Term
| Name 4 components of body fluid |
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Definition
| water, fluid compartments, electrolytes, blood |
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Term
| The human body is made up of how much water? |
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Definition
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Term
| List 5 physiologic transport mechanisms for distributing fluid |
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Definition
| osmosis, filtration, passive/facilitated diffusion, active transport |
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Term
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Definition
| osmosis helps regulate the distribution of water by controlling the movement of fluid from one location to another |
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Term
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Definition
| filtration regulates the movement of water and substances from a compartment where the pressure is HIGHER to one where the pressure is LOWER. |
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Term
| What is the force of filtration known as? |
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Definition
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Term
| What is passive diffusion? |
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Definition
| the physiologic process in which dissolved substances, such as electrolytes and gases, move from an area of HIGHER concentration to an area of LOWER concentration through a semi-permeable membrane (occurs without energy) |
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Term
| What does passive diffusion facilitate? |
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Definition
| electrochemical neutrality = an identical balance of cations with anions |
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Term
| What is facilitated diffusion? |
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Definition
| facilitated diffusion is the process in which certain dissolved substances require the assistance of a carrier molecule to pass from one side of a semipermeable membrane to another |
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Term
| What is active transport? |
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Definition
| active transport, a process of chemical distribution that requires energy (ATP) |
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Term
| Name an example of active transport. |
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Definition
| sodium-potassium pump system which regulates the movement of potassium from LOWER concentrations in the extracellular fluid into cells where it is more highly concentrated |
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Term
| Name 10 examples of assessments that provide data about a client's fluid status |
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Definition
| weight, bp, temp, pulse, resp, urine, stool, skin, eyes, lungs, breathing, energy, cognition, consciousness |
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Term
| List 3 methods for maintaining and restoring fluid volume |
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Definition
| treating the cause of hypovolemmia, increasing oral intake, administering IV fluid replacements, controlling fluid losses |
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Term
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Definition
| hypovolemia refers to a low volume of extracellular fluid which can result in dehydration if left untreated |
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Term
| List 4 methods for reducing fluid volume |
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Definition
| treating the disorder, restricting fluid intake, reducing salt consumption, administering diuretic drugs to promote urination, d/c IV fluid infusions |
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Term
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Definition
| hypervolemia refers to a higher than normal volume of water in the intravascular fluid compartment, this can lead to edema |
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Term
| List 6 reasons for administering IV fluids |
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Definition
| maintain/restore fluid balance, maintain/restore electrolytes, administer water soluble vitamins, provide source of calories, administer drugs, replace blood and blood products |
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Term
| What is a crystalloid solution? |
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Definition
| a solution that is classified as either isotonic (same), hypotonic (contains fewer substances than plasma, will burst), or hypertonic (contains more substances than plasma, will shrink) depending on the concentration of dissolved substances in relation to plasma |
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Term
| What is a colloid solution? |
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Definition
a solution used to replace circulating blood volume because the molecules pull fluid from other compartments
ex: blood, blood products, plasma expanders |
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Term
| List the 4 factors that influence the type of tubing used during IV administration. |
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Definition
| distance, volume to be administered, type of container the solution is packaged, the necessary rate at which the IV diffuses determines the appropriate drop size |
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Term
| When would a filter be necessary for use during an IV administration? |
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Definition
| filtered tubing is generally used when administering nutrition, client is high risk for infection, pediatric clients, or administering blood and packed cells |
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Term
| Describe gravity infusion. |
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Definition
| the height of the IV solution is more important during this method than the type of tubing and is used to overcome the pressure within the clients vein. Elevate solution 18-24 inches about the site of the infusion. |
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Term
| The higher the solution, the ________ the rate of infusion. |
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Definition
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Term
| Describe the purpose of using an electronic infusion device. |
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Definition
| An infusion pump uses pressure to infuse solutions. A volumetric controller instills IV solutions using gravity. |
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Term
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Definition
| is the process in which one accesses the venous system by piercing a vein with a needle. |
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Term
| List 5 criteria when selecting a vein to administer an IV fluid. |
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Definition
| use veins on nondominant side, do not use foot and leg veins, do not use vein on side of previous breast surgery or in which vascular surgery has been performed for dialysis, choose vein in a location uneffected by joint movement, avoid using veins on inner side of wrist, feel/look for a fairly straight vein, never use a vein that looks inflammed or skin looks impaired |
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Term
| List 7 complications associated with IV fluid administration |
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Definition
| circulatory overload, infiltration, phelebitis, thrombus formation, pulmonary embolus, air embolism |
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Term
| Discuss 2 purposes for inserting an intermittent venous access device. |
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Definition
| the patient no longer needs continuous infusions of fluid, needs intermittent administrations of IV medication, may need emergency IV fluid or medications if condition deteriorates |
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Term
| Name 5 types of transfusion reactions |
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Definition
| usually occur within 5-15 minutes of transfusion and can include incompatibility, febrile, septic, allergic, moderate chilling, overload, and hypocalcimia pg.324 |
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Term
| A nurse is initiating a peripheral venous access IV infusion ordered for a patient presurgically. In what position would the nurse place the patient to perform this skill? |
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Definition
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Term
| A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? |
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Definition
50 gtt/min
The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. |
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Term
| Which of the following commonly used intravenous solutions is hypotonic? |
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Definition
| 5% dextrose in 0.45% NaCl is hypotonic. |
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Term
| Name the 3 primary extracellular electrolytes. |
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Definition
| sodium, chloride, bicarbonate |
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Term
| When providing care for a patient who has a peripheral intravenous catheter in situ, the nurse should: |
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Definition
| change the site every 3-4 days |
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Term
| A nurse assessing the IV site of a patient observes swelling and pallor around the site and notes a significant decrease in the flow rate. The patient complains of coldness around the infusion site. What IV complication does this describe? |
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Definition
| Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site and significant decrease in the flow rate. The signs of sepsis include red and tender insertion site, fever, malaise, and other vital sign changes. The symptoms of thrombus are local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea |
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Term
| A patient who is NPO prior to surgery is complaining of thirst. What is the physiologic process that drives the thirst factor? |
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Definition
| Decreased blood volume and intracellular dehydration |
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Term
| If you have 4oz of frozen ice chips, how much liquid would you document? |
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Definition
1/2 of frozen = liquid
answer: 2oz |
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Term
| What is the purpose of administering plasma expanders? |
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Definition
| to increase the blood volume and raise the blood pressure |
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Term
| A nurse monitoring the intake and output of fluids for a patient with severe diarrhea knows that normally how many mL of body fluids is lost via the gastrointestinal tract? |
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Definition
300 ml
Generally, fluid intake averages 2,600 mL per day, with approximately 1,300 mL coming from ingested water, 1,000 mL coming from ingested food, and 300 mL from metabolic oxidation. |
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Term
| A nurse is caring for a client who is to be provided nutrition intravenously for a short duration following a tracheostomy. Which of the following intravenous solutions needs to be administered to this client? |
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Definition
| Crystalloid solutions are to be administered to the client. The crystalloid solutions can be classified as isotonic, hypotonic, and hypertonic. Isotonic solutions are generally administered to maintain fluid balance in clients who may not be able to eat or drink for a short period. Lipid emulsions are administered when the client is severely malnourished and may not be able to consume food for a long period. In this case, lipid emulsion is not necessary because the client will not be able to take food for a short period. In addition, there is a risk of adverse reaction in clients while administering lipid emulsion. Colloid solutions are used to replace circulating blood volume because the suspended molecules pull fluid from other compartments. Plasma expanders are used as economical and virus-free substitutes for blood and blood products when treating hypovolemic shock. |
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Term
| The nurse is administering albumin to a patient to promote movement of fluid into the capillaries. What is the "pulling force" of fluid by use of a protein such as albumin known as? |
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Definition
Plasma proteins, particularly albumin, concentrated in the intravascular space or plasma facilitate the reabsorption of fluid into the capillaries by the action of colloid osmotic pressure. Diffusion is the movement of a solute from an area of higher concentration to an area of lower concentration. Osmosis is the movement of water from an area of lesser solute concentration and more water to an area of greater solute concentration and less water until equilibrium is achieved. Active transport is a process that requires energy for the movement of substances through a cell membrane from an area of lesser solute concentration to an area of higher solute concentration.
pg.307 |
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Term
| When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which of the following guidelines should the nurse follow? |
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Definition
Use larger veins and the distal portion of the vein, leaving the more proximal sites for later venipunctures.
pg.320 |
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Term
| A nurse is choosing a vein to start an IV infusion in a patient. Which of the following are recommended veins to use when initiating an IV infusion? Select all that apply. |
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Definition
• Cephalic vein
• Metacarpal
• Basilic veins
• Superficial veins on the dorsal aspect of the hand |
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Term
| A nurse uses an infusion pump to administer the IV solution to a client. The nurse is aware that an infusion pump adjusts the pressure according to the resistance it meets and there is a possibility that the needle may get displaced. How would a change in the needle's position affect the infusion pump? |
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Definition
The nurse should be aware that an infusion pump continues to infuse fluid even when the needle is displaced. The pump continues to infuse fluid into the tissue until the machine's maximum preset pressure reaches its limit. The infusion pump adjusts the pressure according to the resistance it meets. The pump does not compress the tubing to infuse the solution at a precise, preset rate, which is done by a volumetric controller. An electronic infusion device would sound an audible alarm if the infusion container is empty, air is detected in the tubing, or resistance is met in delivering the fluid. The infusion pump does not stop pushing the fluid in the client's vein when the needle becomes displaced.
pg.318 |
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Term
| A patient asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond? |
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Definition
| There is no way you can receive a disease by GIVING blood. |
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Term
| Which of the following statements accurately describes a guideline when using a venous access? |
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Definition
The system is accessed with a noncoring needle, and patency is maintained by periodic flushing. When venous access is desired, the location of the injection port must be palpated. In general, a ¾-inch, 20-gauge needle is most frequently used. A larger gauge (19-gauge) is preferred for administration of blood products.
pg.342 |
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Term
| A nurse reads the laboratory report for a patient and notes that the patient has hyponatremia. What physical assessment would be made? |
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Definition
Hyponatremia is an ECF sodium deficit, resulting in osmotic pressure changes as ECF moves into the cells. When this occurs, prints from the examiner's fingers tend to remain on the patient's skin over the sternum when pressure is applied with the fingers.
pg.312 |
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Term
| A client has been admitted to the health agency with symptoms of malnutrition. The nurse needs to administer a solution of nutrients to meet the caloric and nutritional needs of the client. The nutrient solution is packaged in a glass container and needs to be administered at a rate of 60 drops/mL. What type of tubing should the nurse use in this case? |
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Definition
The nurse should use filtered tubing to administer the nutrient to the client with symptoms of malnourishment. If unvented tubing is inserted into a glass bottle, the nutrient solution will not leave the glass container. Filtered tubing is generally used to administer parenteral solutions. Primary tubing is used when the tubing must span the distance from a solution that hangs several feet above the infusion site. Macrodrip tubing delivers a standard volume of up to 30 drops/mL, which is again not appropriate for the case.
pg.317 |
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Term
| A nursing instructor is preparing a class presentation for a group of nursing students on fluid balance and developmental considerations. Which of the following would the instructor most likely include when describing newborns and infants? Select all that apply. |
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Definition
Infants have a proportionately larger percentage of total body weight as water (70% to 80%) than do adults (60%). A greater amount of the fluid is contained within the ECF compartment in infants than within that of adults. Because infants also have a greater surface area in relation to weight, they can lose a proportionately larger volume of fluid through the skin. Fluid requirements vary according to age, as do normal urine outputs. The infant’s kidneys are immature and lack the ability to concentrate urine fully. Metabolic and respiratory rates are high in infants, contributing to increased insensible fluid loss. Fluid loss can occur very rapidly in this age group.
pg.306 |
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Term
| The passageways of the kidney permit the urine to flow to the bladder and.... |
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Definition
| When a hypertonic solution is infused, it raises serum osmolarity, pulling fluid from the cells and the interstitial tissues into the vascular space. Examples of hypertonic solutions include 3% (NaCl) and 5% saline (NaCl). |
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Term
(see full question)
Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this? |
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Definition
An infant has considerably more total body fluid and ECF than an adult does. Because ECF is more easily lost from the body than ICF, infants are more prone to fluid volume deficits.
pg.306 |
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Term
| During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which of the following interventions should the nurse perform for this client? |
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Definition
The nurse should prepare to give an antihistamine because these signs and symptoms are indicative of an allergic reaction to the transfusion. The nurse needs to stop the transfusion immediately, infuse saline at a rapid rate, and administer oxygen if the client shows signs of incompatibility.
pg.324 |
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