Mrs. Katz has been admitted to the intermediate care unit with a diagnosis of acute gastrointestinal bleeding. Her blood pressure is 88/50 mm Hg, and her pulse is 120 beats/min. The nurse would expect Mrs. Katz's IV therapy to be:
C. an isotonic fluid, such as normal saline.
Rationale: Although Mrs. Katz may need a blood transfusion, there are no data related to her hematocrit and hemoglobin levels. With a blood pressure of 88/50 mm Hg, she would need IV therapy to replace volume and correct her hypotension, and neither an IV lock nor hypotonic fluid would accomplish this goal.
Mr. Shoen has congestive heart failure. In obtaining a dietary history from Mr. Shoen, the nurse notes that his meals consist of many high-sodium foods. The nurse should teach the patient which of the following?
D. A diet high in sodium will cause him to retain fluid, increasing the workload of his heart.
Rationale: A high-sodium diet would not cause fluid loss, potassium loss, or calcium loss. Sodium contributes to fluid retention.
The nurse notes that a patient on her unit has had a very high temperature for the past 2 days. Today, the patient's skin turgor is poor, and she tells the nurse her mouth feels very dry. Which of the following is the nurse's best response?
C. Encourage the patient to increase oral fluid intake
Rationale: The patient is slightly dehydrated, and an IV fluid bolus would only be necessary if the patient exhibited serious signs of hypovolemia or could not tolerate oral liquids. You would not restrict the fluid intake. Merely measuring the patient's intake and output will not address the dehydration.
Cammy Smith is brought to the emergency room following an attempted robbery. She is extremely distraught and hyperventilating. If an arterial blood gas sample were to be obtained, the nurse would expect to find:
B. a rising pH and a falling PCO2.
Rationale: The patient would be developing respiratory alkalosis, which would be identified by a rise in pH and a decrease in the PCO2 due to the hyperventilation.
The tip of all central venous access devices infuses IV fluids into the:
B. superior vena cava.
Rationale: Although central venous access device catheters may be inserted into the jugular, subclavian, or brachial vein, the end of the catheter is threaded into the superior vena cava.
Intake should not exceed 5.8 grams/day
Low serum levels can lead to cardiac arrhythmias
Vital for cardiac muscle function
Involved in multiple biochemical reactions
Serves as part of the buffering system
True or False: Patients who are placed on a fluid restriction may still have as much crushed ice as they desire.
Rationale: Crushed ice must be counted as fluid intake, as is everything that becomes liquid at room temperature.
True or False: A goal of administering albumin intravenously is to increase oncotic pressure in the vascular space.
Rationale: Albumin is a large serum protein that draws fluid into the vascular space.
True or False: If the nurse is unsuccessful in his attempt to perform venipuncture for IV therapy, he should keep trying until the catheter is placed successfully in the vein.
Rationale: Many institutions have policies regarding the number of attempts that may be made at venipuncture by the nurse. These policies often direct the nurse to enlist the assistance of a CRNA or IV nurse if unable to establish venous access after a number of attempts. We recommend, as do several guidelines, making only two attempts before seeking help.
True or False: A person who has the blood type B+ could receive a transfusion from an O+ donor.
True or False: The best overall measurement of total body fluid loss or gain is the measurement of intake and output.
Rationale: Intake and output only measures the fluid that enters and exits the vascular system. It will not measure the fluid contained interstitially or fluid that is in a third space.