Chapter 39- Fluid, Electrolyte, and Acid-Base Balance
A nurse is administering a potassium supplement to a patient. What will the nurse do to disguise the taste and decrease gastric irritation? A) dilute it B) give it after meals C) mix it with food D) freeze it
A
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? A) 300 mL B) 1,000 mL C) 1,300 mL D) 2,600 mL
A
A physician writes an order to force fluids. What will be the first action the nurse will take in implementing this order? A) Explain to the patient why this is needed. B) Tell the patient and family to increase oral intake. C) Decide how much fluid to increase each 8 hours. D) Divide the intake so the largest amount is at night.
A
Cross-matching of blood is ordered for a patient before major surgery. What does this process do? A) determines compatibility between blood specimens B) determines a persons blood type C) predicts the amount of needed blood replacement D) specifies the donor and the recipient of the blood
A
The nursing assessment of the client demonstrated a change in level of consciousness (LOC), tremors, and weakness. Which lab result result indicates hyponatremia? A. Serum sodium level 122 mEq/L B. Serum sodium level 137 mEq/L C. Serum sodium level 148mEq/L
A
Which of the following descriptions best summarizes fluid homeostasis? A) Almost every body organ and system helps maintain homeostasis. B) The cardiovascular and renal systems primarily maintain homeostasis. C) Homeostasis is maintained through intra- and extracellular exchange. D) Homeostasis is maintained by the arterioles, capillaries, and venules.
A
Which of the following patients would be the most likely candidate for the administration of total parenteral nutrition? A) a patient with severe pancreatitis B) a patient with a myocardial infarction C) a patient with hepatitis B D) a patient with mild malnutrition
A
Which of the following questions about fluid balance would be appropriate when conducting a health history for a patient? A) Describe your usual urination habits. B) Describe your problems with constipation. C) How did you feel when your calcium was low? D) Do you eat fruits and vegetables each day?
A
A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which of the following statements accurately describe this process? Select all that apply. A) The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the bodys needs. B) The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. C) The thyroid gland secretes aldosterone, a mineralocorticoid hormone that helps the body conserve sodium, helps save chloride and water, and causes potassium to be excreted. D) The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acidbase balance. E) Thyroxine, released by the adrenal glands, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output. F) The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus.
A, B, D, F
The nurse has received reports on their clients for the evening shift. Which client is at most risk for hypokalemia and requires monitoring? A. The client taking a loop diuretic B. The vegetarian whose diet is rich in banana, dried fruits, nuts, avacados, and bran C. The client suffering from occasional constipation D. The client with advanced renal disease
A. diuretic
The nurse is caring for a group of clients. Which of the following clients would be at an increased risk for the development of fluid volume deficit? Select all that apply a. A client with food poisoning who is vomiting b. A client who is hemorrhaging from an injury c. A client who is diaphoretic d. A client who is generating too much antidiuretic hormone
A. vomiting
A Nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? Select all that apply a. Increased heart rate b. Increased blood pressure c. Increased Hematocrit d. Increased temperature
ABC
A home care patient is complaining of weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request? A) The nurse is concerned that the patients diet has caused sodium loss. B) The nurse recognizes these symptoms of hypokalemia. C) The patient is actively seeking increased attention. D) The patient had bananas and orange juice for breakfast.
B
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? A) high Fowlers B) low Fowlers C) Sims D) dorsal recumbent
B
A patient is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base a teaching plan? A) Impaired Skin Integrity B) Risk for Deficient Fluid Volume C) Impaired Urinary Elimination D) Urinary Retention
B
A patient scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this? A) The patients family members have been donors. B) The patient donates his or her own blood. C) The patients blood has been rendered sterile. D) The patient will only need fluids, not blood.
B
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? A) Infants have less total body fluid and ECF than adults. B) Infants have more total body fluid and ECF than adults. C) Infants drink less fluid than adults. D) Infants lose more fluids through output than adults.
B
Which body fluid is the fluid within the cells, constituting about 70% of the total body water? A) extracellular fluid (ECF) B) intracellular fluid (ICF) C) intravascular fluid D) interstitial fluid
B
1. The student nurse studying fluid and electrolyte balance learns that which of the following is a function of water? Select all that apply. A) provide a medium for transporting wastes to cells and nutrients from cells B) provide a medium for transporting substances throughout the body C) facilitate cellular metabolism and proper cellular chemical functioning D) act as a buffer for electrolytes and nonelectrolytes E) help maintain normal body temperature F) facilitate digestion and promote elimination
B, C, E, F
You are the nurse and you suspect your patient with electrolyte abnormalities may be experiencing hypomagnesemia. What assessment finding indicates hypomagnesemia? A. Hypothermia B. Decreased deep tendon reflexes C. Increased deep tendon reflexes D. Hyperthermia
B. decreased DTR
fluid volume excess S/S:
BP high, HR high, CRACKLES in lungs, skin edema!!!, bounding pulse, jugular vein distention, increased hematocrit, taught & shiny skin
A nurse measures a patients 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? A) Compare the patients intake with the normal range of adult fluid intake. B) Report the exact milliliter of intake to the physicians office nurse. C) Compare the total intake and output of fluids for the 24 hours. D) Ensure that the information is included in the verbal end-of-shift report.
C
A nurse reads a complete blood count report for a patient who has been admitted to the hospital with fluid overload from late-stage kidney disease. What abnormal result would the nurse expect to find? A) increased white blood cells B) increased platelets C) decreased hematocrit D) increased hematocrit
C
A patient has metabolic (nonrespiratory) acidosis. What type of respirations would be assessed? A) periods of apnea B) decreased depth and rate C) increased depth and rate D) alternating fast and slow
C
A patients PaCO2 is abnormal on an ABG report. Which of the following illnesses would most likely be the medical diagnosis? A) rheumatoid arthritis B) sexually transmitted infection C) chronic obstructive pulmonary disease D) infection of the bladder and ureters
C
A woman has had her left breast removed for cancer. She also had an axillary node dissection on the left during surgery. How would this affect placement of an intravenous line? A) Either arm may be used. B) Neither arm should be used. C) The left arm should not be used. D) The right arm should not be used.
C
By what route do oxygen and carbon dioxide exchange in the lung? A) osmosis B) filtration C) diffusion D) active transport
C
Which of the following locations might the nurse use to assess the condition of an insertion site for a central venous access device? A) below the sternum B) over the fourth intercostal space C) over the jugular vein D) the back of the hand
C
A patient's most recent blood work indicates a potassium level of 7.2 mEq/L. What signs and symptoms should the nurse monitor vigilantly for? A. Muscle weakness B. Increased intracranial pressure C. Cardiac irregularities D. Metabolic acidosis
C. cardiac irregularities
The nurse is caring for a group of clients on a medical-surgical unit. Which of the following clients should the nurse monitor closely for the signs of fluid volume overload? a. The client with a serum sodium of 145 b. The client with a history of difficulty swallowing' c. The client with impaired renal function d. The client receiving diuretics
C. impaired renal function
A nurse reads the laboratory report for a patient and notes that the patient has hyponatremia. What physical assessment would be made? A) Observe skin color and texture. B) Auscultate bowel sounds. C) Percuss lung density. D) Palpate skin of sternum.
D
A patient asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond? A) There is only a very small chance; I know you will be safe. B) Although hepatitis is possible, AIDS is not. C) If I were you, I would request special handling of my blood. D) There is no way you can contract a disease by giving blood.
D
A patient has a decreased potassium level. What high-potassium foods would the nurse teach the patient to eat? A) lunch meat, salted nuts, whole milk B) buttermilk, hard candy, spinach C) carbonated beverages, beer, olives D) oranges, bananas, broccoli
D
A patient has an order to restrict fluids. What is one comfort measure nurses can implement for this patient to alleviate a common problem? A) back rubs B) chewing gum C) hair care D) oral hygiene
D
A patient is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than 4 hours. What should the nurse do next? A) Continue with the transfusion and document the drip rate. B) Report to the next shift the amount of blood left to infuse. C) Take and record vital signs more often. D) Discontinue the blood transfusion.
D
A specially trained nurse has inserted a PICC line. What would be done next? A) Start administration of prescribed fluids. B) Explain the procedure to the patient and family. C) Place the patient on restricted oral fluids. D) Send the patient to the radiology department.
D
A student is learning how to administer intravenous fluids, including accessing a vein. Although all of the following may occur, which is the most potentially harmful risk posed for the patient when accessing the vein? A) discomfort B) pain C) minor bleeding D) infection
D
What is the average adult fluid intake and loss in each 24 hours? A) 500 to 1,000 mL B) 1,000 to 1,500 mL C) 1,500 to 2,000 mL D) 1,500 to 3500 mL
D
Which patient is at most risk for fluid volume deficient?* • A. A patient who has been vomiting and having diarrhea for 2 days. • B. A patient with continuous nasogastric suction. • C. A patient with an abdominal wound vac at intermittent suction. • D. All of the above are correct.
D. all of the above
•You are taking a patient's blood pressure manually. As you pump up the cuff above the systolic pressure for a few minutes you notice that the patient develop a carpal spasm. Which of the following is true?* • A. The patient is having a normal nervous response to an inflating blood pressure cuff that is inflated above the systolic pressure • B. This is known as Trousseau's Sign and is present in patients with HYPERcalcemia • C. This is known as Chvostek's Sign • D. This is known as Trousseau's Sign and is present in patients with hypocalcemia
D. trousseau's sign (hypocalcemia)
HYPOnutremia:
Not enough Na+ cause: vomiting, diarrhea, severe burns Will cause edema in cells → SWELLING OF BRAIN Seizure, cramping, abdominal discomfort Treat: eat processed meats, salty foods, canned foods, cheese, RESTRICT fluid volume
Which lab value should the nurse be most concerned about with the client receiving furosemide (Lasix) therapy (diuretic) BUN of 20 Potassium of 3.4 Creatinine of 1.1 Sodium of 150
Potassium of 3.4
fluid volume deficit signs / symptoms
Skin tenting HH is increased Electrolytes increased!!! (low volume of water so electrolyte concentration increases) Suctioning: can cause fluid volume deficit Elderly: have a decrease in total body water due to decreased muscle mass
The nurse is told during shift report that their client has a positive Chvostek's sign. You would expect the laboratory test results to reveal which of the following? a. A total serum calcium level below 8.8 b. A total serum calcium level above 10.1 c. An ionized calcium level above 5.3 d. An ionized calcium level between 4.4 and 5.3
a.
Which body fluid lies in spaces between the body cells? a. Interstitial b. Intracellular c. Intravascular d. Transcellular
a. interstitial
•Which patient is at most risk for hypomagnesemia?* • A. A 55 year old chronic alcoholic • B. A 57 year old with hyperthyroidism • C. A patient reporting overuse of antacids and laxatives • D. A 25 year old suffering from hypoglycemia
a. the alcoholic
The nurse is caring for a client with difficulty swallowing. Which of the following potential diagnosis related to dysphagia is the highest priority? a. Impaired nutrition b. Aspiration c. Self-care deficit d. Fluid volume deficit
b. ASPIRATION
A patient admitted with heart failure requires careful monitoring of fluid status. What assessment parameter is the best indicator of fluid status? A. Intake and Output levels B. Daily weight C. Electrolyte levels D. Skin turgor
b. daily weights
The nurse is caring for a group of older adult patients and monitors them closely for signs of dehydration. Which of the following is a rationale for why older adults are at an increased risk of dehydration? a. They have more efficient kidney function b. They have a decrease in total body water c. They have a decrease in skin turgor d. They have an increase in their thirst mechanism
b. decreased in total body water
A nurse identifies that an older adult patient may have a problem with excess fluid volume. Which characteristics of the patient's skin support this conclusion? a. Dry and scaly b. Taught and shiny c. Red and irritated d. Thin and dry
b. taught and shiny
It is especially important for the nurse to assess which of the following in a patient who has just undergone a total thyroidectomy? a. Weight gain b Depressed reflexes c Positive Chvostek's sign d Confusion and personality changes
c
A client is receiving a loop diuretic. The nurse should be alert to which of the following symptoms: a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms
c.
Which electrolyte is the primary regulator of fluid volume? a. Potassium b. Calcium c. Sodium d. Magnesium
c. SODIUM = primary regulator of fluid volume
A patient is admitted to the hospital for a fever of an unknown origin. The nursing assessment reveals profuse diaphoresis, dry sticky mucous membranes, weakness, disorientation, and a decreasing level of consciousness. Which electrolyte imbalance does this data support? a. Hyperkalemia b. Hypercalcemia c. Hypernatremia d. Hypermagnesemia
c. hypernatremia
Hypomagnesemia
change in mental status, tetany, twitching, tremors Alcohol abuse patients are most at risk!!
A nurse is assessing a patient who has a calcium level of 8.0 mg/dl. Which of the following findings should the nurse expect? a. Dry sticky mucous membranes b. Polyuria c. Negative Chvosteck's sign d. Muscle tremors
d. muscle tremors
fluid volume deficit causes
hemorrhage, burns, nausea, vomiting, diarrhea
Hypercalcemia
hyperactive bowel sounds, renal disease Treat: HYDRATE
hypocalcemia
inadequate calcium intake, alcohol abuse signs: Truso's, positive Chvostek's sign, muscle tremors Treat: foods high in calcium Need vitamin D to help calcium absorb
hypokalelmia
irregular pulse, EKG changes, muscle weakness / cramps, Dsryhtmias Treat: Monitor pulse, HYPERtonic solution with potassium (may irritate peripheral IV → slow down rate do NOT stop it!!!!)
hyperkalemia
kidney failure, EKG changes, skeletal/muscle WEAKNESS, DECREASED deep tendon reflexes!!!! Goal: decrease the K+
hypercalcemia
kidney failure, too many antacids, prolonged immobilization Will see: kidney stones, muscle weakness, bone pain Treat: HYDRATE
fluid volume excess causes
too much IV fluid, too much PO fluid, kidney failure, drowning, too much Na+
hypernutremia
too much Na+: dehydration, kidney failure, decreased level of consciousness Will cause: Twitching, seizures Treat: limit salty food, give them a HYPOtonic solution!!!!
