Promoting Fluid and Electrolyte Balance
Promoting Fluid and Electrolyte Balance ( 5 Questions)
A nurse is preparing to administer lactated Ringer's (LR) solution to a client who has hypovolemia due to third-space shifting. Which of the following actions should the nurse take? (Select all that apply.)
Assess the client's blood pressure and pulse frequently. This is correct because a client who has hypovolemia due to third-space shifting has lost fluid from the intravascular space to the interstitial space, resulting in decreased blood volume and pressure. The nurse should monitor the client's vital signs to assess the response to fluid replacement and detect any signs of fluid overload or electrolyte imbalance.
Monitor the client's serum electrolyte levels. This is correct because lactated Ringer's solution contains sodium, chloride, potassium, calcium, and lactate, which are important electrolytes for maintaining fluid balance, acid-base balance, nerve conduction, muscle contraction, and cellular function. The nurse should monitor the client's serum electrolyte levels to ensure they are within normal range and to identify any abnormalities that may require intervention.
Warm the solution to body temperature before infusion. This is incorrect because warming the solution is not necessary and may cause hemolysis (destruction of red blood cells) or bacterial growth. The nurse should infuse the solution at room temperature or use a fluid warmer device if indicated.
Use a filter needle when drawing the solution from the bag. This is incorrect because using a filter needle is not required when drawing the solution from the bag. A filter needle is used to remove particles or air bubbles from a vial or ampule before injection. The nurse should use a sterile spike to pierce the bag and connect it to the IV tubing.
Check the solution for cracks or leaks. This is incorrect because checking the solution for cracks or leaks is not specific to lactated Ringer's solution. The nurse should check any IV fluid for cracks or leaks before administration to prevent contamination or infection. The nurse should also check the expiration date, color, clarity, and label of the solution before use.
Choice A reason:
Assess the client's blood pressure and pulse frequently. This is correct because a client who has hypovolemia due to third-space shifting has lost fluid from the intravascular space to the interstitial space, resulting in decreased blood volume and pressure. The nurse should monitor the client's vital signs to assess the response to fluid replacement and detect any signs of fluid overload or electrolyte imbalance.
Choice B reason:
Monitor the client's serum electrolyte levels. This is correct because lactated Ringer's solution contains sodium, chloride, potassium, calcium, and lactate, which are important electrolytes for maintaining fluid balance, acid-base balance, nerve conduction, muscle contraction, and cellular function. The nurse should monitor the client's serum electrolyte levels to ensure they are within normal range and to identify any abnormalities that may require intervention.
Choice C reason:
Warm the solution to body temperature before infusion. This is incorrect because warming the solution is not necessary and may cause hemolysis (destruction of red blood cells) or bacterial growth. The nurse should infuse the solution at room temperature or use a fluid warmer device if indicated.
Choice D reason:
Use a filter needle when drawing the solution from the bag. This is incorrect because using a filter needle is not required when drawing the solution from the bag. A filter needle is used to remove particles or air bubbles from a vial or ampule before injection. The nurse should use a sterile spike to pierce the bag and connect it to the IV tubing.
Choice E reason:
Check the solution for cracks or leaks. This is incorrect because checking the solution for cracks or leaks is not specific to lactated Ringer's solution. The nurse should check any IV fluid for cracks or leaks before administration to prevent contamination or infection. The nurse should also check the expiration date, color, clarity, and label of the solution before use.