Fluid Balance-Evolve – Flashcards
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The nurse plans to assess Clara for orthostatic vital sign changes. What action will the nurse take first? a. Assist Clara to a standing position. b. Position Clara in a supine position. c. Elevate the head of Clara's bed. d. Dangle Clara's feet at the bedside.
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b. Position Clara in a supine position. Orthostatic vital signs are measured in each position: lying, sitting, and standing. The client's vital signs are first assessed in the supine position so that changes that occur when the client sits and stands can be determined. During orthostatic vital sign measurement the client should be placed in another position (a). The client is assisted to a sitting position after vital signs are first measured in another position (c & d).
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The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take? a. Count the client's radial pulse rate. b. Remove the blood pressure cuff. c. Help the client change positions. d. Assess for an auscultatory gap.
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a. Count the client's radial pulse rate. Both the blood pressure and pulse rate are typically measured in each position: lying, sitting, and standing. After the blood pressure cuff is deflated, it is left in the same position on the same arm for all three blood pressure readings (b). Another action should be taken before assisting the client to change positions (c). Assessment for an auscultatory gap is done while the blood pressure measurement is being taken (d).
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Since Clara has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Clara moves from a lying to a standing position? a. Respiratory rate. b. Blood pressure. c. Temperature. d. Pulse rate.
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b. Blood pressure. Fluid volume deficit often causes orthostatic hypotension and tachycardia. Because the client may experience dizziness with orthostatic hypotension, the nurse should take additional safety precautions during this assessment. Respiratory rate and temperature is unlikely to be affected by a change in position. The client's pulse rate is likely to increase upon standing in response to a change in another vital sign.
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In addition to obtaining Clara's vital signs, the nurse performs additional assessments. For ongoing evaluation of Clara's fluid volume status, it is most important to obtain which assessment data? a. Urine color. b. Capillary refill. c. Body weight. d. Skin turgor.
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c. Body weight. Daily weights provide the most important data about fluid volume status, so an initial weight upon admission must be obtained. (a) provides valuable assessment data related to fluid volume, (b) provides valuable assessment data regarding adequacy of tissue perfusion that may be impacted by fluid volume, and (d) provides valuable assessment data related to fluid volume but are not the most important assessment related to fluid volume. (d) provides valuable assessment data related to fluid volume but isn't the most important data for ongoing evaluation of fluid volume.
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The nurse continues to assess the client and observes that Clara's skin tents when a fold of skin over her sternum is pinched. What action should the nurse implement? a. Confirm this finding by pinching the skin on her hand. b. Notify the healthcare provider that the client is now retaining fluid. c. Advise Clara that the fluid deficit seems to be worsening. d. Document the presence of inelastic skin turgor.
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d. Document the presence of inelastic skin turgor. Skin turgor is best assessed in the elderly by gently pinching a fold of skin over the sternum. Inelastic turgor is an expected finding in a client with fluid volume deficit. Additional findings may include weakness, confusion, and tachycardia. The elderly frequently experience inelastic skin turgor of the hands, so this is not a valuable indicator of fluid volume status (a). Tenting is not a sign of fluid retention (b). Tenting is an expected finding in a client with fluid volume deficit (c).
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Clara's daughter reports that her mother usually weighs about 150 lbs. and is 5 feet, 4 inches in height. The nurse weighs Clara and obtains a measurement of 65 kg. The nurse explains to Clara's daughter that Clara has lost approximately how many pounds? a. 3. b. 5. c. 7. d. 9.
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c. 7. 65 kg × 2.2 = 143 lbs. 150 lbs. - 143 lbs. = 7 lbs. This represents an approximate weight loss of 7 pounds.
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The nurse then explains that Clara's weight loss represents approximately how many liters of fluid loss? a. 2 b. 3 c. 4 d. 5
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b. 3 7/2.2 = 3.2 kg. Each kilogram of body weight lost or gained is equivalent to approximately 1 liter of fluid.
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The nurse discusses factors that contributed to Clara's fluid volume deficit with Clara and her daughter. Which problem often occurs in the elderly and may have contributed to the fluid volume deficit Clara is experiencing? a. Decreased hepatic blood flow. b. Decreased drug absorption. c. Decreased drug half-life. d. Decreased GI acidity.
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a. Decreased hepatic blood flow. Decreased hepatic blood flow commonly occurs in the elderly. This decreases drug metabolism, which allows drugs to remain in the body longer and produces a greater drug effect. Factors such as decreased gastrointestinal (GI) motility and decreased GI acidity lead to changes in drug absorption time, but generally, actual drug absorption is not decreased (b). Decreased metabolism in the elderly often leads to an increase in the half-life of drugs taken by them (c). Decreased GI acidity often occurs in the elderly, but this would not be a contributing factor for this client's fluid volume deficit (d).
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The nurse is aware that the elderly often experience an increase in the amount of free, unbound drug molecules, which has the potential to increase the pharmacological effects of the drug. Which lab test will the nurse monitor to determine if this may be a factor contributing to Clara's problem? a. Serum creatinine. b. Serum protein. c. Hemoglobin. d. Hematocrit.
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b. Serum protein. Drug molecules may be distributed through the body bound to plasma protein molecules. A decrease in serum protein levels is an indication that there may be an increase in free, unbound drug molecules in the bloodstream. The client's serum creatinine level , hemoglobin level, and hematocrit level will not provide useful data regarding the potential for increased amounts of free, unbound drug molecules (a, c, & d).
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The nurse starts an intravenous line to administer fluids. The prescription states, "3% Normal Saline to infuse at 100 ml/hour." The client's most recent serum sodium level is 135 mEq/L. What action should the nurse take? a. Hang 0.9% Normal Saline at 100 ml/hour. b. Begin infusing the solution at a keep-open rate. c. Start the intravenous solution as prescribed. d. Consult with the healthcare provider about the prescription.
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d. Consult with the healthcare provider about the prescription. Three percent saline is a hypertonic solution, which will pull fluid from the interstitial and intracellular spaces into the bloodstream. It is usually prescribed for severe hyponatremia (sodium <115 mEq/L). Since Clara is already experiencing a fluid volume deficit, this IV solution could worsen her condition. The nurse should consult with the healthcare provider about this prescription. The nurse does not have the authority to change the prescription unilaterally (a). Even this slow rate of administration has the potential to be harmful in this situation (b). This solution may be harmful to this client (c).
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A short while later, a prescription for 0.9% Normal Saline at 100 ml/hour is received. Clara's primary nurse is at lunch, so another nurse hangs the solution. When checking Clara upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose and 0.9% Normal Saline is infusing at 125 ml/hour. What action should the primary nurse implement? a. Obtain a container of 0.9% Normal Saline to hang when the present solution has finished infusing. b. Decrease the infusion rate of the present solution to 75 ml/hour to compensate for the error made. c. Stop the IV solution currently infusing and monitor the client for signs of an anaphylactic reaction. d. Change the currently infusing solution to 0.9% Normal Saline and change the rate to 100 ml/hour.
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d. Change the currently infusing solution to 0.9% Normal Saline and change the rate to 100 ml/hour. Two errors have occurred: the wrong solution and the wrong rate of administration. These errors should both be corrected.
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After hanging the correct IV solution at the correct rate of infusion, the nurse discusses the error with the nurse who hung the first IV solution. Together, the nurses complete a variance (incident) report. What additional action should the primary nurse take? a. Discuss the consequences of the error with the hospital legal counsel. b. Notify the healthcare provider of the error in treatment that occurred. c. Report to the hospital pharmacist that a variance report was written. d. Notify the hospital educator of the need for staff training about IV fluids.
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b. Notify the healthcare provider of the error in treatment that occurred. Since the prescription was not initially followed, the healthcare provider should be notified in case a change in the treatment plan is warranted. It is not necessary for the nurse to discuss medication errors with a lawyer (a), The variance report will be used by the healthcare agency for risk management purposes (c), and A pattern of medication errors may indicate the need for additional staff training, but this situation does not provide sufficient information to warrant that intervention (d).
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The nurse who made the errors is very upset about writing a variance (incident) report and states, "I've never made an error before. What if I get fired?" How should the primary nurse respond? a. "The variance report will show that this is your first medication error." b. "As long as you understand your error, we can disregard this report." c. "Since no harm was done to the client, the variance report will not matter." d. "Variance reports are used to find ways to prevent further errors."
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d. "Variance reports are used to find ways to prevent further errors." Variance reports are used by the risk management department of healthcare agencies to look for patterns that contribute to errors so that preventive measures can be instituted. The variance report provides information about the specific event, not the pattern of errors made by an individual nurse (a), The variance report provides important data for the healthcare agency (b), and the healthcare agency's risk management program.
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Later that day, Clara's IV pump alarm sounds. The nurse notes that the IV is not infusing in the right antecubital area, and the alarm indicates an obstruction is present. The nurse determines that all the clamps are open and there are no kinks in the tubing. What intervention should the nurse take next? a. Apply light pressure above the site. b. Lower the IV solution below the site. c. Straighten the joint above the site. d. Change the IV site dressing.
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c. Straighten the joint above the site. Obstruction is often caused by client movement, resulting in a bend in the client's proximal joint. Therefore, this noninvasive measure should be the next action taken by the nurse. This will create further obstruction (a). This is often helpful to check for the presence of a blood flashback, indicating the IV is still infusing in the vein. However, another action should be taken first (b). Although dressing that is too tight may obstruct the flow of the IV solution, another action should be taken first (d).
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The nurse resolves the obstruction, and the IV solution begins to infuse. The next day the nurse observes that the IV insertion site is inflamed and tender. The label on the IV site indicates the current IV has been in place for 36 hours. What action should the nurse take? a. Continue the IV with the arm elevated on a pillow. b. Remove the IV and restart it in a different location. c. Notify the healthcare provider that the IV site appears inflamed. d. Complete a variance report regarding the IV site.
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b. Remove the IV and restart it in a different location. The client is experiencing phlebitis, which can lead to further complications if left untreated. Since the nurse has the responsibility to take action when IV site complications occur, the IV should be discontinued, action should be taken for the inflammation according to agency policy, and a new IV should be started at a different site. Elevating the arm on a pillow will not improve the situation (a). The nurse is authorized to take needed action when an IV site complication occurs (c). Variance (incident) reports are completed when a situation takes place that is inconsistent with the routine care of a client. An error in treatment has not occurred. IV site complications are an anticipated adverse effect of treatment and do not require the completion of a variance report (d).
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The nurse used the nursing process in deciding to remove Clara's IV and restart it in a new location. When assessing the IV site, what step of the nursing process did the nurse use? a. Analyze the data. b. Plan interventions. c. Determine the problem. d. Establish a goal.
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a. Analyze the data. The nurse analyzes the assessment data to determine if characteristics occur that define a problem. A problem is then stated, a goal is established, and interventions are planned and implemented. The other choices are not the next step in the nursing process.
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The nurse used the nursing process in deciding to remove Clara's IV and restart it in a new location. Which problem did the nurse identify as most pertinent in that situation? a. Risk for impaired skin integrity. b. Risk for injury (thrombus formation). c. Fluid volume deficit. d. Infection.
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b. Risk for injury (thrombus formation). The phlebitis at the IV site places Clara at high risk for thrombus formation. So, the nurse identified this problem, established the goal that the risk for injury will be reduced, and implemented the interventions of removing the IV and providing care at the site of inflammation. Impaired skin integrity already exists at the IV insertion site (a). While this is pertinent to Clara's overall plan of care, it was not the priority problem in that situation (c). Phlebitis is an inflammatory process, not an infectious process (d).
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Clara continues to receive 0.9% Normal Saline at a rate of 100 ml/hour. She is stronger and has started taking oral food and fluids well. She receives a regular no-added-salt diet. Her breakfast includes one cup of scrambled eggs, one bowl of oatmeal, a fresh orange, and a carton of milk. In addition to the milk, which item should be measured as fluid intake? a. Scrambled eggs. b. Bowl of oatmeal. c. Fresh orange. d. Only the milk.
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d. Only the milk. Oral fluid intake includes only foods that are liquid at room temperature. The other options are not measured as fluid intake.
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When Clara was first admitted, the healthcare provider did not include intake and output measurement in the initial prescriptions, but the primary nurse initiated this assessment activity. Now that Clara is taking oral fluids well, what action should the nurse implement? a. Notify the healthcare provider that a prescription to continue intake and output measurement is needed. b. Continue the measurement of the client's fluid intake and output. c. Stop measuring the client's fluid intake and output as long as she takes oral fluids. d. Measure the client's fluid output, but discontinue measuring fluid intake.
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b. Continue the measurement of the client's fluid intake and output. Since Clara is still receiving a significant volume of IV fluids, she remains at risk for fluid volume alterations. The nurse may initiate and maintain intake and output measurement without a prescription from the healthcare provider. The nurse may initiate and maintain intake and output measurement without a prescription from the healthcare provider (a). Clara remains at risk for fluid volume alterations even though she is taking oral fluids (c). The measurement of Clara's fluid intake should not be discontinued because she is still at risk for fluid volume alterations (d).
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Clara's intake and output measurements indicate her intake is greater than her output. The nurse is concerned that Clara may develop fluid volume excess. Which assessment is important for the nurse to perform? a. Auscultate the client's breath sounds. b. Measure the client's tympanic temperature. c. Compare the client's muscle strength bilaterally. d. Ask the client if she is experiencing any syncope.
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a. Auscultate the client's breath sounds. Fluid volume excess often causes abnormal breath sounds. Fluid collection in the lungs can impair oxygen exchange and result in hypoxemia. The other options are not a significant assessment to perform for suspected fluid volume excess.
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The nurse also observes that Clara's feet and ankles are swollen. When the nurse presses a finger over the client's ankle (bony prominence), a 4 mm indentation appears. How will the nurse document this finding? a. Large amount of edema in the lower extremities. b. 2+ pitting edema present around ankles and feet. c. Stage 2 pressure ulcer forming due to ankle edema. d. Blanching and induration present bilaterally.
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b. 2+ pitting edema present around ankles and feet. This documentation concisely describes the degree of indentation present and its location. The client is experiencing edema, but this documentation does not provide the best description of the edema (a). The indentation is not an indication of a stage 2 pressure ulcer (c). Neither blanching nor induration are indicated by this assessment (d).
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Clara has abnormal breath sounds, bilateral pitting edema, and jugular vein distention. Which change in Clara's pulse will the nurse anticipate? a. Increase in rate and volume. b. Decrease in rate and volume. c. Increase in rate, but no change in the volume. d. Decrease in rate, but no change in the volume.
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a. Increase in rate and volume. As fluid volume increases to the point of fluid volume excess, the client will develop tachycardia (increase in rate) and a bounding pulse (increase in volume). The others are not typical changes with fluid volume excess.
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Further findings include oxygen saturation level of 90%, serum sodium of 140 mEq/L, and serum potassium of 3 mEq/L. The nurse reports the findings to the healthcare provider and receives several prescriptions. Which prescription should the nurse question? a. Furosemide (Lasix) 40 mg IV push now. b. Potassium chloride 40 mEq IV push now. c. Decrease the Normal Saline to 30 ml/hour. d. Administer oxygen per nasal cannula at 2 L/minute.
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b. Potassium chloride 40 mEq IV push now. Clara's serum potassium is low. She needs potassium replacement, but potassium chloride should never be administered IV push. A prescription for potassium chloride diluted in an IV solution to be administered over several hours should be obtained from the healthcare provider. The administration of a diuretic and decreasing intravenous fluid intake is an expected prescription for a client with fluid volume excess (a &c). Clara's oxygen saturation level is lower than the desired range (95% to 100%). The administration of oxygen via nasal cannula is an expected prescription (d).
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It is most important for the nurse to monitor which lab value for Hydrochlorothiazide, a diuretic? a. Hemoglobin. b. White blood cell count. c. Serum potassium. d. Prothrombin Time (PT/INR).
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c. Serum potassium. Hydrochlorothiazide, a potassium-wasting diuretic, may cause significant hypokalemia. Use of hydrochlorothiazide may also result in a decrease in serum magnesium and sodium and an increase in serum calcium and glucose. The other lab values will not be significantly impacted by Hydrochlorothiazide.
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Before Clara's discharge, the nurse provides client teaching related to the prescribed hydrochlorothiazide (HydroDIURIL). Clara's fluid volume excess improves and the prescription for hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted. The nurse will emphasize the importance of taking this medication only once a day, on what schedule? a. Before eating breakfast. b. With breakfast. c. After lunch. d. At bedtime.
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b. With breakfast. To reduce the likelihood of nocturia, the client should be instructed to take diuretics in the morning. Additionally, taking the medication with food may reduce adverse effects, such as nausea. It is not recommended to take hydrochlorothiazide on an empty stomach (a). This is not the best time of day to take a diuretic (c & d).
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Since Clara is receiving a diuretic that contributes to the loss of potassium, the nurse must provide dietary teaching. Which food(s) selected by the client indicate an understanding of potassium-rich foods? (Select all that apply.) a. Baked potato b. Green beans c. Chicken breast d. Apple e. Grapefruit juice
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a. Baked potato e. Grapefruit juice 1 long potato contains 844 mg potassium. This shows that the client has an understanding of potassium-rich foods (a). 8 oz of grapefruit juice contains 825 mg of potassium. This shows that the client has an understanding of potassium-rich foods (e). 1/2 cup of green beans contains 100 mg potassium, 1 apple contains 159 mg of potassium, and 4oz of chicken breast contains 458 mg potassium. These selections show that the client does not have a good understanding of potassium-rich foods.
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In preparing to administer the hydrochlorothiazide, the nurse notes that the prescribed dose is 12.5 mg, and the tablet available is 25 mg. What action should the nurse take? a. Observe the tablet to see if it is scored. b. Notify the pharmacist of the error. c. Hold the medication until the right dose is available. d. Document the change in dose on the medication record.
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a. Observe the tablet to see if it is scored. A scored tablet can safely be divided so that the client may receive the prescribed dose. Hydrochlorothiazide is a scored tablet. The nurse should also assess Clara's ability to break the tablet because 25 mg is the lowest tablet strength available. The tablet may not be available in the smaller dose. Another nursing action should be taken (b & c). The prescribed dose has not been changed. Administration of the entire tablet would result in a medication error (d).
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Upon entering Clara's room with the medication, the nurse checks Clara's identification band. Clara states, "You take care of me every day. Why do you keep looking at my identification?" What is the best response by the nurse? a. "It is hospital policy to always check client identification." b. "Your healthcare provider has asked that we always perform this check." c. "Wearing an identification band is important for all patients." d. "This is a double-check to ensure that no errors occur."
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d. "This is a double-check to ensure that no errors occur." This response provides the best client teaching. The client can participate in the plan of care more actively if explanations for interventions are provided. While this is probably correct, it is more beneficial to explain the rationale for the action to the client (a). This is a nursing action, not an action prescribed by the healthcare provider (b). This is true but does not provide client teaching that explains the importance of checking the identification band (c).
