Module 11 Study Quiz

Of the four patients receiving care, which patient's chart leads the nurse to suspect development of a fluid volume deficit? PATIENT A: Dx: Diabetes insipidus; Restlessness, decreased skin turgor & cap refill, urine sp gravity 1.037 PATIENT B: Dx. Heart Failure; Headache, polyuria, dyspnea, urine sp gravity 1.003 PATIENT C: Dx. Heat Stroke; Flushed skin, n/v, urine sp gravity 1.025 PATIENT D: Syndrome of Inappropriate antidiuretic hormone(SIADH); Generalized muscle weakness, hyporeflexia, urine sp gravity 1.008 Patient A Patient B Patient C Patient D

Patient A Rationale The clinical manifestations of fluid volume depletion include restlessness, decreased skin turgor, decreased capillary refill, and concentrated urine and can be caused by diabetes insipidus, so Patient A is the correct answer. Heart failure—as in Patient B—can be a cause of fluid volume excess, not deficit. Heatstroke—as in Patient C—can be a cause of fluid volume deficit; however, in this case the urine specific gravity is within normal limits, and flushed skin, nausea, and vomiting are signs of heatstroke. SIADH—as in Patient D—can be a cause of fluid volume excess, not deficit.

Which patient statements indicate understanding of nursing instructions regarding skin care management? Select all that apply. A. "Avoid extreme temperatures." B. "Apply moisturizers even at night." C. "Wash my hands and legs frequently with soap." D. "Change my position regularly while at rest." E. "I will not use the foot lift on my recliner."

A. "Avoid extreme temperatures." B. "Apply moisturizers even at night." D. "Change my position regularly while at rest." Rationale Good skin care management is essential to prevent fluid loss. The patient should limit the use of soap to prevent the skin from drying. The nurse should advise the patient to either take precautions or to avoid extreme temperatures in order to avoid dehydration of the skin. Regular skin care by applying moisturizers and changing positions while at rest help to maintain skin hydration and may prevent skin breakdown. Elevation of extremities promotes venous return, so the patient would elevate the feet when in a recliner.

The nurse provided care instructions for an older adult patient's dementia and fluid balance maintenance at home. Which caregiver statements indicate understanding of the nurse's teachings? Select all that apply. A. "I should increase fluid intake and lower dietary sodium." B. "I should provide fluids only when the patient voices thirst." C. "I should assist the patient when holding utensils and cups." D. "I should encourage the patient to pass urine before going to bed." "E. I will make sure the patient has a glass of milk near them all the time."

A. "I should increase fluid intake and lower dietary sodium." C. "I should assist the patient when holding utensils and cups." D. "I should encourage the patient to pass urine before going to bed." Rationale The caregiver would decrease the patient's dietary sodium intake. Musculoskeletal changes such as stiffness of the hands and fingers may lead to an inability to hold containers and requires assistance. The patient should make a habit of urinating before bed to decrease the chance of nocturia. Mental status alterations are a common problem in old age and may lead to decreased ability to express thirst and obtain fluids. Therefore older adult patients are always encouraged to drink fluids, even when they are not requesting them. The patient would need to increase their intake of other fluids, with water being the better fluid source.

Which grade of edema would the nurse document when the patient's skin is cool, sternal skin is taut, and sternal pressure with a thumb yields a 2-mm indentation? A. 1+ B. 2+ C. 3+ D. 4+

A. 1+ Rationale Cool, taut, and hard skin indicates fluid accumulation. An indentation of 2-mm after pressing with the thumb to assess edema indicates a grade of 1+. A 4-mm indentation warrants a grade of 2+, a 6-mm indentation a grade of 3+, and an 8-mm indentation a grade of 4+.

Which clinical manifestations would the nurse anticipate when providing care for a patient with hyperkalemia? Select all that apply. A. 1+ deep tendon reflexes B. Rapid and shallow respirations C. Serum blood glucose level of 250 mg/dL D. Numbness and tingling in the hands and feet E. Ventricular fibrillation noted on the electrocardiogram

A. 1+ deep tendon reflexes D. Numbness and tingling in the hands and feet E. Ventricular fibrillation noted on the electrocardiogram Rationale Clinical manifestations of hyperkalemia include decreased reflexes, paresthesia, and an irregular pulse. These are manifested in 1+ deep tendon reflexes, numbness and tingling in the hands and feet, and ventricular fibrillation noted on an electrocardiogram, respectively. Rapid and shallow respirations and hyperglycemia (serum blood glucose of 250 mg/dL) would be anticipated when providing care to a patient with hypokalemia, not hyperkalemia.

For a patient with heart failure, which interventions would the nurse include in the plan of care when the patient has 4+ edema of the lower extremities and sacral area? Select all that apply. A. Elevate edematous lower extremities. B. Protect the patient's tissues from extreme heat or cold. C. Apply moisturizing creams or lotions to the skin frequently. D. Rotate the patient from left side-lying to right side-lying every two hours. E. Frequently assess for edema in areas where soft tissue covers bony areas. F. Encourage the patient to double fluid intake to improve tissue integrity.

A. Elevate edematous lower extremities. B. Protect the patient's tissues from extreme heat or cold. C. Apply moisturizing creams or lotions to the skin frequently. E. Frequently assess for edema in areas where soft tissue covers bony areas. Rationale Providing proper skin care is vitally important in patients dealing with edema to prevent impaired skin and tissue integrity. Elevating the edematous extremities helps promote venous return. Protecting the patient's tissues from extreme hot or cold decreases the possibility of skin or tissue impairment. Applying moisturizers to the skin frequently promotes moisture retention and stimulates circulation. Edema tends to accumulate in areas where tissue overlies bone such as the sacrum, tibia, and fibula and must be assessed frequently to avoid the risk of pressure ulcers. The patient's position should be frequently changed but is not restricted to side-lying. There is not enough data to determine the fluid needs of the patient, and this is not a standard intervention but is based upon patient need.

Which intervention would the nurse implement to relieve the edema associated with a patient's soft tissue injury to their ankle? A. Elevating the extremity B. Massaging the ankle every one to two hours C. Applying a warm compress to the ankle D. Applying warm saline soaks to the extremity

A. Elevating the extremity Rationale Elevation promotes good venous return, allowing extracellular fluid to flow more readily away from the edematous area. In addition, ice or a cold compress helps ease edema and pain. Warm saline soaks, massage of the extremity, and warm compresses will increase venous circulation and congestion, thereby worsening the edema, as well as the pain.

For the patient with recent removal of a pituitary tumor, which clinical manifestation would the nurse report immediately to the health care provider? A. Excessive thirst B. Calcium level of 8.6 mg/dL C. Potassium level of 3.5 mEq/L D. Urine output of 300 mL in eight hours

A. Excessive thirst Rationale A patient who has had surgery on the pituitary gland is at risk for diabetes insipidus. Excessive thirst is an indicator of inadequate antidiuretic hormone (ADH) synthesis or release. The nurse should monitor the urine output closely and notify the health care provider of excessive thirst. One would expect large volumes of urine in the absences of ADH production. A urine output of 300 mL in eight hours would not be alarming. The calcium and potassium levels are at the low end of normal. The nurse should continue to monitor these electrolytes.

Which clinical manifestations would the nurse observe when assessing cardiovascular changes in a patient suspected of having a medical diagnosis of fluid volume excess? Select all that apply A. Full, bounding pulse B. Distended neck veins C. Orthostatic hypotension D. Increase in the heart rate E. Presence of an S3 heart sound

A. Full, bounding pulse B. Distended neck veins E. Presence of an S3 heart sound Rationale Fluid volume excess results in a full, bounding pulse; presence of an S3 heart sound; and jugular venous distention (distended neck veins). Orthostatic hypotension and an increased heart rate are clinical manifestations of deficient, not excess, fluid volume.

A patient with chronic kidney disease is experiencing severe hyperphosphatemia. The nurse notifies the health care provider in anticipation of which ordered treatment? A. Hemodialysis B. Fluid restriction C. Potassium supplementation D. Loop diuretic therapy

A. Hemodialysis Rationale For severe hyperphosphatemia, hemodialysis can decrease levels rapidly. Fluid restriction, potassium supplementation, and diuretic therapy without volume expansion are not treatment options for hyperphosphatemia.

When extracellular fluid and intracellular fluid have the same osmolality, which term would the nurse use? A. Isotonic B. Hypotonic C. Hypertonic D. Oncotic pressure

A. Isotonic Rationale Extracellular fluid and intracellular fluid have the same osmolality; this characteristic is termed isotonic, meaning that there is no net movement of fluids. Hypotonic refers to fluids with a lower osmolality, which results in water moving into the cell when the cell is surrounded by a hypotonic fluid. Hypertonic refers to fluids with a higher osmolality, which results in water moving out of the cells when they are surrounded by a hypertonic solution. Oncotic pressure refers to the pressure of plasma colloids in a solution.

Which assessments would the nurse perform to avoid risk factors associated with administration of a hypertonic solution to a patient with dehydration? Select all that apply. A. Lung sounds B. Bowel sounds C. BP D. Serum sodium level E. Serum potassium level

A. Lung sounds C. BP D. Serum sodium level Rationale BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions. Bowel sounds and serum potassium levels do not need to be monitored frequently.

Which patient outcome would the nurse use to evaluate the effectiveness of the treatment regimen for a patient's dehydration? A. Oral intake balances output. B. Oral intake is less than output. C. Oral intake is greater than output. D. No significant difference in fluid balance.

A. Oral intake balances output. Rationale Oral intake should equal output if fluid balance has been restored and dehydration has been corrected. Less intake than output would result in dehydration. Greater intake than output may indicate decreased renal function or impaired ability to excrete urine.

When a patient is admitted with dehydration, which intervention would the nurse include in a patient's plan of care? A. Perform daily weights. B. Reorient the patient hourly. C. Restrict sodium intake to 2 grams per day. D. Provide continuous oxygen saturation monitoring.

A. Perform daily weights. Rationale Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. The nurse would recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water. This patient is not disoriented, and that is not a common assessment finding in a patient with dehydration. Continuous oxygen saturation monitoring is not indicated. Sodium intake does not need to be restricted.

Which clinical manifestations support a patient's admitting diagnosis of fluid volume excess related to heart failure? Select all that apply. A. Polyuria B. Dizziness C. Lung crackles D. Muscle spasms E. Peripheral edema F. Increased respiratory rate

A. Polyuria C. Lung crackles D. Muscle spasms E. Peripheral edema Rationale Heart failure can cause fluid volume excess, which is characterized by polyuria, fluid in the lungs causing crackles, muscle spasms, and peripheral edema. Dizziness and increased respiratory rate are clinical manifestations of fluid volume deficit, not excess.

For which clinical manifestations would the nurse monitor a patient with a total serum calcium level of 11.2 mg/dL? Select all that apply. A. Polyuria B. Hypotension C. Nephrolithiasis D. Chvostek's sign E. Trousseau's sign

A. Polyuria C. Nephrolithiasis Rationale Plasma concentration of calcium greater than 10.2 mg/dL indicates hypercalcemia, which results in increased concentration of calcium in the urine. This impairs sodium and water reabsorption and causes polyuria. Hypercalcemia can cause kidney stones, or nephrolithiasis, because an increased concentration of calcium in the urine deposits crystals in the kidney, which combine to form kidney stones. Hypotension, Chvostek's sign, and Trousseau's sign are clinical manifestations of hypocalcemia.

When assessing a patient's skin turgor, the nurse pinched a fold of skin over the sternum and released the fold. Return of the skin to the original position required 22 seconds. Which term would the nurse use to document this finding? A. Poor B. Lagged C. Normal D. Decreased

A. Poor Rationale Poor skin turgor is characterized by skin that takes 20 to 30 seconds to return to normal after being pinched. "Lagged" is not a term used to describe skin turgor. With normal skin turgor, the skin resumes shape within seconds of being released. "Decreased" skin turgor is too vague a description of the finding.

A patient's prescription was 0.9% sodium chloride (normal saline) IV at a rate of 100 mL per hour. The current bag of 1000 mL was hung at 1000. During 1300 rounds, the nurse notes the IV bag contains 900 mL of normal saline. When completing the incident report, which error would the nurse record? A. Wrong rate B. Wrong route C. Wrong solution D. Wrong documentation

A. Wrong rate Rationale After three hours of infusion time, 300 mL of IV solution should have infused, but the patient has received 100 mL. Therefore the patient has received the wrong rate, regardless of the reason (infiltration, turned off, IV pump stopped). The solution, route, and documentation are correct.

Which revision to a plan of care would the nurse integrate for a patient with a new diagnosis of hypercalcemia resulting from treatment of hypocalcemia? A.Encourage weight-bearing exercises. B. Teach the patient to breathe into a bag. C. Administer IV calcium gluconate. D. Administer a thiazide diuretic rather than a loop diuretic.

A.Encourage weight-bearing exercises. Rationale A patient with hypercalcemia as a result of treatment for hypocalcemia would require the addition of weight-bearing exercises to the plan of care. These exercises will facilitate the movement of extra calcium ions in the blood to the bone. Teaching the patient to breathe into a bag, administering calcium gluconate, and administering a thiazide diuretic are all appropriate for hypocalcemia; therefore these actions should be removed from the revised plan of care, not added.

Which process of molecule transport would occur when a patient develops pedal edema and their blood pressure is 160/90 mm Hg? A.Osmosis B. Diffusion C. Active transport D. Facilitated diffusion

A.Osmosis Rationale A patient with blood pressure of 160/90 mm Hg has hypertension and develops pedal edema due to excess sodium in the blood. This leads to movement of water down the gradient. Therefore the water from the blood vessels moves from higher concentrations to lower concentration across the semipermeable membrane with the help of osmotic pressure and leads to accumulation of water in the extracellular spaces. This movement of water across a semipermeable membrane to balance the solute is called osmosis. Diffusion and facilitated diffusion involve molecules moving from a higher to lower concentrations, and active transport involves molecules moving from a lower to higher concentration.

After removing 5 liters of fluid during a patient's paracentesis, which IV solution may be used to pull fluid into the intravascular space? A. 0.9% sodium chloride B. 25% albumin solution C. Lactated Ringer's solution D. 5% dextrose in 0.45% saline

B. 25% albumin solution Rationale After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action.

The patient with an adrenal gland tumor reports feeling unusually sleepy and extremely thirsty. Which action, per protocol, would the nurse implement when the patient is at risk for hypernatremia secondary to primary aldosteronism? A. Encourage sodium intake. B. Administer furosemide (Lasix). C. Administer conivaptan (Vaprisol). D. Change IV fluids to normal saline.

B. Administer furosemide (Lasix). Rationale A tumor of the adrenal glands may cause hypersecretion of aldosterone, resulting in hypernatremia. Hypernatremia should be treated with a diuretic (to promote excretion of excess sodium) and with sodium-free IV fluids such as 5% dextrose in water (to dilute the sodium concentration). Sodium intake should also be restricted. Conivaptan is administered when treating hyponatremia. Normal saline is 0.9% sodium chloride, which increases the amount of sodium; use sodium-free fluids.

When preparing to administer IV albumin 5% to a patient, the nurse understands the solution is used to treat which metabolic alteration? A. Alkalosis B. Hypovolemia C. Hyperkalemia D. Mixed acid-base disorder

B. Hypovolemia Rationale Albumin is a colloid solution that pulls fluid into the blood vessels, which restores blood volume. This medication is used to treat hypovolemia. Albumin is not effective in the treatment of alkalosis, hyperkalemia, or a mixed acid-base disorder.

Which health care provider prescription will the nurse implement when admitting a patient with fluid volume deficit due to severe diarrhea? A. Restrict the patient's dietary sodium intake. B. Insert an IV access and infuse lactated Ringer's solution. C. Transfuse packed red blood cells as soon as they are available. D. Initiate hypertonic sodium chloride IV fluids.

B. Insert an IV access and infuse lactated Ringer's solution. Rationale To correct fluid volume deficit due to severe diarrhea, the nurse should anticipate a prescription for lactated Ringer's solution which is isotonic and replaces fluid and electrolytes. Giving hypertonic sodium chloride would exacerbate the patient's dehydration. A blood transfusion would be given if the fluid volume deficit was due to blood loss and not dehydration. Sodium intake should be restricted in case of fluid volume excess.

Which clinical manifestation would the nurse expect to see when assessing a patient with hypocalcemia? A. Shortened ST segment B. Prolonged QT segment C. Ventricular dysrhythmias D. Increased digitalis effects

B. Prolonged QT segment Rationale A prolonged QT segment is a clinical manifestation the nurse should expect to see when assessing a patient with hypocalcemia. A shortened ST segment, ventricular dysrhythmias, and increased digitalis effects are anticipated when assessing a patient with hypercalcemia.

Which conditions would the nurse associate with the patient being monitored for clinical manifestations of hyperkalemia? Select all that apply. A. Alkalosis B. Renal failure C. Low blood volume D. Large urine volume E. Adrenal insufficiency

B. Renal failure E. Adrenal insufficiency Rationale Hyperkalemia is a condition in which there is an abnormal increase of potassium in the blood. Renal failure may cause hyperkalemia, because the kidneys cannot remove potassium from the body. Adrenal insufficiency causes aldosterone deficiency, which leads to the retention of potassium ions and also may result in hyperkalemia. Alkalosis is typically associated with hypocalcemia, not hyperkalemia. Low blood volume and a large urine volume can result in hypokalemia.

Which patient disorder has a potential complication of developing increased extracellular fluids? A. Osmotic diuresis B. Renal impairment C. Intestinal obstruction D. Drainage from a rectal fistula

B. Renal impairment Rationale Extracellular fluid accounts for one third of total body fluids, which consist of interstitial fluid, plasma, and transcellular fluid. The extracellular fluid may become excessive when the elimination of water is impaired, especially during kidney failure. Conditions such as fistula drainage, osmotic diuresis, and intestinal obstruction result in a loss of body fluid.

Which intervention would the nurse implement when a pregnant patient reports headaches and shortness of breath and the nurse auscultates crackles and a bounding pulse? A. Apply hot and cold compresses. B. Restrict the intake of dietary sodium. C. Ask the patient to sit and then stand. D. Provide ice chips to hydrate the patient.

B. Restrict the intake of dietary sodium. Rationale A pregnant woman with increased extracellular fluid may develop hypertension and pregnancy-related complications. Restriction of dietary sodium helps to control the fluid accumulation and may help to maintain fluid balance. Application of warm and cold compresses will not relieve the patient's symptoms. Changing the position does not benefit the patient, and providing ice chips may increase the fluid volume and worsen the condition.

A patient with heart failure accidentally overused the prescribed diuretics. For which potential respiratory manifestation would the nurse monitor? A. Shortness of breath B. Pulmonary congestion C. Increased respiratory rate D. Moist crackles on inspiration

C. Increased respiratory rate Rationale Patients with deficient fluid volume experience decreased tissue perfusion and hypoxia resulting in an increased respiratory rate. Pulmonary congestion, shortness of breath, and moist crackles on inspiration are all characteristic of a fluid volume excess, not deficit.

Which statement would the nurse use in response to a patient's inquiry about why his or her health care provider prescribed a b-type natriuretic peptide (BNP)? A. "The BNP is a diagnostic procedure to rule out urine retention." B. "The peptide is a blood test elevated in patients with hyponatremia." C. "The blood test will let us know if there is excess fluid in the heart." D. "The test is an x-ray that helps determine the presence of stomach ulcers."

C. "The blood test will let us know if there is excess fluid in the heart." Rationale BNP is a hormone produced when the atrial pressure increases. This blood test is used to diagnose the severity and treatment outcomes of congestive heart failure (CHF). The atrial pressure increases because of increased venous return and hypernatremia. The test gives no information to rule out urine retention or the presence of stomach ulcers. A serum sodium level is needed to determine hyponatremia.

Which fluid and electrolyte imbalance would the nurse associate with the patient's laboratory data: Na + 132 mEq/L, BUN 5 mg/dL, and HCT 33%? A. Hyperkalemia B. Hypernatremia C. Excess fluid volume D. Deficient fluid volume

C. Excess fluid volume Rationale A decreased sodium level (normal sodium ranges from 135 to 145 mEq/L), decreased BUN (normal BUN ranges from 7 to 20 mg/dL), and decreased HCT (normal level 35% to 47% for women and 39% to 50% for men) indicate fluid volume excess. The patient has hyponatremia, not hypernatremia, because the sodium level is below 135 mEq/L. There is no indication from the data that the patient is hyperkalemic. Because these values indicate excess, the patient is not at risk for a fluid volume deficit, nor does he or she have one.

The nurse prepares to administer a lactated Ringer's IV solution to a patient requiring supportive care after several days of vomiting and diarrhea. Clinical manifestations include a urine specific gravity of 1.040 with 15 mL urine output in one hour, BP 84/48 mm Hg upon standing, and a heart rate of 100 beats/min. The nurse would associate the clinical manifestations and the IV solution with treatment of which imbalance? A. Hyponatremia B. Hyperkalemia C. Extracellular fluid volume deficit D. Extracellular fluid volume excess

C. Extracellular fluid volume deficit Rationale A patient history of vomiting and diarrhea for the past several days, postural hypotension, increased heart rate, and decreased urine output all indicate fluid volume deficit. Balanced IV solutions such as lactated Ringer's solution are commonly used to treat fluid volume deficit. The signs and symptoms do not support a diagnosis of hyponatremia, hyperkalemia, or fluid volume excess

Which clinical manifestations would the nurse evaluate for the presence of dehydration in the older adult patient admitted with nausea and vomiting? Select all that apply. A. Hypertension B. Bradypnea C. Tachycardia D. Restlessness E. Urine output 10 mL/hr

C. Tachycardia D. Restlessness E. Urine output 10 mL/hr Rationale Decreased urine output below 30 mL/hour, tachycardia, and restlessness are all signs of dehydration. Dehydration will cause hypotension and would increase, not decrease, respiratory rate.

Which mechanism would the nurse use to explain a patient's insensible water loss of an estimated 900 mL/day? A. Excreted via urine B. Excreted in the feces C. Vaporized by the lungs and skin D. Secreted into the digestive tract

C. Vaporized by the lungs and skin Rationale Approximately 600-900 mL of water is lost each day via insensible water loss, which is vaporization by the lungs and skin. Approximately 1500 mL is excreted in the urine and 100 mL in the feces. Approximately 8000 mL of digestive fluids are secreted daily, but most are reabsorbed in the gastrointestinal tract.

Which assessment finding is consistent with a phosphate level of 1.8 mg/dL? A. Tetany B. Diarrhea C. Weakness D. Muscle cramps

C. Weakness Rationale Signs of hypophosphatemia include weakness, confusion, coma, and diminished reflexes. Tetany and muscle cramps are manifestations of hyperphosphatemia. Diarrhea is commonly seen with sodium and potassium imbalances.

A family member inquires as to the meaning of "third spacing," which the nurse used when assessing their loved one, who has acute pancreatitis. Which explanation would the nurse use to explain the process? A. "This is just a term that we use to describe generalized edema." B. "Third spacing refers to how the fluids are distributed in the cells and vessels." C. "Third spacing describes potential fluid locations, such as the cells, blood vessels, and lymph system." D. "Fluid becomes trapped between the cells or in the abdomen and has difficulty moving back into the cells."

D. "Fluid becomes trapped between the cells or in the abdomen and has difficulty moving back into the cells." Rationale Third spacing refers to the collection of excess fluid in the nonfunctional areas between the cells. The fluid becomes trapped and has difficulty moving back into the cells. First spacing describes the normal distribution of fluids in the intracellular fluid and extracellular fluid compartments. Second spacing refers to edema. "Extracellular" and "intracellular" are terms that describe places where fluids can be found in the cells, blood vessels, and lymph system.

When planning the care of a patient with dehydration, which data would the nurse instruct the unlicensed assistive personnel (UAP) to report? A. 60 mL urine output in 90 minutes B. 1200 mL urine output in 24 hours C. 300 mL urine output per 8-hour shift D. 20 mL urine output for two consecutive hours

D. 20 mL urine output for two consecutive hours Rationale The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for two consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

Which task may a registered nurse (RN) on a general medical-surgical unit delegate to a licensed practical nurse (LPN), as permitted by the state nurse practice act? A. Administering a saline infusion to a patient with diabetic ketoacidosis B. Assessing a patient with heart failure who has signs of fluid overload C. Determining if an IV infusion should be given to a patient with an acid-base imbalance D. Decreasing the rate of an existing IV infusion for a patient about to be discharged home

D. Decreasing the rate of an existing IV infusion for a patient about to be discharged home Rationale Depending on the state's nurse practice act, an LPN can adjust the IV infusion rate for stable patients. A patient about to be discharged home is considered stable. Clients with diabetic ketoacidosis, acid─base imbalance, and fluid overload are not considered stable, so tasks related to IV infusions and fluid status for these patients cannot be delegated to the LPN.

Which type of imbalance would the nurse associate with a patient who has second-degree (partial-thickness) burns over 30% of the total body surface area with poor skin turgor, urine output of <50 mL over the past two hours, a rapid and thready pulse, and restlessness? A. Hyperkalemia B. Metabolic acidosis C. Hyperphosphatemia D. Extracellular fluid volume deficit

D. Extracellular fluid volume deficit Rationale Patients with burns are susceptible to third-space shifts, resulting in extracellular fluid volume deficit. Extracellular fluid volume deficit is characterized by poor skin turgor, decreased urine output, a rapid and thready pulse, and restlessness. Hyperkalemia is characterized by weakness, irregular pulse, and paresthesias. Hyperphosphatemia is characterized by numbness and tingling, hyperreflexia, tetany, and seizures. Metabolic acidosis is characterized by drowsiness, confusion, decreased BP, dysrhythmias, nausea, and vomiting.

A patient's treatment resulted in blood sugar levels decreasing from 210 mg/dL to 150 mg/dL. Which method of fluid movement between intracellular and extracellular fluids support the effectiveness of the patient's treatment? A. Osmosis B. Diffusion C. Active transport D. Facilitated diffusion

D. Facilitated diffusion Rationale Facilitated diffusion is a process that involves the movement of molecules from higher concentrations to lower concentrations by a protein carrier across the membrane. It is a passive process in which the glucose molecules are transported into the cell by combining with the carrier molecule from extracellular fluid to intracellular fluid. Osmosis allows transport of molecules from lower concentration to higher concentration across the semipermeable membrane. It occurs mainly during urine formation in the kidneys. Diffusion is a simple process of movement of molecules from higher to lower concentration. Active transport is a process similar to diffusion but occurs in the presence of external energy.

Which fluid shift would the nurse anticipate in the patient with dehydration related to nausea and vomiting? A. Fluid movement from the blood vessels into the cells B. Fluid movement from the interstitial spaces into the cells C. Fluid movement from the blood vessels into interstitial spaces D. Fluid movement from the interstitial space into the blood vessels

D. Fluid movement from the interstitial space into the blood vessels Rationale In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.

Which clinical manifestation would the nurse associate with the patient's admitting problem of deficient fluid volume related to nausea and vomiting? A. Polyuria B. Decreased pulse C. Difficulty breathing D. General restlessness

D. General restlessness Rationale Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma. Polyuria, decreased pulse, and difficulty breathing do not support a determination of deficient fluid volume.

Which clinical manifestation would the nurse relate to a patient's body temperature of 103° F (39.4° C)? A. Muscle spasm B. Bounding pulse C. Jugular vein distention D. Orthostatic hypotension

D. Orthostatic hypotension Rationale Orthostatic or postural hypotension is the clinical manifestation the nurse should anticipate observing when assessing a patient with a body temperature of 103° F (39.4° C). The febrile patient will have reduced blood volume from fluid loss due to sweating and increased insensible water loss, as well as vasodilation from heat. Although a reduced blood volume with an elevated temperature would produce an increased pulse rate, it would not be a bounding pulse. Muscle spasm, a bounding pulse, and jugular vein distention are manifestations of an increase (not a decrease) in blood volume.