsequent venipuncture sites, the best place to initially start an IV is the:

a.
antecubital vein of the patient’s nondominant arm.
b.
most appropriate distal vein on the nondominant arm.
c.
most appropriate proximal vein available on either arm.
d.
antecubital vein of the patient’s dominant arm.

ANS: B

Initially place IV catheters at the most distal point, which allows for the use of proximal sites later if the patient needs a venipuncture site change (INS, 2011). Use the most distal site in the nondominant arm, if possible. Vascular access device placement in the dominant arm interferes with activities of daily living.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:483 | 484 | 497

OBJ:Describe purpose and procedures for initiation and maintenance of intravenous therapy.TOP:Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

24.During a clinical rotation at an orthopedic unit, a nursing student is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site. The nursing student assesses the site and finds that the site is cool and pale. The student stops the IV and reports the situation to the nurse. What does the nursing student suspect?

a.
Phlebitis
b.
Infiltration
c.
Thrombophlebitis
d.
Local inflammation

ANS: B

An infiltration occurs when IV fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein. Infiltration causes swelling (from increased interstitial fluid), paleness, and coolness (from decreased circulation) around the venipuncture site. The IV infusion may slow or stop. Pain may occur, increasing as the infiltration progresses. Phlebitis is inflammation of a vein. Signs and symptoms include redness, tenderness, and warmth along the course of the vein starting at the access site, with possibly a red streak and/or palpable cord along the vein. Phlebitis can be dangerous because blood clots (thrombophlebitis) can form, increasing the risk for an embolus, a clot that becomes dislodged and can travel to the lungs. Local infection at the VAD site is possible. The insertion site will be red and/or edematous; exudate may occur.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:487 | 488

OBJ: Discuss complications of intravenous therapy and what to do if they occur.

TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity

25.When a nurse is selecting a vein for IV placement, what is the most appropriate action?

a.
Select a vein that appears to be well dilated.
b.
Elevate the extremity to visualize the vein.
c.
Tap and rub the vein vigorously with friction.
d.
Stroke from proximal to distal above the site.

ANS: A

Use the most distal site in the nondominant arm, if possible. Select a well-dilated vein. Methods to foster venous distention include place the extremity in a dependent position if possible and stroke from distal to proximal below the proposed venipuncture site. Apply warmth to the extremity for several minutes, for example, with a warm washcloth. Vigorous friction and multiple tapping of a vein, especially in older adults, can cause hematoma and/or venous constriction. Avoid vein selection in areas with tenderness, pain, infection, or wounds, or extremities affected by previous stroke (CVA), paralysis, mastectomy, or dialysis graft. Choose a site that will not interfere with the patient’s activities of daily living (ADLs).

PTS:1DIF:Cognitive Level: Applying (Application)

REF:497 | 498

OBJ:Describe the purpose and procedures for initiation and maintenance of intravenous therapy.TOP:Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

26.The nurse suspects that the patient is experiencing a blood transfusion reaction. The nurse stops the infusion but is concerned about losing the IV line if blood clots in the catheter. The nurse should:

a.
replace the entire transfusion line with a new set primed with normal saline.
b.
turn off the blood and turn on the normal saline infusion to flush the tubing.
c.
discontinue the IV and start a new IV of lactated Ringer’s in the other extremity.
d.
maintain the patency of the current IV line by hanging a new IV bag of D5W.

ANS: A

Remove the blood component and tubing containing the blood product. Replace them with new primed tubing with a container of 0.9% sodium chloride (normal saline). Connect tubing to hub of IV catheter. Do not turn off the blood and simply turn on the 0.9% sodium chloride (normal saline) that is connected to the Y-tubing infusion set. This would cause blood remaining in the Y-tubing to infuse into the patient. Even a small amount of mismatched blood can cause a major reaction. Keep the IV site in case it becomes difficult to start another. Maintain a patent IV line using 0.9% normal saline.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:489

OBJ:Describe the procedure for initiating a blood transfusion and complications of blood therapy.TOP:Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

SHORT ANSWER

1.A patient is diagnosed with renal insufficiency. The results of an ABG analysis indicate metabolic acidosis. In metabolic acidosis, the nurse would expect the pH to decrease to less than _____ and the bicarbonate level to decrease to less than _____.

ANS:

7.35; 22

The normal arterial blood pH value is 7.35 to 7.45 (acidic is less than 7.35, and alkalotic is greater than 7.45). The normal range of bicarbonate (HCO3–) is 22 to 26 mEq/L. Levels below 22 mEq/L usually indicate metabolic acidosis.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:471

OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Diagnosis

MSC: NCLEX: Physiological Integrity

2.Yesterday morning the patient weighed 169.4 lb (77 kg). This morning the patient weighs 171.6 lb (78 kg). The nurse determines that the patient has gained _____ liter(s) of fluid.

ANS:

Each kilogram (2.2 lb) of weight gained or lost overnight is equal to 1 L of fluid gained or lost.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:474

OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1.A nurse is caring for a patient after a bowel resection. The nurse plans assessment based on the knowledge that body fluids maintain balance through homeostasis, which includes what processes? (Select all that apply.)

a.
Fluid intake
b.
Fluid distribution
c.
Fluid output
d.
Fluid catabolism

ANS: A, B, C

Fluid homeostasis is the dynamic interplay of three processes: fluid intake and absorption, fluid distribution, and fluid output. Our daily fluid output consists of hypotonic sodium-containing fluid. To maintain fluid balance, we must have an intake of an equivalent amount of hypotonic sodium-containing fluid (water plus foods with some salt). Fluid is not catabolized (broken down into components to release energy) in the body.

PTS: 1 DIF: Cognitive Level: Understanding (Comprehension)

REF:466

OBJ: Describe basic physiological mechanisms responsible for maintaining fluid, electrolyte, and acid-base balances. TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

2.The nurse is working for a medical unit in a hospital. The nurse is responsible for obtaining intake and output measurements for patients. What items should be considered intake? (Select all that apply.)

a.
Gelatin eaten as a snack or for lunch or dinner
b.
Water used to flush tubing between jejunostomy feedings
c.
Amount of fluid contained in the gastric suction container
d.
Volume of the blood components that were given IV
e.
Volume of the postsurgical wound drainage

ANS: A, B, D

Fluid intake includes all liquids that a person eats (e.g., gelatin, ice cream, broth), drinks (e.g., juice, coffee, tea, water), or receives through nasogastric or jejunostomy feeding tubes. Intravenous fluids (continuous and intermittent) and blood components also count as intake. A patient receiving tube feedings may receive numerous liquid medications; water will be used to flush the tube before and/or after the medications. Liquid output includes urine, diarrhea, vomitus, gastric suction, and blood and drainage from postsurgical wounds, burns, or other tubes.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:474 | 476

OBJ:Identify appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.TOP:Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

3.A patient has a peripheral IV. The nurse should assess the IV site for what primary signs and symptoms of infiltration? (Select all that apply.)

a.
Redness
b.
Swelling
c.
Pallor
d.
Warmth
e.
Red streaks

ANS: B, C

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:487

OBJ: Discuss complications of intravenous therapy and what to do if they occur.

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4.A patient complains of chills, dizziness, and feeling hot during a blood transfusion. What are the nurse’s most appropriate actions? (Select all that apply.)

a.
Check the patient’s vital signs.
b.
Stop the blood transfusion.
c.
Slow the rate of infusion.
d.
Notify the physician and blood bank.

ANS: A, B, D

STOP (do not slow down) the transfusion immediately even when you just suspect a reaction. Remain with the patient, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Immediately notify the health care provider or emergency response team and the blood bank.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:489

OBJ:Describe the procedure for initiating a blood transfusion and complications of blood therapy.TOP:Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity