Chapter 32: Fluid, Electrolytes, and Acid-Base - Foundations

7. A nurse is reviewing the arterial blood gas results of a client. Which pH value would the nurse document as indicating acidosis? 7.30 7.37 7.41 7.47

7.30 Explanation: The normal pH ranges from 7.37 to 7.43. A pH of 7.30 indicates acidosis while a pH of 7.47 indicates alkalosis. A pH of 7.37 or 7.41 would be within normal limits.

10. Which is a common anion? magnesium potassium chloride calcium

chloride Explanation: Chloride is a common anion, which is a negatively charged ion. Magnesium, potassium, and calcium are cations, or positively charged ions.

43. A nurse suspects a client with electrolyte imbalances is experiencing hypomagnesemia. Which nursing assessment finding may indicate hypomagnesemia? hyperactive deep tendon reflexes (DTRs) hypoactive deep tendon reflexes (DTRs) hyperthermia hypothermia

hyperactive deep tendon reflexes (DTRs) Explanation: Hypomagnesemia may lead to heart block, change in mental status, hyperactive deep tendon reflexes (DTRs), and respiratory paralysis.

The nurse is caring for a client who was in a motor vehicle accident and has severe cerebral edema. Which fluid does the nurse anticipate infusing? isotonic hypotonic hypertonic hypotonic, followed by isotonic

hypertonic Explanation: A hypertonic solution is more concentrated than body fluid and draws cellular and interstitial water into the intravascular compartment. This causes cells and tissue spaces to shrink. Hypertonic solutions are used infrequently, except in extreme cases when it is necessary to reduce cerebral edema or to expand the circulatory volume rapidly. The nurse does not anticipate using isotonic fluids.

1. Endurance athletes who exercise for long periods of time and consume only water may experience a sodium deficit in their extracellular fluid. This electrolyte imbalance is known as: hyponatremia. hypernatremia. hyperkalemia. hypokalemia.

hyponatremia. Explanation: Hyponatremia refers to a sodium deficit in the extracellular fluid caused by a loss of sodium or a gain of water. Hypernatremia refers to a surplus of sodium in the ECF. Hypokalemia refers to a potassium deficit in the ECF. Hyperkalemia refers to a potassium surplus in the ECF.

2. Which body fluid is the fluid within the cells, constituting about 70% of the total body water? extracellular fluid (ECF) intracellular fluid (ICF) intravascular fluid interstitial fluid

intracellular fluid (ICF) Explanation: Intracellular fluid is the fluid within the cells, constituting about 70% of total body fluid. Extracellular fluid is all fluid outside the cells and includes intravascular and interstitial fluids.

15. The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy does the nurse identify as out of scope nursing practice? preparing solution for administration ordering type of solution, additive, amount of infusion, and duration performing venipuncture regulating the rate of administration

ordering type of solution, additive, amount of infusion, and duration Explanation: The nurse prepares the solution for administration, performs a venipuncture, regulates the rate of administration, monitors the infusion, and discontinues the administration when fluid balance is restored. The health care provider, not the nurse, specifies the type of solution, additional additives, the volume (in mL), and the duration of the infusion.

A client's most recent arterial blood gases indicate a pH of 7.52 with decreased PaCO2 and decreased HCO3-. What is this client experiencing? respiratory alkalosis with compensation respiratory acidosis without compensation metabolic acidosis with compensation metabolic alkalosis without compensation

respiratory alkalosis with compensation Explanation: A pH of 7.52 constitutes alkalosis and the decreased PaCO2 indicates a respiratory etiology. When compensation occurs, PaCO2 and HCO3- trend in the same direction.

4. A health care provider writes a prescription to "force fluids." What will be the first action the nurse will take in implementing this prescription? Explain to the client why this is needed. Tell the client and family to increase oral intake. Decide how much fluid to increase every 8 hours. Divide the intake so the largest amount is at night.

Explain to the client why this is needed. Explanation: Several techniques are recommended to help the client drink greater than average amounts of fluids. The nurse should begin by explaining to the client in understandable terms the rationale for the increased fluids and the specific goal of taking the daily amount of fluids prescribed. The largest amount of fluid should be consumed during the day to decrease night wakings to void. It is not necessary for the nurse to decide how much fluid to increase every 8 hours

56. Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium? Insulin promotes the transfer of potassium from the extracellular fluid into skeletal muscle and liver cells. Aldosterone enhances renal excretion of potassium. A person loses approximately 30 mEq (30 mmol) of potassium. Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L).

Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L). Explanation: Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

24. By which route do oxygen and carbon dioxide exchange in the lung? osmosis filtration diffusion active transport

diffusion Explanation: Oxygen and carbon dioxide exchange in the lung's alveoli and capillaries by diffusion. Diffusion is the tendency of solutes to move freely throughout a solvent by moving from an area of higher concentration to an area of lower concentration.

46. A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid? maintenance of cell size maintenance of blood volume transportation of nutrients removal of waste

maintenance of cell size Explanation: The main function of the intracellular fluid is to maintain cell size. Vascular fluid is essential for the maintenance of adequate blood volume, blood pressure, and cardiovascular system functioning. Interstitial fluid, which surrounds the body's cells, is important for the transportation of oxygen, nutrients, hormones, and other essential chemicals between the blood and the cell cytoplasm. Vascular and interstitial fluids also are important for waste removal.

49. Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? muscle cramping and tetany nausea, vomiting, and constipation diminished cognitive ability and hypertension muscle weakness, fatigue, and constipation

muscle cramping and tetany Explanation: Manifestations of hypocalcemia include numbness and tingling of fingers, mouth, or feet; tetany; muscle cramps; and seizures. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

26. A home care nurse is teaching a client and family about the importance of a balanced diet. The nurse determines that the education was successful when the client identifies which of the following as a rich source of potassium? Dairy products Apricots Processed meat Bread products

Apricots Explanation: Apricots are a rich source of potassium. Dairy products are rich sources of calcium. Processed meat and bread products provide sodium.

32. The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? "Fluid inside cells." "Fluid outside cells." "Fluid in the tissue space between and around cells." "Watery plasma, or serum, portion of blood."

"Fluid in the tissue space between and around cells." Explanation: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

21. A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? decreased blood volume and intracellular dehydration increased blood volume and intracellular dehydration increased blood volume and extracellular overhydration decreased blood volume and extracellular overhydration

decreased blood volume and intracellular dehydration Explanation: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.

20. A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance? hyponatremia hypokalemia hypercalcemia hypermagnesemia

hypokalemia Explanation: All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia

52. The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? excessive use of laxatives diaphoresis renal failure increased cardiac output

renal failure Explanation: Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

35. An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Ask the client every hour to drink more fluid. Offer small amounts of preferred beverage frequently. Have a loved one tell the client to drink more. Leave water on the bedside table.

Offer small amounts of preferred beverage frequently. Explanation: Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

17. A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? Slow the rate of IV fluids. Remove the IV. Apply a warm compress. Elevate the arm.

Remove the IV. Explanation: The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate, but should occur after the IV is removed.

50. A client is brought into the emergency department with a suspected opioid overdose. The nurse would anticipate that the client would most likely experience which acid-base imbalance? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis Explanation: An overdose of narcotics such as opioid overdose would depress the client's neurologic function and subsequently his breathing ability. The client would most likely develop respiratory acidosis. Respiratory alkalosis is associated with hyperventilation. Metabolic acidosis can occur with loss of bicarbonate, as may happen with severe diarrhea, or with acid accumulation (e.g., ketoacids formed in uncontrolled diabetes mellitus or lactic acids produced by oxygen deprivation). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes of metabolic alkalosis.

19. A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? Allow nothing by mouth. Give the client a glass of orange juice with added sugar. Encourage fluid intake. Start an IV of normal saline as prescribed.

Start an IV of normal saline as prescribed. Explanation: To treat a client with hypovolemia, the nurse should obtain an IV bag with normal saline (0.9% sodium chloride) as prescribed. Fluid intake by mouth will not provide fluid quickly enough for the desired effect but should be attempted if feasible, in addition to an IV. Orange juice with additional sugar may be given to a person with low blood sugar.

37. The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. What is the priority nursing action? Assess oxygen levels. Stop the transfusion. Assess for visible rash. Call for assistance.

Stop the transfusion. Explanation: Life-threatening transfusion reactions generally occur within the first 5 to 15 minutes of the infusion, so the nurse or someone designated by the nurse usually remains with the client during this critical time. Whenever a transfusion reaction is suspected or identified, the nurse's first step is to stop the transfusion, thereby limiting the amount of blood to which the client is exposed. All other options should occur after the transfusion is stopped.

11. Edema happens when there is which fluid volume imbalance? extracellular fluid volume deficit water deficit water excess extracellular fluid volume excess

extracellular fluid volume excess Explanation: When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space.

38. The nurse is calculating an infusion rate for the following order: Infuse 1,000 mL of 0.9% NaCl over 12 hours using an electronic infusion device. What is the infusion rate? 83 mL/hr 103 gtts/hr 100 mL/hr 13 mL/hr

83 mL/hr Explanation: When calculating the infusion rate with an electronic device, divide the total volume to be infused (1,000 mL) by the total amount of time in hours (12). This is 83 mL/hr. Other options are incorrect.

A client has metabolic (nonrespiratory) acidosis. Which type of respirations would be assessed? periods of apnea decreased depth and rate increased depth and rate alternating fast and slow

increased depth and rate Explanation: Metabolic (nonrespiratory) acidosis is a proportionate deficit of bicarbonate in the ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate. The lungs attempt to increase the excretion of carbon dioxide by increasing the rate and depth of respirations.

18. The health care provider is concerned that the client has hypokalemia. During the physical examination, which question should the nurse ask the client? "Have you been experiencing chest pain?" "Have you been experiencing muscle weakness or leg cramps?" "Have you been having diarrhea?" "Have you been experiencing difficulty breathing?"

"Have you been experiencing muscle weakness or leg cramps?" Explanation: Hypokalemia is a potassium deficit. When the level of potassium decreases, potassium moves out of the cells, creating an intracellular potassium deficiency. Typical symptoms include muscle weakness and leg cramps. Hyperkalemia is likely to cause diarrhea. Hypokalemia is not known to cause chest pain or difficulty breathing, unless an arrhythmia occurs due to an imbalance in the potassium level.

8. A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? 3,750 3,000 1,000 500

3,000 Explanation: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? 3.5 cm H2O 5 cm H2O 9.5 cm H2O 12 cm H2O

3.5 cm H2O Explanation: The normal pressure is approximately 4 to 11 cm H2O. An increase in the pressure, such as a reading of 12 cm H2O may indicate an ECF volume excess or heart failure. A decrease in pressure, such as 3.5 cm H2O, may indicate an ECF volume deficit

27. A nurse is calculating the output of a client with renal failure and takes into account all modes of fluid loss. When addressing the client's insensible fluid loss, which amount would the nurse anticipate as the usual average? 100 to 200 mL/day 200 mL/day 300 to 400 mL/day 1500 mL/day

300 to 400 mL/day Explanation: The fluid lost through insensible loss is about 300 to 400 mL/day. Insensible water loss occurs when water molecules move from an area of higher concentration, such as the body, to an area of lower concentration, like the atmosphere. Loss of fluid through the skin as perspiration accounts for an average daily loss of 100 to 200 mL of fluid. Loss of fluid through the gastrointestinal system in the form of feces is approximately 200 mL. Normal urine output for 24 hours is approximately 1500 mL if intake is normal.

6. A nurse is preparing to measure jugular venous distention in a client. To ensure accuracy, the nurse would elevate the head of the client's bed to: 30 degrees 45 degrees 60 degrees 90 degrees

45 degrees Explanation: When measuring jugular venous distention, the nurse would elevate the head of the client's bed to 45 degrees so that the sternal angle is 5 cm above the right atrium. Any other elevation would lead to inaccurate results.

31. Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? Constipation related to immobility Pain related to surgical incision Acute Confusion related to cerebral edema Risk for Infection related to inadequate personal hygiene

Acute Confusion related to cerebral edema Explanation: Edema in and around the brain increases intracranial pressure, leading to the likelihood of confusion. Constipation related to immobility, Pain related to surgical incision, Risk for Infection related to inadequate personal hygiene are nursing diagnoses that have no connection to fluid and electrolyte imbalance.

29. What is the lab test commonly used in the assessment and treatment of acid-base balance? Complete blood count Basic metabolic panel Arterial blood gas Urinalysis

Arterial blood gas Explanation: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level.

28. A home care nurse is visiting a client with renal failure who is on fluid restriction. The client tells the nurse, "I get thirsty very often. What might help?" What would the nurse include as a suggestion for this client? Avoid salty or excessively sweet fluids. Use regular gum and hard candy. Eat crackers and bread. Use an alcohol-based mouthwash to moisten your mouth.

Avoid salty or excessively sweet fluids. Explanation: To minimize thirst in a client on fluid restriction, the nurse should suggest the avoidance of salty or excessively sweet fluids. Gum and hard candy may temporarily relieve thirst by drawing fluid into the oral cavity because the sugar content increases oral tonicity. Fifteen to 30 minutes later, however, oral membranes may be even drier than before. Dry foods, such as crackers and bread, may increase the client's feeling of thirst. Allowing the client to rinse the mouth frequently may decrease thirst, but this should be done with water, not alcohol-based, mouthwashes, which would have a drying effect.

A nurse is performing a venipuncture on an older client. The client has visible veins that appear to roll. What nursing technique is mostappropriate? Avoid use of a tourniquet. Select a large-gauge needle. Consider venipuncture in the foot where veins are less visible. Use the client's nondominant hand to hold the vein in place.

Avoid use of a tourniquet. Explanation: It may be possible and advantageous to avoid using a tourniquet when accessing a vein that is visually prominent on an older adult. Use of a tourniquet may result in bursting the vein, sometimes referred to as "blowing the vein," when it is punctured with a needle. Using a large-gauge needle may also "blow" the vein. A small gauge or butterfly should be used. Using veins in the foot is not appropriate nor is attempting to hold the vein in place.

13. A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that he had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? Banana Milk Yogurt Turkey

Banana Explanation: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

25. A nurse measures a client's 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? Compare the client's intake with the normal range of adult fluid intake. Report the exact milliliter of intake to the physician's office nurse. Compare the total intake and output of fluids for the 24 hours. Ensure that the information is included in the verbal end-of-shift report

Compare the total intake and output of fluids for the 24 hours. Explanation: The nurse must pay attention to certain parameters when assessing a client's fluid status. This means comparing the total intake and output of fluids for a given period of time. It is more accurate to compare the client's fluid intake with the previous time period than another client. The nurse does not need to report that fluid to the physician's nurse but rather document the information in the client's health record and if there are differences then that information should be reported to the physician and the end-of-shift report.

53. The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? Bowel motility will be restored within 24 hours after beginning supplemental K+. ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. ECG will show no cardiac dysrhythmias within 24 hours after beginning supplemental K+. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet.

ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Explanation: If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac dysrhythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.

59. Assessment of a client reveals the following findings: elevated body temperature, dry skin, low urinary output, and increased pulse rate. Which action should the nurse take? Encourage to drink more water. Encourage the intake of salty liquids like broth and tomato juice. Encourage the client to eat foods that contain a high amount of fluid. Encourage the client to eat foods that are low in sodium.

Encourage the intake of salty liquids like broth and tomato juice. Explanation: Treatment for extracellular fluid volume deficit includes either oral or IV replacement of sodium, chloride, and water in the same concentrations found in body fluid. The nurse can use oral rehydration fluids and salty liquids such as broth and tomato juice and/or IV normal saline (0.9% sodium chloride). Drinking additional water or foods that contain a high amount of fluid will not provide the sodium required for recovery.

A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed? Isotonic Hypertonic Hypotonic Osmolar

Hypertonic Explanation: A hypertonic solution has a greater osmolarity than plasma, which causes water to move out of the cells and be drawn into the intravascular compartment. A hypotonic solution has a lower osmolarity than plasma; therefore, fluid would move out of the intravascular space rather than pulling fluids from the tissues into the vascular space. An isotonic fluid remains in the intravascular compartment without any net flow across the semipermeable membrane. The concentration of particles in a solution is referred to as the osmolarity of a solution.

45. 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? Infants have less total body fluid and ECF than adults. Infants have more total body fluid and ECF than adults. Infants drink less fluid than adults. Infants lose more fluids through output than adults.

Infants have more total body fluid and ECF than adults. Explanation: 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. Because infants' main food is from breast milk or formula, typically infants drink more than adults.

51. A group of nursing students is reviewing information about the body's electrolytes. The students demonstrate understanding of the material when they identify which electrolyte as having a reciprocal relationship with calcium? Sodium Potassium Phosphorus Magnesium

Phosphorus Explanation: Calcium and phosphorus typically show a reciprocal relationship such that an increase in one leads to a decrease in the other. Sodium is the major cation in the extracellular fluid. Sodium, potassium, and magnesium do not share a relationship with calcium.

3. A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan? Impaired Skin Integrity Risk for Deficient Fluid Volume Impaired Urinary Elimination Urinary Retention

Risk for Deficient Fluid Volume Explanation: An appropriate nursing diagnosis for a client taking a diuretic that increases urinary output would be Risk for Deficient Fluid Volume. The nurse would educate the client on the symptoms of dehydration, how to increase fluid intake, and the need to maintain a record of daily weights. Diuretics do not affect elimination or cause urinary retention. In addition, diuretics do not affect the skin.

55. Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). Sodium is regulated by the renin-angiotensin-aldosterone system. If sodium is low, it means that there is not enough water. Sodium is not regulated by natriuretic peptides

Sodium is regulated by the renin-angiotensin-aldosterone system. Explanation: Normal serum sodium levels range from 135 to 145 mEq/L (135 to 145 mmol/L). Water usually follows sodium so if sodium is low, it means that there is too much water. Sodium along with chloride and a proportionate volume of water are regulated by the renin-angiotensin-aldosterone system and natriuretic peptides.

58. The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? Tighten the roller clamp to stop the infusion. Twist the tubing around a pencil. Tap the tubing below the air bubbles. Milk the air in the direction of the drip chamber.

Tighten the roller clamp to stop the infusion. Explanation: The priority nursing action is to tighten the roller clamp on the tubing as this action prevents forward movement of air. All other options are appropriate to remove the air once the tubing has been clamped.

44.Which statement most accurately describes the process of osmosis? Water moves from an area of lower solute concentration to an area of higher solute concentration. Solutes pass through semipermeable membranes to areas of lower concentration. Water shifts from high-solute areas to areas of lower solute concentration. Plasma proteins facilitate the reabsorption of fluids into the capillaries.

Water moves from an area of lower solute concentration to an area of higher solute concentration. Explanation: Osmosis is the primary method of transporting body fluids, in which water moves from an area of lesser solute concentration and more water to an area of greater solute concentration and less water. Solutes do not move during osmosis. Plasma proteins do not facilitate the reabsorption of fluid into the capillaries, but assist with colloid osmotic pressure, which is related to, but not synonymous with, the process of osmosis.

A nurse is caring for a postoperative client who reports feeling dizzy when getting up from bed. The nurse suspects extracellular fluid (ECF) volume deficit and assesses the effect that position change has on pulse rate and blood pressure. What would the nurse interpret as indicative of ECF volume deficit? a drop of more than 15 mmHg in systolic pressure a drop of more than 10 mmHg in diastolic pressure an increase in pulse rate of more than 20 beats per minute dizziness when standing up suddenly

an increase in pulse rate of more than 20 beats per minute Explanation: An increase in pulse rate of more than 20 beats per minute indicates ECF volume deficit in the client. A drop of more than 15 mmHg in systolic pressure or 10 mmHg in diastolic pressure with an increase in pulse rate frequently means the client is experiencing ECF volume depletion. However, an increase in pulse rate of more than 20 beats per minute is a more sensitive indicator of ECF volume deficit than is a decrease in blood pressure. Dizziness when standing up suddenly is not a specific symptom, as it may be related to many other disease conditions.

42. The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? calcium and phosphorus potassium and sodium chloride and magnesium potassium and chloride

calcium and phosphorus Explanation: The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance.

23. A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? cardiac irregularities muscle weakness increased intracranial pressure (ICP) metabolic acidosis

cardiac irregularities Explanation: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac dysrhythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

33. The nurse is monitoring intake and output (I&O) for a client who recently had surgery. Which will the nurse document on the I&O record? Select all that apply. client drinking milk client's urination client eating a sandwich vomiting infusion of intravenous solution.

client drinking milk client's urination vomiting infusion of intravenous solution Explanation: The nurse will document all fluid intake and fluid loss. This includes drinking liquids, urination, vomitus, and fluid infusion. Ingested solids, such as a sandwich, are not included in the intake and output.

22. A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the bestindication of the client's fluid status? daily weights daily BUN and serum creatinine monitoring output measurements daily electrolyte monitoring

daily weights Explanation: Due to the possible numerous sources of inaccuracies in fluid intake and output measurement, the record of a client's daily weight may be the more accurate measurement of a client's fluid status. Laboratory tests are helpful in assessing kidney function and electrolyte values, but do not provide the precise information on fluid losses or gains as is provided by a daily weight (at the same time, using the same scale). Output measurements are not meaningful without intake measurements.

54. A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? muscle twitching distended neck veins fingerprinting over sternum nausea and vomiting

distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

30. The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is: fluid volume deficit. myocardial infarction. fluid volume excess. atelectasis.

fluid volume excess. Explanation: A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess.

The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase that may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? isotonic hypotonic hypertonic plasma

hypertonic Explanation: Because a hypertonic solution has a greater osmolarity, water moves out of the cells and is drawn into the intravascular compartment, causing the cells to shrink. Because of a lower osmolarity, a hypotonic solution in the intravascular space moves out of the intravascular space and into intracellular fluid, causing cells to swell and possibly burst. An isotonic fluid remains in the intravascular compartment. Plasma is an isotonic solution.

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? hypervolemia hypovolemia edema circulatory overload

hypovolemia Explanation: The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.

14. A nurse is preparing an education plan for a client with heart failure who is experiencing edema. As part of the plan, the nurse wants to describe the underlying mechanism for why the edema develops. Which mechanism would the nurse most likely address? increased hydrostatic pressure decreased colloid oncotic pressure blockage of the lymph nodes increased capillary permeability

increased hydrostatic pressure Explanation: The edema that occurs with heart failure is caused by decreased cardiac output with a back-up of blood resulting from increased hydrostatic pressure. Decreased colloid oncotic pressure is the mechanism responsible for edema of malnutrition, liver failure, and nephrosis. Lymph node blockage is the mechanism responsible for edema associated with a mastectomy or lymphoma. Increased capillary permeability is the mechanism responsible for edema associated with allergies, septic shock and pulmonary edema.

A client is diagnosed with metabolic acidosis. The nurse develops a plan of care for this client based on the understanding that the body compensates for this condition by: increasing ventilation through the lungs. increasing the excretion of HCO3− into the urine. decreasing the excretion of H+ ion into the urine. preventing excretion of acids into the urine.

increasing ventilation through the lungs. Explanation: The body compensates for the metabolic acidosis by increasing ventilation through the lungs, thus increasing the rate of carbonic acid excretion, resulting in a fall in PaCO2. To compensate for respiratory alkalosis, the kidneys increase the excretion of HCO3− to the urine. Kidneys compensate for respiratory acidosis by increasing the excretion of H+ ion into the urine. The kidneys respond to metabolic alkalosis by retaining acid and excreting HCO3−.

48. The nurse, along with a nursing student, is caring for Mrs. Roper, who was admitted with dehydration. The student asks the nurse where most of the body fluid is located. The nurse should answer with which fluid compartment? interstitial extracellular intracellular intravascular

intracellular Explanation: Intracellular is the fluid within cells, constituting about 70% of the total body water. Extracellular is all the fluid outside the cells, accounting for about 30% of the total body water. Interstitial fluid is part of the extracellular compartment. Intravascular is also part of the extracellular compartment.

12. A nurse is assessing a client and suspects an ECF volume excess. Which finding would the nurse identify as being most significant? weight gain of 0.75 kg in a day increased blood pressure bounding pulse slightly distended neck veins

weight gain of 0.75 kg in a day Explanation: Although increased blood pressure, bounding pulse, and distended neck veins are signs of ECF volume excess, rapid weight gain (more than 0.5 kg per day) is the most significant symptom indicating ECF volume excess. A weight gain of 1 kg reflects retention of 1 L of ECF. Additionally, because the veins are very distensible, large volumes of fluid can be retained without any increase in blood pressure or changes in pulse or neck veins.

40. While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance? "How much do you typically urinate during the day?" "How often do you usually have a bowel movement?" "How often do you experience leg cramps? "How much coffee do you drink during a typical day?"

"How much do you typically urinate during the day?" Explanation: Questions and leading statements about fluid balance are part of a comprehensive health history. Urinary output is one factor to consider in fluid balance. Bowel movements, especially if a client is having multiple loose stools a day, may affect fluid balance but is not the most appropriate question to ask. Leg cramps can occur when there is an electrolyte imbalance but is not the most appropriate question. Lastly, coffee can have diuretic-like properties but is also not the most appropriate question to ask to assess fluid balance.

16. A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? "I need to drink no more than 1,000 mL/day" "I should drink 1,500 mL/day of fluid." "I should drink 2,500 mL/day of fluid." "I should drink more than 3,500 mL/day of fluid."

"I should drink 2,500 mL/day of fluid." Explanation: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.

60. A client is prescribed a diuretic as part of the treatment plan for heart failure. The nurse educates the client about the drug and dietary measures to prevent complications. What statement made by the client indicates the need for further education? "I will add spinach to my salads." "I will increase my snacking on apricots." "I will start drinking orange juice daily." "I will add carrots to my vegetable side dishes."

"I will add spinach to my salads." Explanation: The client needs to increase consumption of potassium-containing foods such as apricots, orange juice, and carrots. Spinach is high in calcium and magnesium but not potassium.

57.A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I was breathing so fast because I was so anxious and in so much pain." "I've been taking antacids almost every 2 hours over the past several days." "I've had a fever for the past 3 days that just doesn't seem to go away." "I've had a GI virus for the past 3 days with severe diarrhea."

"I've been taking antacids almost every 2 hours over the past several days." Explanation: Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.

47. The nurse is assessing a newly admitted client and finds that he has edema of his right ankle that is 2 mm and just perceptible. The nurse documents this at which grade? 1+ 2+ 3+ 4+

1+ Explanation: The edema in the client should be graded as 1+, which means that the edema is just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates moderate edema of 4 to 6 mm. A measurement of 4+ indicates severe edema of 8 mm or more.

34. The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O? 23-year-old with ulnar and radial fracture 34-year-old whose urinary catheter was discontinued yesterday 48-year-old who has had a bowel movement after surgery 55-year-old with congestive heart failure on furosemide

55-year-old with congestive heart failure on furosemide Explanation: Agencies often specify the types of clients that are placed automatically on I&O. Generally, they include clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy. The client with congestive heart failure that is on a diuretic should have I&O documented. The other clients do not require the nurse to document all I&O.

36. The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate? "Granulocytes are a type of white blood cell that can help fight infection." "Granulocytes replace clotting factors that are altered from infection." "Granulocytes help third spacing of fluid that occurs with infection." "Granulocytes help to control bleeding associated with infection."

Granulocytes are a type of white blood cell that can help fight infection." Explanation: Granulocytes are a type of white blood cell that are used to fight infection. All other options are incorrect statements related to granulocytes.

9. Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease? The secretion of aldosterone and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess. Increased plasma levels of antidiuretic hormone lead to water excess. There may be an abnormal loss or accumulation of sodium, chloride, potassium, and fluid in the body, resulting in extracellular fluid and water excesses or deficits. Hyperkalemia and hypocalcemia are common, and metabolic acidosis occurs in this disease's final stage. A disruption of acid-base balance occurs. A disruption in this organ's ability to excrete carbon dioxide causes the pH of the person's blood to fall.

Increased plasma levels of antidiuretic hormone lead to water excess. Explanation: In addition to increased plasma levels of antidiuretic hormones, plasma levels of albumin decrease, so that the distribution of extracellular fluid changes, vascular volume decreases, and interstitial volume increases. Complications often lead to ascites. Complications from cardiac failure can be described as the secretion of aldosterone, and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess. Hyperkalemia and hypocalcemia are common, and metabolic acidosis occurs with renal failure. Complications associated to respiratory failure include a disruption of acid-base balance and a disruption in this organ's ability to excrete carbon dioxide; this causes the pH of the person's blood to fall.

The nurse is assessing a client who was hospitalized due to a fall with brief loss of consciousness. Which sign(s) alerts the nurse that the client is severely dehydrated? Select all that apply. The client has dark-colored urine with a noticeable odor. The client reports dizziness when standing up from a chair. The client has been working outside in warm temperatures. The client reports having increased saliva production. The client reports a loss of 3 lb (1.4 kg) over the past 2 weeks.

The client has dark-colored urine with a noticeable odor. The client reports dizziness when standing up from a chair. The client has been working outside in warm temperatures. Explanation: Signs of severe dehydration or hypovolemia can include having concentrated, dark-colored urine that can carry an odor, due to the high specific gravity. Dizziness when changing positions caused by postural hypotension, a condition that results from a rapid drop in blood pressure when standing from sitting or sitting up from lying down, can happen when the client is experiencing a fluid volume deficit secondary to severe dehydration as a result of lower blood volume in circulation. Any client who work outside in warm temperatures is at risk for dehydration. The combination of activity with warm temperatures leads to increase insensible fluid losses through sweat and respiration. A client with severe dehydration would report having a dry mouth with reduced saliva production. A weight lost of 3 lb (1.4kg) over 2 weeks is not considered concerning or indicative of severe dehydration. A client who has lost over 2 lb (2.8 kg) over 24 hours, however, would indicate the severe dehydration. A weight loss of 9% to 15% of body weight over a short period of time could indicate severe fluid volume deficit.

A nurse explains the homeostatic mechanisms involved in fluid homeostasis to a student nurse. Which statements accurately describe this process? Select all that apply. The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. 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. The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance.

The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. The lungs regulate oxygen and carbon dioxide levels of the blood, which is especially crucial in maintaining acid-base balance. The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus. Explanation: Fluid homeostasis normally functions automatically and effectively. Almost every organ and system in the body helps in some way to maintain fluid homeostasis. The kidneys selectively retain electrolytes and water and excrete wastes and excesses according to the body's needs. The cardiovascular system is responsible for pumping and carrying nutrients and water throughout the body. The adrenal glands secrete aldosterone, a mineralocorticoid hormone that helps the body conserve sodium, helps save chloride and water, and causes potassium to be excreted. The lungs regulate oxygen and carbon dioxide levels of the blood. Regulation of the carbon dioxide level is especially crucial in maintaining acid-base balance. Thyroxine, released by the thyroid gland, increases blood flow in the body, leading to increased renal circulation and resulting in increased glomerular filtration and urinary output. The parathyroid glands secrete parathyroid hormone, which regulates the level of calcium and phosphorus. Parathyroid hormone draws calcium into the blood from the bones, kidneys, and intestines. It also facilitates the movement of phosphorus from the blood to the kidneys, where it is excreted in the urine.

41. The nurse is administering albumin to a client to promote movement of fluid into the capillaries. The "pulling force" of fluid by use of a protein such as albumin is known as: colloid oncotic pressure. diffusion. osmosis. active transport.

colloid oncotic pressure. Explanation: Plasma proteins, particularly albumin, concentrated in the intravascular space or plasma facilitate the reabsorption of fluid into the capillaries by the action of colloid oncotic 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.

5. A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: electrolytes. nonelectrolytes. colloid solution. interstitial fluid.

electrolytes. Explanation: The nurse knows that the client's electrolytes need to be restored. Rehydration after exercise can only be achieved if the electrolytes lost in sweat, as well as the lost water, are replaced. The client does not need to have nonelectrolytes, colloid solution, or interstitial fluid restored. Nonelectrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane.