Test Bank- Electrolytes and Fluid Balance

The nurse is caring for a diabetic patient with a blood sugar of 879 mg/dL, and notes the patient has fruity breath, and Kussmaul respirations. Which acid-base imbalance should the nurse expect? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

ANS A Diabetic ketoacidosis is a common cause of metabolic acidosis that occurs in patients with dangerously high blood sugars. Kussmaul respirations are a compensatory mechanism of the body during metabolic acidosis to raise the serum pH by blowing off additional carbon dioxide.

Which is the highest priority of the nurse immediately after withdrawing the needle from the IV catheter after venipuncture? Engage the safety device to cover the needle. Check for blood return in the flashback chamber. Stabilize the catheter with the nondominant hand. Align the catheter on the top of vein at a 15-degree angle.

ANS A The nurse's highest priority after withdrawing the needle from the IV catheter after venipuncture is to engage the safety device and cover the needle. It is absolutely essential for this to be done in order to prevent needlestick injury. The nurse will check for blood return in the flashback chamber prior to withdrawing the needle. Stabilizing the catheter with the nondominant hand is less important than engaging the safety device. The catheter is aligned on top of the vein prior to venipuncture.

Lactated Ringer's solution is administered to the patient during surgery. What is the purpose of this infusion? Cause cells to shrink and reduce swelling. Expand the body's intravascular fluid volume. Move fluid from intravascular space into cells. Pull fluid from cells into the intravascular space.

ANS B Fluids that have the same osmolality as normal blood are called isotonic. Isotonic solutions such as Lactated Ringer's expand the body's extracellular fluid volume without causing water to shift in or out of cells. Infusion of hypertonic intravenous solutions (more concentrated than normal blood), such as 3% sodium chloride, pulls fluid from cells by osmosis, causing them to shrink. Physiologically hypotonic solutions (less concentrated than normal blood after they are infused) move water from the extracellular compartment into the cells by osmosis, causing them to swell.

The nurse is caring for a patient with a sodium level of 156 mEq/L due to diabetes insipidus. Which is the highest priority nursing diagnosis for this patient? Activity intolerance related to fatigue from chronic illness Imbalanced nutrition related to excessive carbohydrate intake Excess fluid volume related to increased isotonic fluid retention Risk for ineffective airway clearance related to secretions during seizure

ANS D Diabetes insipidus is caused by a lack of antidiuretic hormone (ADH). Excessive urination causes dehydration and hypernatremia. The patient's sodium level of 156 mEq/L puts the patient at risk for seizures and risk for ineffective airway clearance related to secretions during seizure. Diabetes insipidus is not related to blood sugar levels unlike diabetes mellitus so imbalanced nutrition related to excessive carbohydrate intake is not appropriate for the patient. Excess fluid volume related to increased isotonic fluid retention is appropriate for a patient with SIADH rather than diabetes insipidus. Activity intolerance is not as important as risk for ineffective airway clearance.

The nurse is caring for a patient who is very malnourished and laboratory results show that the patient's albumin level is extremely low. Which finding would the nurse expect to observe during the patient's physical assessment? The patient has generalized edema. The patient is confused and irritable. The patient has an irregular heartbeat. The patient's eyes are red, irritated, and itchy.

ANS: A Albumin is responsible for keeping water within the bloodstream using oncotic pressure. Low albumin levels allow water to seep from the bloodstream into the tissues causing generalized edema. Confusion, irregular pulse, and irritated eyes are not expected with low albumin levels.

The nurse is caring for a patient who has been vomiting. The patient's sodium level is 124 mEq/L. Which laboratory result will the nurse also expect to see in the patient's chart? Chloride 81 mEq/L Calcium 11.1 mg/dL Phosphate 5.1 mg/dL Magnesium 2.3 mEq/L

ANS: A Chloride levels are closely associated with sodium levels. When the serum sodium level is low, the chloride level will drop as well. The normal sodium level is 135 to 145 mEq/L so the patient's 124 mEq/L level indicates hyponatremia. The nurse will expect to find the patient's chloride level to be 81, below the 95 to 105 normal range. Hypercalcemia, normal magnesium level, and hyperphosphatemia are not expected with hyponatremia due to vomiting.

The nurse is caring for a patient with a poorly controlled hypoparathyroid condition. Which is the highest priority nursing diagnosis for this patient? Risk for injury/fracture related to bone fragility Disturbed energy field related to chronic illness Deficient knowledge related to importance of exercise Disturbed body image related to hormonal changes

ANS: A Hypoparathyroid disease can lead to low serum calcium levels and osteoporosis, putting the patient at risk for developing a pathological fracture. Risk for fracture is the highest priority diagnosis for this patient. Disturbed energy field, deficient knowledge, and disturbed body image are not as important as the risk for fracture.

The nurse works on the cardiac unit of a hospital. The health care provider has ordered 20 mEq of KCl per L to be added to the fluids that the patient is receiving. The patient currently has a bag of D5W IV fluid infusing. Which is the priority action of the nurse? Check the patient's potassium level before hanging the new IV solution. Administer 20 mEq KCl diluted in 5 mL of fluid by IV push in 5 minutes. Give the KCl undiluted by IV push in 5 minutes for the most rapid action. Estimate the amount of fluid in the IV bag and add KCl to equal 20 mEq/L.

ANS: A Remember that failure to verify that a patient has adequate renal function and urine output before administering an IV solution containing potassium could cause hyperkalemia. Under no circumstances should KCl be given in an IV push. A direct IV infusion of KCl may be fatal. Intravenous administration of KCl requires dilution in solution and infusion slowly over a period of time. In most hospitals, nurses do not add KCl to IV bags

The patient is scheduled for hip replacement surgery and significant blood loss is expected. What is the best possible action of the patient to reduce the risk of transfusion complications? Arrange for an autologous blood donation. Take an iron supplement daily prior to the surgery. Expect transfusions will come from a directed donor. Request that donated blood be screened twice by the blood bank.

ANS: A The patient should be advised to arrange for an autologous blood donation. This way the patient will receive his/her own blood rather than from a donor. Iron supplementation will not be sufficient to compensate for the blood loss expected with hip replacement surgery. Patients cannot request extra screening precautions for transfusions. The patient should not be instructed to expect that transfusions will come from a directed donor.

The nurse is caring for a patient with metabolic acidosis due to severe hyperglycemia. Which assessment finding indicates to the nurse that the patient's body is attempting to compensate for the acidosis? The patient's breathing is very deep and rapid. The patient's temperature has been rising steadily. The patient's skin is flushed and warm to the touch. The patient is urinating large amounts of light colored urine.

ANS: A The patient's deep breathing is an attempt by the body to blow off additional carbon dioxide which converts to carbonic acid. Reduction of carbonic acid in the body will raise the pH and compensate for the acidosis. Elevated temperature, flushed skin, and increased urine output will not compensate for the acidosis.

Which is the appropriate action of the nurse when selecting a vein for IV placement? Select a vein that appears to be well dilated. Elevate the extremity to visualize the vein. c. Tap and rub the vein vigorously with friction. Stroke from proximal to distill above The site.

ANS: A Use the most distal site in the nondominant arm, if possible. Select a well-dilated vein. Methods to foster venous distention include place the extremity in a dependent position if possible and stroke from distal to proximal below the proposed venipuncture site. Apply warmth to the extremity for several minutes, for example, with a warm washcloth. Vigorous friction and multiple tapping of a vein, especially in older adults, can cause hematoma and/or venous constriction. Avoid vein selection in areas with tenderness, pain, infection, or wounds, or extremities affected by previous stroke (CVA), paralysis, mastectomy, or dialysis graft. Choose a site that will not interfere with the patient's activities of daily living (ADLs).

Which intake and output measurement can the nurse delegate to the nursing assistant? Oral fluid intake Nasogastric tube intake Wound drainage output Intravenous fluid intake

ANS: A You can delegate portions of intake and output measurement to nursing assistants. In many agencies nursing assistants can record oral intake but not intake through tubes or IVs. Nursing assistants can record urine, diarrhea, and vomitus output, but not drainage through wound drainage tubes.

The nurse is caring for a patient who has just been found in respiratory arrest. Which laboratory values will the RN expect to find in the patient's chart? (Select all that apply.) pH 7.28 PaO2 65 mm Hg PaCO2 58 mm Hg HCO3- 15 mEq/L

ANS: A, B, C Normal arterial blood pH value is 7.35 to 7.45 (acidic is less than 7.35, and alkalotic is greater than 7.45). Respiratory acidosis is an increased PaCO2 and an increased hydrogen ion concentration (pH below 7.35) that reflect the excess carbonic acid (H2CO3) in the blood. Hypoventilation produces respiratory acidosis. The elevated PaCO2 level is a result of the patient not breathing (normal range is 35 to 45 mm Hg). The low PaO2 is also a result of not breathing (normal range is 80 to 100 mm Hg). The low HCO3- is not expected as a result of respiratory arrest (normal range is 22 to 26 mEq/L).

The nurse is caring for a patient whose pituitary secretes excessive amounts of antidiuretic hormone (ADH). Which findings will the nurse expect to see during assessment of the patient? (Select all that apply.) The patient's serum sodium level is 122 mEq/L. The patient's serum chloride level is 116 mEq/L. The patient is voiding large amounts of watery urine. The patient's mucus membranes are dry and cracked. The patient has gained 5 pounds and has swollen feet.

ANS: A, E Excessive amounts of ADH (SIADH) will lead to hyponatremia with a serum sodium level of 122 mEq/L. Fluid retention from excess ADH will cause weight gain and swollen feet. Diabetes insipidus (DI) causes hyperchloremia, dry mucus membranes, and excessive urination due to a shortage of ADH.

Which complication is suspected when the patient's IV site is swollen, cool, and pale with no blood return? Phlebitis Infiltration Thrombophlebitis Local inflammation

ANS: B An infiltration occurs when IV fluids leak into the subcutaneous tissue around the venipuncture site because the catheter tip no longer is in the vein. Infiltration causes swelling (from increased interstitial fluid), paleness, and coolness (from decreased circulation) around the venipuncture site. The IV infusion may slow or stop. Pain may occur, increasing as the infiltration progresses. Phlebitis is inflammation of a vein. Signs and symptoms include redness, tenderness, and warmth along the course of the vein starting at the access site, with possibly a red streak and/or palpable cord along the vein. Phlebitis can be dangerous because blood clots (thrombophlebitis) can form, increasing the risk for an embolus, a clot that becomes dislodged and can travel to the lungs. Local infection at the VAD site is possible. The insertion site will be red and/or edematous; exudate may occur.

Which assessment findings indicate that the patient has developed fluid overload as a result of transfusing two units of packed red blood cells? Hypotension and thirst Dyspnea and tachycardia Shivering and high fever Hypotension and urticaria

ANS: B Dyspnea and tachycardia are signs of pulmonary edema and fluid overload after transfusion. Hypotension and urticaria indicate anaphylactic shock. Shivering and high fever are signs of a transfusion reaction rather than fluid overload. Hypotension and thirst indicate fluid deficit.

The patient receives an infusion of albumin to pull water from the tissues into the bloodstream. Which process is demonstrated by this treatment? a. Diffusion b. Osmosis c. Filtration d. Clarification

ANS: B Osmosis is movement of water across a semipermeable membrane from a compartment of lower particle concentration to one that has a higher particle concentration. Diffusion is passive movement of electrolytes or other particles from an area of higher concentration to an area of lower concentration. Filtration is the net effect of several forces that tend to move fluid across a membrane. Clarification is explanation of a concept in greater detail or removal of impurities.

The patient is receiving an intravenous infusion of 40 mEq of potassium chloride in a 1000 mL solution of 0.9% saline. The patient states that the area around the IV site burns. What intervention does the nurse perform first? Notify the physician. Stop the IV infusion. Document the finding. Increase the IV drip rate.

ANS: B The nurse's first action should be to stop the IV infusion and assess the IV site carefully. The physician does not need to be notified. The IV drip rate should not be increased as it will increase tissue damage and phlebitis risk. The finding should be documented after the patient's IV line has been taken care of.

Approximately 30 minutes into the transfusion of this blood product, the patient becomes short of breath with wheezing, low BP, and hives. Which medication must be administered to the patient immediately? 500 mL 0.9 NS IV fluid bolus Epinephrine 0.4 mg IM Diphenhydramine 50 mg IV Methylprednisolone 40 mg IV

ANS: B The patient is experiencing an anaphylactic reaction to the transfusion and requires epinephrine immediately to prevent the development of shock. Methylprednisolone, normal saline IV, and diphenhydramine may be given after epinephrine.

What causes the patient to feel thirsty and drink more water? Colloid osmotic pressure Osmoreceptor stimulation Increased oncotic pressure Decreased hydrostatic pressure

ANS: B Thirst, a conscious desire for water, regulates fluid intake when plasma osmolality increases (osmoreceptor-mediated thirst) or the blood volume decreases (baroreceptor-mediated thirst and angiotensin II-mediated thirst). The thirst-control mechanism is in the hypothalamus of the brain. Osmoreceptors there continually monitor plasma osmolality; when osmolality increases, the hypothalamus stimulates thirst. Colloid osmotic pressure (oncotic pressure) is an inward-pulling force caused by the presence of protein molecules. Hydrostatic pressure is the force of a fluid pressing outward against the walls of its container. Thus capillary hydrostatic pressure is an outward-pushing force.

Which is the priority assessment to be documented prior to administering a blood product to a patient? Strength of peripheral pulses Vital signs and pulse oximetry Presence/absence of bowel sounds Height, weight, and body mass index (BMI)

ANS: B Vital signs and pulse oximetry must be documented before administering a blood product to the patient. This will allow the nurse to compare subsequent findings after the transfusion has started. Peripheral pulses, boNwelRsouIndsG, andBh.eCightM/weight are not as important as vital signs USNT O and pulse oximetry prior to starting a transfusion.

A patient reports chills, dizziness, and feeling hot during a blood transfusion. What are the appropriate actions of the nurse? (Select all that apply.) Slow the rate of infusion. Stop the blood transfusion. Check the patient's vital signs. Notify the physician and blood bank. Restart the patient's IV at a different site.

ANS: B, C, D STOP (do not slow down) the transfusion immediately even when you just suspect a reaction. Remain with the patient, observing signs and symptoms and monitoring vital signs as often as every 5 minutes. Immediately notify the health care provider or emergency response team and the blood bank. The patient's IV should not be restarted at a different site.

The nurse is teaching a patient with vomiting and diarrhea about appropriate dietary fluids. Which option chosen by the patient would indicate further teaching is needed? Ice chips Tap water Black coffee Chicken broth

ANS: C Coffee should be avoided by a patient with vomiting and diarrhea as caffeine is a diuretic that can worsen dehydration. The patient should consume fluids high in Na (e.g., electrolyte oral solution, chicken broth). Strategies to encourage fluid intake include offering small sips of fluid frequently, popsicles, and ice chips.

Which is the best method for measuring the patient's daily weight? Weigh the patient daily using different scales for comparison. Teach that daily weights are done in hospitals, but not at home. Monitor daily weight, comparing with the previous day's weight. Weigh the patient at different times of the day to determine trends.

ANS: C Daily weights are an important indicator of fluid status. Each kilogram (2.2 pounds) of weight gained or lost overnight is equal to 1 L of fluid gained or lost. Weigh heart failure patients daily, as well as other patients who are at high risk for or actually have ECV excess. Obtain the weight at the same time each day with the same calibrated scale after a patient voids. Teach heart failure patients to take and record daily weights at home and to contact their health care provider if weight increases suddenly according to parameters their providers set. Classic research shows that heart failure patients who are hospitalized for decompensated heart failure often experience steady increases in daily weights during the week before hospitalization.

Which patient has the greatest risk for extracellular fluid volume (ECV) deficit? A female with Crohn's disease A male with peptic ulcer disease An infant with fever and vomiting An adolescent with acute appendicitis

ANS: C Fever increases insensible water loss through the skin and lungs. Infants and very young children have relatively more body surface area and higher percentage of body water than older children and adults. They have greater water needs and immature kidneys. Infants are at greater risk for ECV deficit and hypernatremia because their body water loss is proportionately greater per kilogram of weight. Although acute appendicitis may cause vomiting and an active episode of Crohn's disease may cause diarrhea, adolescents and young adults have less risk of ECV deficit than an infant. An older adult has increased risk of ECV deficit if there is a large fluid output; however, peptic ulcer disease ordinarily does not cause a large fluid output.

The nurse is to administer 40 mEq of IV KCl to the patient with severe hypokalemia. Why did the pharmacy send up four 100 mL IV bags with 10 mEq of KCl in each bag? To prevent the patient from receiving too much IV fluid. The four smaller bags are less expensive than one large one. To prevent accidentally infusing the 40 mEq of KCl too quickly. The doctor may change his mind and lower the prescribed KCl dose.

ANS: C Rapid infusion of KCl can cause life-threatening cardiac dysrhythmias. The pharmacy sent up four separate IV bags containing 10 mEq KCl in each to prevent accidentally infusing the 40 mEq of KCL too quickly. Four smaller bags are not necessarily less expensive than one large bag but the cost is less important than patient safety. The small amount of extra fluid is negligible. The infusion may be stopped if the physician lowers the ordered dose of KCl.

Which assessment findings prevent the nurse from starting an IV in the patient's right arm? (Select all that apply.) The patient is right-handed. The IV pole will be on the left side of the bed. c. The patient has a dialysis fistula in the right arm. The patient has right-sided paralysis after a stroke. The patient had a right mastectomy 6 years ago.

ANS: C, D, E Dialysis fistula, history of mastectomy, and paralysis all prevent the nurse from starting the patient's IV in the right arm. The patient's preferences for the right hand and IV pole position have no bearing on where to start the IV

Which patient should receive an IV solution of D5W? A trauma patient with massive hemorrhage A patient being resuscitated after cardiac arrest A patient with CHF and acute pulmonary edema A patient with a serum sodium level of 162 mEq/L

ANS: D D5W solution is used to lower elevated serum sodium levels. Normal saline solution should be administered to hypovolemic patients and during resuscitation after cardiac arrest. D5W solution will worsen fluid overload with CHF and acute pulmonary edema.

The patient reports muscle weakness after taking prescribed furosemide daily. Which laboratory finding will the nurse expect to see in the patient's chart? Chloride 84 mEq/L Sodium 124 mEq/L Calcium 12.6 mg/dL Potassium 2.8 mEq/L

ANS: D Loop diuretics cause hypokalemia. The nurse will expect to find the patient's potassium level to be 2.8 mEq/L as a result. The patient would not have hyponatremia (sodium 124 mEq/L), hypercalcemia (calcium 12.6 mg/dL), or hypochloremia (chloride 84 mEq/L) as a result of taking loop diuretics.

The nurse is caring for a patient with bulimia. The patient vomits after eating and is experiencing tingling of the fingers and toes and muscle cramps. What is the patient's expected acid-base status? Respiratory acidosis Metabolic acidosis Respiratory alkalosis Metabolic alkalosis

ANS: D Metabolic alkalosis results from acid loss from the body or an increase in levels of bicarbonate. The most common causes are vomiting and gastric suction. Respiratory acidosis N R I G B.C Mresults from respiratory diseaseUs orSothNer cTonditioOns that reduce alveolar ventilation (hypoventilation), preventing excretion of the carbonic acid continuously produced by cells. Metabolic acidosis results from conditions that increase metabolic acids in the body or decrease the amount of base (bicarbonate). Diabetic ketoacidosis is a common cause of metabolic acidosis. Hyperventilation produces respiratory alkalosis, which causes cerebrospinal fluid and brain cells to become alkalotic, decreasing the level of consciousness.

The nurse is caring for a patient with a serum potassium level of 7.1 mEq/L. Which is the highest priority nursing diagnosis for this patient? Risk for spiritual distress related to chronic illness despair Powerlessness related to illness-related physical limitations Impaired social interaction related to limited physical activity Risk for decreased cardiac output related to altered heart rhythm

ANS: D The patient's potassium level is dangerously high, which can cause ventricular fibrillation. For this reason the highest priority diagnosis for the patient is risk for decreased cardiac output related to altered heart rhythm. Risk for spiritual distress, powerlessness, and impaired social interaction are not the priority.

The nurse is caring for a dyspneic patient with a long history of smoking. The blood gas report shows a pH of 7.33, PaCO2 of 47, PaO2 of 78, and HCO3- of 26. What is the patient's acid-base status? Respiratory alkalosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

ASN B Normal arterial blood pH value is 7.35 to 7.45 (acidic is less than 7.35, and alkalotic is greater than 7.45). Respiratory acidosis is an increased PaCO2 and an increased hydrogen ion concentration (pH below 7.35) that reflect the excess carbonic acid (H2CO3) in the blood. Hypoventilation produces respiratory acidosis, which causes the cerebrospinal fluid and brain cells to become acidic, thus decreasing the level of consciousness. Respiratory alkalosis is a decreased PaCO2 and increased pH (above 7.45) that reflect the deficit of carbonic acid (H2CO3) in the blood. Metabolic acidosis results from conditions that increase metabolic acids in the body or decrease the amount of base (bicarbonate). The bicarbonate level is always low because the bicarbonate system buffers metabolic acids. Metabolic alkalosis results from a gain of bicarbonate or excessive excretion of metabolic acid.