Nursing Fund
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1. A nurse is caring for an Blood lab results
elderly client with de-
mentia who has devel- Rationale: Blood lab results provide objective data about fluid and elec-
oped dehydration as trolyte status as well as about hemoglobin and hematocrit. Intake and
a result of vomiting output results provide data only about fluid balance but doesn't present
and diarrhea. Which a comprehensive picture of the client's fluid and electrolyte status and
assessment best re- therefore is not the best answer. Skin turgor is not a reliable indicator of
flects the fluid balance hydration status for the elderly client because it is generally decreased with
of this client? age. The client's report about fluid intake is a subjective data in general and
not reliable because this client has dementia and therefore has memory
problems.
2. A client with a histo- 0.9% sodium chloride
ry of severe diarrhea
for the past 3 days is Rationale: An IV solution of 0.9% sodium chloride is the most appropriate
admitted for dehydra- initial IV fluid for this client, because it is an isotonic solution that will
tion. The nurse antici- act as a volume expander to quickly replace volume losses and promote
pates that which intra- physiological stabilization. 3% sodium chloride, is a high concentration
venous solution will be (hypertonic) electrolyte solution; it would only be used in a client with
prescribed initially? hyponatremia and must be closely monitored during infusion. 5% dextrose
and 0.9% sodium chloride and 5% dextrose and lactated Ringer's may be
appropriate fluids to infuse after 0.9% sodium chloride.
3. The health care 31
provider orders 1000
mL normal saline to Rationale: Administering 1,000 mL over 8 hours is equal to administering
be infused over 8 125 mL over 1 hour (60 minutes). To find the number of milliliters per
hours for a client with minute: 125/60 min = X/1 minute 60X = 125X = 2.1 mL/minute To find the
a diagnosis of de- number of drops/minute: 2.1 mL/X gtts = 1 mL/15 gtts X = 31 gtts/minute
hydration. The intra-
venous (IV) tubing de-
livers 15 drops per
, Nursing Fund
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milliliter (drop factor).
The nurse should ad-
minister the IV infu-
sion at a rate of ____
gtts/minute. (Record
your answer using a
whole number.)
4. A specimen for ar- Metabolic acidosis
terial blood gases
is obtained from Rationale:
a severely dehydrat- The blood pH indicates acidosis; the bicarbonate (HCO3-) level is further
ed 3-month-old infant from the expected range than is the partial pressure of carbon dioxide
with a history of di- (Pco2), indicating a metabolic origin (losses from diarrhea). The blood pH
arrhea. The pH is indicates acidosis, not alkalosis. The HCO3- level is farther from the ex-
7.30, Pco2 is 35 mm pected range than the Pco2 level, indicating a metabolic, not a respiratory,
Hg, and HCO3- is 17 origin of the acidosis. The blood pH indicates an acidic, not an alkalotic,
mEq/L. What compli- state; also, it is of metabolic origin.
cation does the nurse
conclude has devel-
oped?
5. A 6-month-old infant 28 mL
weighing 15 lb is
admitted with a di- Rationale: At 15 lb the infant weighs about 7 kg; 4 mL × 7 kg is 28 mL. The
agnosis of dehydra- other amounts (32 mL, 38 mL, 42 mL) are too much.
tion. A prescription for
oral rehydration ther-
apy 4 mL/kg Pedialyte
over 4 hours is made.
What is the approxi-
mate amount of fluid
Study online at https://quizlet.com/_6qt1bc
1. A nurse is caring for an Blood lab results
elderly client with de-
mentia who has devel- Rationale: Blood lab results provide objective data about fluid and elec-
oped dehydration as trolyte status as well as about hemoglobin and hematocrit. Intake and
a result of vomiting output results provide data only about fluid balance but doesn't present
and diarrhea. Which a comprehensive picture of the client's fluid and electrolyte status and
assessment best re- therefore is not the best answer. Skin turgor is not a reliable indicator of
flects the fluid balance hydration status for the elderly client because it is generally decreased with
of this client? age. The client's report about fluid intake is a subjective data in general and
not reliable because this client has dementia and therefore has memory
problems.
2. A client with a histo- 0.9% sodium chloride
ry of severe diarrhea
for the past 3 days is Rationale: An IV solution of 0.9% sodium chloride is the most appropriate
admitted for dehydra- initial IV fluid for this client, because it is an isotonic solution that will
tion. The nurse antici- act as a volume expander to quickly replace volume losses and promote
pates that which intra- physiological stabilization. 3% sodium chloride, is a high concentration
venous solution will be (hypertonic) electrolyte solution; it would only be used in a client with
prescribed initially? hyponatremia and must be closely monitored during infusion. 5% dextrose
and 0.9% sodium chloride and 5% dextrose and lactated Ringer's may be
appropriate fluids to infuse after 0.9% sodium chloride.
3. The health care 31
provider orders 1000
mL normal saline to Rationale: Administering 1,000 mL over 8 hours is equal to administering
be infused over 8 125 mL over 1 hour (60 minutes). To find the number of milliliters per
hours for a client with minute: 125/60 min = X/1 minute 60X = 125X = 2.1 mL/minute To find the
a diagnosis of de- number of drops/minute: 2.1 mL/X gtts = 1 mL/15 gtts X = 31 gtts/minute
hydration. The intra-
venous (IV) tubing de-
livers 15 drops per
, Nursing Fund
Study online at https://quizlet.com/_6qt1bc
milliliter (drop factor).
The nurse should ad-
minister the IV infu-
sion at a rate of ____
gtts/minute. (Record
your answer using a
whole number.)
4. A specimen for ar- Metabolic acidosis
terial blood gases
is obtained from Rationale:
a severely dehydrat- The blood pH indicates acidosis; the bicarbonate (HCO3-) level is further
ed 3-month-old infant from the expected range than is the partial pressure of carbon dioxide
with a history of di- (Pco2), indicating a metabolic origin (losses from diarrhea). The blood pH
arrhea. The pH is indicates acidosis, not alkalosis. The HCO3- level is farther from the ex-
7.30, Pco2 is 35 mm pected range than the Pco2 level, indicating a metabolic, not a respiratory,
Hg, and HCO3- is 17 origin of the acidosis. The blood pH indicates an acidic, not an alkalotic,
mEq/L. What compli- state; also, it is of metabolic origin.
cation does the nurse
conclude has devel-
oped?
5. A 6-month-old infant 28 mL
weighing 15 lb is
admitted with a di- Rationale: At 15 lb the infant weighs about 7 kg; 4 mL × 7 kg is 28 mL. The
agnosis of dehydra- other amounts (32 mL, 38 mL, 42 mL) are too much.
tion. A prescription for
oral rehydration ther-
apy 4 mL/kg Pedialyte
over 4 hours is made.
What is the approxi-
mate amount of fluid
