NSG 310 - Foundations - DavidEdge for F+E, Acid Base, Oxygenation

Question 2. A nurse evaluates a client who has received diuretic therapy for FVE. Which finding should indicate to the nurse that the therapy has been effective? 1. Decrease in body weight 2. Increase in respiratory rate 3. Decrease in urine output 4. Increase in blood pressure

1 (Rationale Option 1: A decrease in body weight should indicate to the nurse that therapy for FVE has been effective. A decrease in body weight corresponds to a decrease in excess fluid, which is the goal of diuretic therapy. Option 2: An increase in respiratory rate is a sign of FVE. Option 3: A decrease in urine output is a potential cause or sign of FVE. Option 4: An increase in blood pressure is a sign of FVE.)

Question 7. What can the nurse expect the patient to do when urine output is less than fluid intake? 1. Gain weight 2. Void frequently 3. Become jaundiced 4. Experience nausea

1 (Rationale Option 1: Fluid weighs 1 kg (2.2 lb) per liter. A patient can gain 6 to 8 pounds before edema can be identified through inspection. Option 2: The opposite is true; the patient will void infrequently. Option 3: Jaundice is related to impaired liver function, not fluid volume excess. Option 4: Nausea is not a common symptom of fluid volume excess.)

Question 3. A patient's urine specific gravity is 1.035. Which does the nurse conclude is needed based on this test result? 1. Fluids 2. Protein 3. Glucose 4. Antibiotics

1 (Rationale Option 1: Specific gravity indicates the degree of concentration of dissolved substances in the urine. Expected specific gravity is 1.010 to 1.030. The higher the specific gravity, the more concentrated the urine. Concentrated urine indicates dehydration; fluids are indicated when a patient is dehydrated. Option 2: A negative nitrogen balance, not an increased specific gravity, indicates the need for increased protein intake. Option 3: An increased urine specific gravity is not related to the need for an increase in glucose. Option 4: An increased white blood cell count or a positive culture and sensitivity, not specific gravity, indicates the presence of infection and the need for antibiotics.)

Question 7. A nurse is obtaining a health history from a patient who is has a serum potassium level of 3.2 mEq. What patient statement indicates a potential precipitating cause of this clinical manifestation? Course Topic: Fluids and Electrolytes Concept(s): Communication; Critical Thinking; Fluid and Electrolyte BalanceCognitive Level: Analysis [Analyzing] 1. "I've had diarrhea for several days." 2. "We eat a lot of green leafy vegetables in our house." 3. "I take electrolyte supplements because I'm on a diuretic." 4. "My blood glucose has been very high lately because I have diabetes."

1 (Rationale Option 1: The expected serum potassium level is 3.5 to 5.0 mEq; a level of 3.2 mEq indicates hypokalemia. Potassium is an ion found in gastrointestinal fluids; vomiting, gastric decompression, and diarrhea all can result in hypokalemia. Option 2: This should not result in hypokalemia. Green leafy vegetables, such as spinach, contain potassium. Option 3: Excessive intake of potassium chloride can result in hyperkalemia, not hypokalemia. Option 4: Diabetic ketoacidosis precipitates hyperkalemia; potassium, an intracellular ion, is released when cells break down to meet energy needs.)

Question 8. A nurse notes that a client diagnosed with congestive heart failure is hypertensive and has gained 3 pounds (1.4 kilograms) over the past 24 hours. Which nursing diagnosis is most appropriate for this client? 1. Fluid Volume Excess 2. Fluid Volume Deficit 3. Decreased Cardiac Output 4. Ineffective Breathing Pattern

1 (Rationale Option 1: The most appropriate nursing diagnosis for this client is Fluid Volume Excess (FVE). Hypertension and weight gain are classic signs of FVE. Option 2: Hypotension would be associated with fluid volume deficit. Option 3: Hypotension would be associated with decreased cardiac output. Option 4: Although a nursing diagnosis of Ineffective Breathing Pattern may be appropriate for this client, there is not enough information to suggest that it would apply at this time.)

Question 3. A nurse is caring for a client diagnosed with fluid volume excess (FVE). Which electrolyte imbalance should the nurse associate with the development of FVE? 1. Sodium 2. Calcium 3. Magnesium 4. Phosphate

1 (Rationale Option 1: The nurse should associate a sodium imbalance with the development of FVE. Sodium is the major cation in the extracellular fluid (ECF) and maintains ECF osmolarity. Option 2: Calcium does not directly affect fluid volume status. Option 3: Magnesium does not directly affect fluid volume status. Option 4: Phosphate does not directly affect fluid volume status.)

Question 18. A nurse is assessing a client for signs of hypocalcemia. Which action should the nurse perform to assess for the presence of Trousseau's sign? 1. Apply a blood pressure cuff to the upper arm, inflate the cuff to a reading higher than the client's systolic blood pressure for 1 to 4 minutes, and observe for carpopedal spasm. 2. Tap the facial nerve anterior to the earlobe and just below the zygomatic arch, and observe for facial twitching on the same side as the stimulus. 3. Assess the biceps, triceps, and brachioradialis reflexes of the arm and wrist, and observe for hyperstimulation. 4. Instruct the client to hyperventilate, and observe for muscle spasms of the hands or feet.

1 (Rationale Option 1: The nurse should elicit Trousseau's sign by inflating a blood pressure cuff on the upper arm to a reading higher than the client's systolic blood pressure for 1 to 4 minutes and observing for carpopedal spasm, which indicates the presence of hypocalcemia. Option 2: Chvostek's sign is elicited by tapping the client's facial nerve anterior to the earlobe and observing for twitching of the mouth, nose, or cheek on the same side as the stimulus. Option 3: Hypocalcemia increases neuromuscular irritability and results in cells that depolarize more easily and at inappropriate times, increasing DTRs, but this does not constitute a positive Trousseau's sign. Option 4: Hyperventilation may elicit a positive Trousseau's sign, but one would not observe for muscle spasms in the hands and feet.)

Question 9. Which vital sign reading should a nurse associate with the development of fluid volume deficit (FVD)? Course Topic: Fluids and Electrolytes Concept(s): Critical Thinking; Fluid and Electrolyte BalanceCognitive Level: Analysis [Analyzing] 1. Blood pressure (BP) 82/58 mm Hg, pulse 115 bpm, respirations 24 breaths per minute 2. BP 100/70 mm Hg, pulse 86 bpm, respirations 20 breaths per minute 3. BP 110/80 mm Hg, pulse 72 bpm, respirations 18 breaths per minute 4. BP 140/70 mm Hg, pulse 68 bpm, respirations 16 breaths per minute

1 (Rationale Option 1: The nurse should recognize a decrease in blood pressure (82/58 mm Hg) and an increase in pulse rate (115 bpm) as indicative of FVD. The normal accepted adult range is 100 to 120 mm Hg for systolic blood pressure and 60 to 80 mm Hg for diastolic blood pressure. The normal resting adult heart rate ranges from 60 to 100 bpm. The normal adult respiratory rate is 12 to 20 breaths per minute. Option 2: These vital signs are all within normal limits. Option 3: These vital signs are all within normal limits. Option 4: A blood pressure of 140/70 mm Hg would be associated with fluid volume excess, not FVD. The pulse and respiratory rates are within normal limits.)

Question 15. A patient is receiving a potassium-sparing diuretic. For which nontherapeutic effect should the nurse assess the patient? 1. Muscle weakness 2. Hypoactive reflexes 3. Respiratory depression 4. Dry, sticky mucous membranes

1 (Rationale Option 1: This is a classic nontherapeutic response to a potassium-sparing diuretic that indicates hyperkalemia. The amount of potassium accumulating in the blood eventually causes hyperkalemia. Option 2: Hypoactive reflexes indicate hypercalcemia. Hypocalcemia, not hypercalcemia, is a nontherapeutic response to a potassium-sparing diuretic. Option 3: Respiratory depression indicates hypermagnesemia. Hypomagnesemia, not hypermagnesemia, is a nontherapeutic response to a potassium-sparing diuretic. Option 4: Dry, sticky mucous membranes indicate hypernatremia, which is not a nontherapeutic response to a potassium-sparing diuretic.)

Question 19. A client develops moist crackles and dyspnea while receiving an IV infusion. Based on this information, which nursing interventions are appropriate for this client? Select all that apply. 1. Stop the infusion and notify the primary health-care provider. 2. Assess the client for peripheral edema. 3. Place the client in semi-Fowler's position. 4. Elevate the client's head of bed to 60 degrees. 5. Administer oxygen via nasal cannula at 2 L/min.

1, 2, 4, 5 (Rationale Option 1: The nurse should stop the infusion and notify the primary health-care provider. Moist crackles and dyspnea are classic signs of fluid overload. IV fluids should be stopped to prevent further fluid volume excess. Option 2: The nurse should assess the client for peripheral edema because it is a sign of fluid overload. Option 3: Elevating the client's head of bed to 30 degrees (semi-Fowler's position) does not promote cardiac and respiratory function with the same effectiveness as Fowler's position. Option 4: The nurse should place the client in Fowler's position (45 to 60 degrees) to ease respiratory effort. Option 5: The nurse should administer oxygen to the client to ease the work of breathing.)

Question 19. A nurse is evaluating a client who has been treated for fluid volume deficit (FVD). Which findings should indicate to the nurse that the client's FVD has not resolved? Select all that apply. 1. Decrease in skin turgor 2. Weak, rapid pulse 3. Increase in blood pressure 4. Decrease in urine output 5. Increase in serum hematocrit

1, 2, 4, 5 (Rationale Option 1: a decrease in skin turgor is a sign of FVD. Option 2: a weak, rapid pulse should indicate to the nurse that the client's FVD has not resolved. Option 3: an increase in the client's blood pressure would indicate that the client's FVD has improved. Option 4: the client's FVD has not resolved if the client continues to exhibit a decrease in urine output. Option 5: the client's serum hematocrit level would increase in the presence of FVD because there is less blood volume, which increases the red blood cell concentration (hemoconcentration).)

Question 14. A nurse assesses a newly admitted client with a serum sodium level of 120 mEq/L. The nurse should observe the client for which clinical manifestations? Select all that apply. 1. Disorientation 2. Constipation 3. Generalized weakness 4. Tachypnea 5. Headache

1, 3, 5 (Rationale Option 1: The nurse should observe the client with hyponatremia (a serum sodium level less than 135 mEq/L) for changes in mental status, including disorientation, confusion, and personality changes, which are caused by cerebral edema. Option 2: Constipation is not associated with sodium imbalance. Diarrhea may occur in a client with hyponatremia (a serum sodium level less than 135 mEq/L). Option 3: Weakness, nausea, vomiting, and diarrhea may also occur in a client with hyponatremia (a serum sodium level less than 135 mEq/L). Option 4: Tachypnea is not associated with a sodium imbalance. Option 5: Cerebral edema is directly responsible for headache, which may be an indication of the development of hyponatremia; observe a client with hyponatremia (a serum sodium level less than 135 mEq/L) for signs of headache.)

Question 18. A client presents to a clinic reporting fatigue, shortness of breath, and restlessness. A nurse assesses the client, suspecting fluid volume excess (FVE). Which manifestations, if identified during assessment, should the nurse associate with FVE? Select all that apply. 1. Oliguria 2. Weak pulse 3. Weight loss 4. Crackles in lungs 5. Decreased respirations

1, 4 (Rationale Option 1: The nurse should associate oliguria and the presence of crackles in lungs with fluid volume excess. Other signs of FVE include weight gain, a bounding pulse, an increased respiratory rate, increased blood pressure, and venous distention. Option 2: A weak pulse is associated with fluid volume deficit (FVD), not FVE. Option 3: Weight loss is associated with FVD, not FVE. Option 4: The nurse should associate the presence of crackles in lungs with FVE. Option 5: Decreased respirations are associated with FVD, not FVE.)

Question 5. A nurse assesses a client diagnosed with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which factors, if assessed in a client with fluid volume excess, should the nurse associate with SIADH? Select all that apply. Course Topic: Fluids and Electrolytes Concept(s): Assessment; Cognition; Critical Thinking; Fluid and Electrolyte Balance; Neurologic RegulationCognitive Level: Analysis [Analyzing] 1. Hyponatremia 2. Bradycardia 3. Polyuria 4. Headache 5. Recent pneumonia

1, 4, 5 (Rationale Option 1: The nurse should associate hyponatremia with SIADH. SIADH is a disorder of the posterior pituitary gland in which antidiuretic hormone (ADH) continues to be released even though plasma osmolarity is normal or near normal. The excess ADH, also called vasopressin, leads to water retention by interfering with the renal excretion of water, producing concentrated urine and hyponatremia. ADH decreases urine production by causing the renal tubules to reabsorb water from the urine and return it to the intravascular compartment. Option 2: SIADH may cause tachycardia, not bradycardia. Option 3: SIADH causes fluid retention, not polyuria. Option 4: The nurse should associate headache with SIADH. The drop in the serum sodium level may cause headaches and changes in the level of consciousness. Option 5: The nurse should associate recent pneumonia with SIADH. Current or recent viral or bacterial pneumonia may cause SIADH to occur.)

Question 10. When caring for a patient with hypertension, the nurse should anticipate that the practitioner will first limit the patient's intake of: 1. Potassium 2. Sodium 3. Protein 4. Fluids

2 (Rationale Option 1: Potassium restriction is a therapy associated with kidney disease, not hypertension. If diuretics are used to treat a patient's hypertension, potassium supplementation through diet or medications may be employed. Option 2: In the stepped-care approach to the management of hypertension, sodium intake is restricted in step 1. Option 3: Protein intake may be restricted when a patient has kidney disease, not hypertension. Option 4: Fluid restriction is not part of the four-part stepped-care management of hypertension. Adequate fluids (a minimum of 1500 to 2000 mL) are necessary for fluid balance. Fluids may be restricted as an intervention for kidney disease or pulmonary edema, not hypertension.)

Question 4. A nurse is caring for a client diagnosed with hypovolemic hyponatremia. Which IV solution order should the nurse anticipate? 1. 0.45% saline solution 2. 0.9% saline solution 3. 3% saline solution 4. Dextrose 5% in water

2 (Rationale Option 1: A 0.45% saline solution would replace minimal sodium, increasing the risk of exacerbating the client's hyponatremia. Option 2: The nurse should anticipate an order for 0.9% saline solution. A client with hypovolemic hyponatremia requires the replacement of sodium and fluid. The best choice in this case is 0.9% (normal) saline solution because it replaces both. Option 3: A 3% saline solution replaces primarily sodium, leaving the client at risk for hypernatremia because the fluid deficit still exists. Option 4: Dextrose 5% in water would replace no sodium at all, increasing the risk of exacerbating the client's hyponatremia.)

Question 2. A nurse assessing a client who experienced a seizure during a water-drinking contest should associate the client's seizure with which electrolyte imbalance? Course Topic: Fluids and Electrolytes Concept(s): Critical Thinking; Fluid and Electrolyte Balance; Neurologic RegulationCognitive Level: Analysis [Analyzing] 1. Hyponatremia related to an actual decrease in sodium 2. Hyponatremia related to a relative decrease in sodium 3. Hypernatremia related to an actual increase in sodium 4. Hypernatremia related to a relative increase in sodium

2 (Rationale Option 1: A client who experienced a seizure during a water-drinking contest is most likely experiencing hyponatremia, but not related to an actual decrease in sodium. Based on the history of recent ingestion of excessive amounts of water, the client is experiencing a relative decrease in sodium secondary to the increase in plasma volume, causing a dilution of serum sodium. Option 2: The nurse should associate the client's seizure with hyponatremia related to a relative decrease in sodium. Based on the history of recent ingestion of excessive amounts of water, the client is experiencing a relative decrease in sodium secondary to the increase in plasma volume, causing a dilution of serum sodium. Option 3: A client who experienced a seizure during a water-drinking contest is most likely experiencing hyponatremia, not hypernatremia. Option 4: A client who experienced a seizure during a water-drinking contest is most likely experiencing hyponatremia, not hypernatremia.)

Question 1. A patient is admitted to the hospital after several days of diarrhea, nausea, and vomiting. Which clinical indicator should the nurse expect to identify when completing an admission nursing assessment? 1. Adventitious breath sounds 2. Nonelastic skin turgor 3. Frothy sputum 4. Weight gain

2 (Rationale Option 1: Adventitious breath sounds, such as moist crackles, are associated with fluid volume excess, not deficit. Option 2: Nonelastic skin turgor occurs with hypovolemia because fluid has moved from the interstitial spaces into the intravascular system; the pinch of skin does not return to its original position in less than 2 to 3 seconds. Option 3: Frothy sputum is associated with fluid volume excess, not fluid volume deficit; the elevated blood pressure associated with hypervolemia can cause the movement of fluid into the lung (pleural effusion), which results in frothy sputum. Option 4: Weight loss, not weight gain, is associated with fluid volume deficit. Every liter of fluid is equal to 2.2 pounds.)

Question 16. Which client should a nurse classify as having the greatest risk of fluid volume deficit (FVD)? Course Topic: Fluids and Electrolytes Concept(s): Bowel Elimination; Critical Thinking; Fluid and Electrolyte Balance; NursingCognitive Level: Analysis [Analyzing] 1. An older adult with congestive heart failure 2. An adolescent with ulcerative colitis 3. An infant with congenital heart disease 4. An older adult with hypertension

2 (Rationale Option 1: Although an older adult is at increased risk for FVD in general, this client would not be at greatest risk for FVD. Option 2: The nurse should identify the client with ulcerative colitis as being at greatest risk for FVD. Ulcerative colitis is an inflammatory bowel disease characterized by frequent bloody diarrhea and fecal incontinence. Clients with ulcerative colitis can experience more than 10 bloody stools per day (depending on the severity), losing fluid, electrolytes, and blood with each stool. Option 3: Although an infant is at increased risk for FVD in general, this client would not be at greatest risk for FVD. Option 4: Although an older adult is at increased risk for FVD in general, this client would not be at greatest risk for FVD.)

Question 19. A nurse who is admitting a client with a serum sodium level of 128 mEq/L and a serum chloride level of 88 mEq/L obtains a list of the client's current medications. Which medication should the nurse identify as having the potential to decrease serum sodium and chloride levels? 1. Acetaminophen with phenylephrine and dextromethorphan (Tylenol® Cold) 2. Metoprolol and hydrochlorothiazide (Lopressor® HCT) 3. Simvastatin (Zocor®) 4. Esomeprazole (Nexium®)

2 (Rationale Option 1: Cold remedies have the potential to increase, not decrease, sodium and chloride levels. Option 2: The nurse should identify Lopressor® HCT as the medication most likely to decrease the client's serum sodium and chloride levels. Lopressor® HCT contains the diuretic hydrochlorothiazide, which can deplete serum sodium, chloride, and potassium levels. Option 3: Zocor® does not affect sodium or chloride levels. Option 4: Nexium® does not affect sodium or chloride levels.)

Question 4. A nurse assesses the laboratory values of an adult client. Which imbalance should a nurse associate with a serum sodium level of 150 mEq/L? 1. Hyponatremia 2. Hypernatremia 3. Hypokalemia 4. Hyperkalemia

2 (Rationale Option 1: Hyponatremia is defined as a serum sodium level less than 135 mEq/L. Option 2: The nurse should associate a serum sodium level of 150 mEq/L with hypernatremia. Hypernatremia is defined as a serum sodium level greater than 145 mEq/L. Option 3: Hypokalemia is defined as a serum potassium level less than 3.5 mEq/L. Option 4: Hyperkalemia is defined as a serum potassium level greater than 5.0 mEq/L.)

Question 1. A nurse is assessing a client for signs of hypocalcemia. Which action should the nurse perform to assess for the presence of Chvostek's sign? 1. Apply a blood pressure cuff to the upper arm, inflate the cuff to a reading higher than the client's systolic blood pressure for 1 to 4 minutes, and observe for carpopedal spasm. 2. Tap the facial nerve anterior to the earlobe and just below the zygomatic arch, and observe for facial twitching on the same side as the stimulus. 3. Assess the biceps, triceps, and brachioradialis reflexes of the arm and wrist, and observe for hyperstimulation. 4. Instruct the client to hyperventilate, and observe for muscle spasms of the hands or feet.

2 (Rationale Option 1: Inflating a blood pressure cuff on the upper arm is used to elicit Trousseau's sign, not Chvostek's sign. Trousseau's sign is also a sign of hypocalcemia. Option 2: The nurse assessing a client for hypocalcemia should elicit Chvostek's sign by tapping the client's facial nerve anterior to the earlobe and just below the zygomatic arch and observing for facial twitching of the mouth, nose, or cheek on the same side as the stimulus. Twitching in response to this stimulus is considered a positive Chvostek's sign and indicates the presence of hypocalcemia. Hypocalcemia increases neuromuscular irritability and results in cells that depolarize more easily and at inappropriate times. Option 3: Assessing deep tendon reflexes is important in a client with calcium imbalance, but this does not assess for the presence of Chvostek's sign. Option 4: Instructing the client to hyperventilate and observing for muscle spasms is not an appropriate assessment to conduct on any client.)

Question 16. Which client should a nurse identify as being at highest risk for hypernatremia? 1. A young child on NPO status before surgery 2. An older adult client admitted with vomiting and diarrhea 3. A client admitted with congestive heart failure 4. An older adult client who has hypertension

2 (Rationale Option 1: NPO status before surgery is usually not long enough to develop hypernatremia, even for a young child. Option 2: The nurse should identify the older adult client with vomiting and diarrhea as being at high risk for relative hypernatremia secondary to dehydration. Because of the fluid loss, the client retains sodium in an effort to reabsorb water. Option 3: The client with congestive heart failure is at risk for hyponatremia, not hypernatremia. Option 4: Hypertension alone would not increase the client's risk for hypernatremia. There are many underlying causes of increased blood pressure in older adult clients.)

Question 8. A nurse is planning care for a client admitted with severe hyponatremia. Which should be the priority intervention for the nurse to achieve the goal, "The client will remain free from injury"? 1. Restrict free water intake. 2. Initiate seizure precautions. 3. Assess intake and output every shift. 4. Teach the client about sodium restriction.

2 (Rationale Option 1: Restricting free water intake is important in the treatment of hyponatremia, but is not the priority intervention to maintain client safety. Option 2: Initiating seizure precautions should be the nurse's priority to achieve the goal, "The client will remain free from injury" for the client admitted with severe hyponatremia. When the serum sodium level is very low, fluid enters the cells, resulting in cerebral edema, which increases the client's risk for seizures. Option 3: Assessing intake and output is a means of monitoring fluid volume status, but is not directly related to maintaining client safety. Option 4: A sodium-restricted diet would worsen the client's hyponatremia)

Question 7. A nurse is caring for a client diagnosed with fluid volume deficit (FVD). Which vital sign should the nurse identify as most indicative of FVD? 1. Temperature: 99 ºF (37.2 ºC) 2. Blood pressure: 86/54 mm Hg 3. Heart rate: 82 beats per minute 4. Respiratory rate: 12 breaths per minute

2 (Rationale Option 1: The client's temperature may be elevated if the FVD is moderate to severe, but is not the best indicator of FVD. Option 2: A blood pressure of 86/54 mm Hg (hypotension) is most supportive of FVD. Blood pressure decreases as the circulating blood volume decreases. Option 3: In the presence of FVD, the heart rate would increase to compensate for the decrease in blood pressure. Option 4: The respiratory rate should not be affected by FVD unless there is an associated electrolyte imbalance.)

Question 8. A nurse takes the vital signs of a client who collapsed while working outdoors. Which parameter in the client's blood pressure measurement should the nurse associate with FVD? Course Topic: Fluids and Electrolytes Concept(s): Critical Thinking; Fluid and Electrolyte Balance; PerfusionCognitive Level: Analysis [Analyzing] 1. Increasing diastolic blood pressure 2. Decreasing systolic blood pressure 3. Prominent Korotkoff sounds 4. Widening pulse pressure

2 (Rationale Option 1: The diastolic blood pressure would also decrease, not increase, in FVD, although not as noticeably as the systolic blood pressure. Option 2: The nurse should associate a decrease in systolic blood pressure with the development of FVD. The systolic blood pressure decreases as a direct result of FVD. Option 3: Korotkoff sounds (the sounds heard through a stethoscope when taking a client's blood pressure) would become less prominent or remain unchanged in FVD, depending on the severity of the deficit. Option 4: Pulse pressure, the difference in the systolic and diastolic blood pressures, narrows in FVD.)

Question 6. A nurse identifies that an older patient may have a problem with excess fluid volume. Which characteristics of the skin support this conclusion? Course Topic: Fluids and Electrolytes Concept(s): Fluid and Electrolyte Balance; Skin IntegrityCognitive Level: Comprehension [Understanding] 1. Dry and scaly 2. Taut and shiny 3. Red and irritated 4. Thin and inelastic

2 (Rationale Option 1: These are signs of aging and dehydration, not excessive fluid volume. Option 2: With excessive fluid volume, the increased hydrostatic pressure moves fluid from the intravascular compartment into the interstitial compartment. As fluid collects in the interstitial compartment (edema), the skin appears taut and shiny. Option 3: These are signs of the local inflammatory response, not of excessive fluid volume. Option 4: These are characteristics of skin in the older adult because of a loss of subcutaneous fat and a reduced thickness and vascularity of the dermis, not of excessive fluid volume)

Question 1. A patient is suspected of being hypovolemic. For which clinical finding should the nurse assess the patient? 1. Decreased heart rate 2. Thready pulse 3. Hypertension 4. Dyspnea

2 (Rationale Option 1: When a patient is hypovolemic, the heart rate will increase, not decrease, in an attempt to maintain an effective cardiac output. Option 2: When a patient is hypovolemic, there is a reduced volume of circulating blood and less pressure within the vessels, which are reflected in weak, thready peripheral pulses and flattened neck veins. Option 3: When a patient is hypovolemic there is a reduced volume of circulating blood, resulting in hypotension, not hypertension. Option 4: Dyspnea is associated with fluid volume excess, not deficit, because of pulmonary congestion.)

Question 15. A nurse is developing a care plan for a client with fluid volume excess (FVE). Based on this information, which nursing diagnoses should the nurse include in this client's care plan? Select all that apply. 1. Risk for Imbalanced Fluid Volume 2. Ineffective Breathing Pattern 3. Risk for Electrolyte Imbalance 4. Decreased Cardiac Output 5. Excess Fluid Volume

2, 3, 5 (Rationale Option 1: the client is currently experiencing excess fluid volume; therefore, a nursing diagnosis of Risk for Imbalanced Fluid Volume is inappropriate at this time. Option 2: the nurse should include the nursing diagnosis of Ineffective Breathing Pattern in the client's care plan because clients with FVE often have difficulty breathing because of pulmonary congestion. Option 3: an excess in circulating fluid places the client at risk for dilutional electrolyte imbalances. Option 4: Decreased Cardiac Output, in the absence of congestive heart failure, is usually associated with fluid volume deficit. Option 5: The client is experiencing FVE.)

Question 14. A nurse is assessing a client who has a history of multiple chronic illnesses. Which conditions should the nurse identify as placing the client at risk for fluid volume excess (FVE)? Select all that apply. 1. Diabetes insipidus 2. End-stage renal disease 3. Type 2 diabetes mellitus 4. Long-term corticosteroid therapy 5. Syndrome of inappropriate antidiuretic hormone secretion

2, 4, 5 (Rationale Option 1: Diabetes insipidus would result in polyuria and dehydration. Option 2: The nurse should identify end-stage renal disease as placing this client at risk for the development of FVE, which occurs when fluid intake or retention is greater than the body's fluid needs. Option 3: Although type 2 diabetes increases the client's risk for renal failure, early-phase renal failure would result in dehydration, not FVE. Option 4: The nurse should identify long-term corticosteroid therapy as placing this client at risk for the development of FVE. The conditions most commonly associated with FVE are those related to excessive intake or an inadequate excretion of fluid. Option 5: The nurse should identify syndrome of inappropriate antidiuretic hormone secretion (SIADH) as placing this client at risk for the development of FVE. Causes of FVE include excessive fluid replacement, renal failure, heart failure, long-term corticosteroid therapy, SIADH, psychiatric disorders with polydipsia, and water intoxication.)

Question 12. Which manifestations should a nurse identify as the most serious complications associated with hyponatremia? 1. Anorexia, nausea, and vomiting 2. Generalized weakness, muscle cramps, and twitching 3. Lethargy, acute confusion, and decreased level of consciousness 4. Tachycardia, weak, thready pulses, and decreased blood pressure

3 (Rationale Option 1: Anorexia, nausea, and vomiting are not the most serious complications associated with hyponatremia. Option 2: Generalized weakness, muscle cramps, and twitching are not the most serious complications associated with hyponatremia. Option 3: The nurse should identify lethargy, acute confusion, and a decreased level of consciousness as the most serious changes associated with hyponatremia. These signs may indicate the development of cerebral edema. Cerebral edema is usually associated with serum sodium levels less than 110 mEq/L and can lead to respiratory arrest and death. The other manifestations are not as serious as neurological changes. Option 4: Tachycardia; weak, thready pulses; and decreased blood pressure are not the most serious complications associated with hyponatremia.)

Question 2. A health-care provider orders daily weights for the purpose of evaluating a patient's fluid loss or gain. When should the nurse weigh the patient? Course Topic: Fluids and Electrolytes Concept(s): Fluid and Electrolyte Balance; Urinary EliminationCognitive Level: Comprehension [Understanding] 1. Twice a day 2. One hour before meals 3. At the same time each day 4. Before urinating in the morning

3 (Rationale Option 1: Weighing a patient twice a day is unnecessary. Weight varies over the course of the day depending on food and fluids ingested and the weight of clothing being worn. These factors produce information that is not comparable. Option 2: Weighing a patient 1 hour before meals is unnecessary. Meal times may vary from day to day, and the information collected will not be comparable. Weighing the patient once a day is sufficient. Option 3: To obtain the most accurate comparable data, patients should be weighed at the same time every day (preferably first thing in the morning), after toileting, wearing the same clothing, and using the same scale. This controls as many variables as possible to make the daily measurements an accurate reflection of the patient's weight. Option 4: Weighing the patient before urinating in the morning collects information influenced by the volume of urine in the urinary bladder. Weights should always be measured after, not before, voiding to obtain the most accurate, comparable measurements. One liter of fluid is equal to 2.2 pounds.)

Question 5. The nurse is caring for a patient who has dependent edema. What pressure has caused the excess fluid in the interstitial compartment? 1. Oncotic pressure 2. Diffusion pressure 3. Hydrostatic pressure 4. Intraventricular pressure Rationale

3 (Option 1: Oncotic (colloid osmotic) pressure is the force exerted by colloids (e.g., proteins) that pull or keep fluid within the intravascular compartment. Oncotic pressure is the major force opposing hydrostatic pressure in the capillaries. Option 2: Diffusion is a continual intermingling of molecules with movement of molecules from a solution of higher concentration to a solution of lower concentration. Option 3: Hydrostatic pressure is the pressure exerted by a fluid within a compartment, such as blood within the vessels. Hydrostatic pressure moves fluid from an area of greater pressure to an area of lesser pressure. Hydrostatic pressure within vessels of the body moves fluid from the intravascular compartment into the interstitial compartment. Interstitial fluid is extracellular fluid that surrounds cells. Option 4: Intraventricular pressure is the pressure that exists in the left and right ventricles of the heart. These pressures do not move fluid from the intravascular compartment to the interstitial compartment.)

Question 19. A nurse is planning care for a client on fluid restriction because of FVE. Which solution should the nurse plan to use when diluting the client's medications? Course Topic: Fluids and Electrolytes Concept(s): Fluid and Electrolyte Balance; MedicationCognitive Level: Comprehension [Understanding] 1. Hypertonic solution 2. Isotonic solution 3. Smallest volume possible 4. Dextrose solution

3 (Rationale Option 1: A hypertonic solution may exacerbate the client's FVE because it could increase vascular volume as the body attempts to dilute the solution. Option 2: An isotonic solution may be appropriate for dilution of the client's IV medications, but it is not the best answer. Option 3: When fluid restriction is required, the nurse should ensure that IV medications are diluted in the smallest volume possible and delivered using a syringe pump or manual IV push. For example, 1 gm of antibiotic could be diluted in 10 mL of normal saline solution instead of the more common 50 mL. Option 4: A dextrose solution, depending on its tonicity and volume, may be appropriate for dilution of the client's IV medications, but it is not the best answer.)

Question 7. An older adult client has had nausea, vomiting, and diarrhea for 3 days. Assessment by a nurse reveals dry oral mucosa, amber urine, and decreased skin turgor. Which measurement should the nurse obtain to best determine the client's current fluid status? Course Topic: Fluids and Electrolytes Concept(s): Assessment; Critical Thinking; Fluid and Electrolyte Balance; PerfusionCognitive Level: Application [Applying] 1. Respiratory rate 2. Temperature 3. Blood pressure 4. Pulse oximetry

3 (Rationale Option 1: Although the respiratory rate may be affected by FVD, it would not reveal the client's fluid status as precisely as decreased blood pressure. Option 2: Although temperature may be affected by FVD, it would not reveal the client's fluid status as precisely as decreased blood pressure. Option 3: To best determine the client's fluid status, the nurse should assess the blood pressure. The client has signs and symptoms of FVD (nausea, vomiting, and diarrhea for 3 days; dry oral mucosa; amber urine; and decreased skin turgor). A decrease in blood pressure is the best indicator of FVD related to a lack of circulating vascular volume. Option 4: Pulse oximetry should not be affected by the client's fluid status.)

Question 3. Which meal option should a nurse choose for a client with FVE who is placed on a low-sodium diet? Course Topic: Fluids and Electrolytes Concept(s): Critical Thinking; Fluid and Electrolyte Balance; NutritionCognitive Level: Application [Applying] 1. Bologna sandwich on whole wheat bread, potato chips, sliced cucumbers, and iced tea 2. Spaghetti with meat sauce, salad, hard-crust bread, and milk 3. Baked chicken breast, corn on the cob, dinner roll, and milk 4. Steak, broccoli with cheese sauce, crackers, and hot tea

3 (Rationale Option 1: Bologna is a luncheon meat that is high in sodium. Option 2: Spaghetti with meat sauce contains sausage, which is high in sodium. Option 3: The meal consisting of baked chicken breast, corn on the cob, dinner roll, and milk is the only option that does not include foods either naturally or artificially high in sodium. Option 4: Cheese sauce is high in sodium.)

Question 13. What should the nurse do to encourage a confused patient to drink more fluid? 1. Serve fluid at a tepid temperature 2. Explain the reason for the desired intake 3. Offer the patient something to drink every hour 4. Leave a pitcher of water at the patient's bedside

3 (Rationale Option 1: Fluids should be administered at the temperature usually associated with the fluid, for example, cool temperatures for juice, soda, and milk and warm temperatures for tea, coffee, and soup. Hot liquids should be avoided for safety reasons. Option 2: This probably will be ineffective because a confused person has difficulty understanding cause and effect. Option 3: Frequent smaller volumes of fluid (50 to 100 mL/hr) are better tolerated physiologically and psychologically than infrequent larger volumes of fluid. Option 4: A confused patient, having difficulty understanding cause and effect, may ignore a pitcher of water.)

Question 2. A nurse is caring for an older adult client who is experiencing a fluid imbalance. Which age-related change should a nurse associate with fluid imbalance in an older adult? Course Topic: Fluids and Electrolytes Concept(s): Assessment; Fluid and Electrolyte Balance; NursingCognitive Level: Comprehension [Understanding] 1. Efficient temperature regulation 2. Increased glomerular filtration rate 3. Decreased perception of thirst, interfering with the thirst mechanism 4. Higher percentage of total body water than younger or middle-aged adults

3 (Rationale Option 1: Older adults have less efficient temperature regulation, increasing their risk for fluid imbalance. Option 2: Older adults have a decreased glomerular filtration rate, increasing their risk for fluid imbalance. Option 3: The nurse should associate a decreased perception of thirst with fluid imbalance in an older adult client. Older adults also have less efficient temperature regulation, a decreased glomerular filtration rate, and a lower percentage of total body water than younger adults, increasing their risk for fluid imbalance. Option 4: Older adults have a lower percentage of total body water than younger adults, increasing their risk for fluid imbalance.)

Question 15. A nurse is caring for an adult client with a serum potassium level of 2.3 mEq/L. Which order for potassium chloride should the nurse identify as being most appropriate for this client? Course Topic: Fluids and Electrolytes Concept(s): Critical Thinking; Fluid and Electrolyte Balance; MedicationCognitive Level: Comprehension [Understanding] 1. Administer potassium chloride 40 mEq/L intramuscularly now. 2. Administer potassium chloride 40 mEq/L by IV push now. 3. Administer potassium chloride 40 mEq/L by IV infusion over 4 hours. 4. Administer potassium chloride 40 mEq/L PO three times daily.

3 (Rationale Option 1: Potassium should not be administered intramuscularly because it is a severe tissue irritant. Option 2: Potassium should never be given by IV push or bolus because rapid infusions of potassium chloride can cause death. Option 3: The nurse should identify an order for IV potassium chloride 40 mEq/L over 4 hours as the most appropriate order to treat hypokalemia in this client. A serum potassium level of 2.3 mEq/L is considered critical and requires an IV infusion of potassium for replacement. Option 4: Oral potassium supplements are given once or twice daily to treat mild to moderate hypokalemia, not severe hypokalemia.)

Question 17. In error, a nurse administers 3% saline solution intravenously to a preoperative client with a normal fluid and electrolyte balance. Which physiological reaction should the nurse anticipate as a result of this error? 1. The client would experience only an increase in plasma volume. 2. The client would experience only an increase in interstitial volume. 3. The client would experience an increase in plasma volume and a decrease in interstitial volume. 4. The client would experience an increase in plasma volume and an increase in interstitial volume.

3 (Rationale Option 1: The nurse should anticipate that this client would experience an increase in plasma volume and a decrease in interstitial volume, not just an increase in plasma volume. Option 2: The nurse should anticipate that this client would experience an increase in plasma volume and a decrease, not an increase, in interstitial volume. Option 3: The nurse should anticipate that a client with a normal fluid and electrolyte balance who mistakenly received a 3% saline IV solution would experience an increase in plasma volume and a decrease in interstitial volume. If a hypertonic IV solution is infused into a client with normal extracellular fluid osmolarity, the infusing fluid will make the client's intravascular compartment hyperosmotic (or hypertonic). In an attempt to balance this, the client's interstitial fluid will be pulled into the intravascular compartment to dilute the blood osmolarity back to normal, resulting in an increase in plasma volume and a decrease in the interstitial volume. Isotonic solutions, such as 0.9% saline solution, would increase plasma volume without causing a fluid shift between compartments. Hypotonic solutions, such as 0.45% saline solution, would cause an increase in both plasma volume and interstitial volume because fluid is pulled out of the intravascular compartment and into the interstitial fluid and cells. Option 4: The nurse should anticipate that this client would experience an increase in plasma volume and a decrease in interstitial volume, not an increase in both plasma and interstitial volume.)

Question 12. A nurse is planning care for a client on fluid restriction because of fluid volume excess (FVE). Which nursing intervention should be the priority when caring for this client? 1. Encourage and measure fluid intake. 2. Administer 0.9% saline solution as prescribed. 3. Assess the client for crackles and edema. 4. Insert an indwelling catheter.

3 (Rationale Option 1: The nurse should not encourage fluid intake because the client has FVE; however, measuring intake and output is an appropriate action. Option 2: The nurse should not administer IV solutions because this would worsen the client's FVE. Option 3: The priority nursing intervention should be to assess the client for crackles and edema, which are signs that indicate worsening of the client's FVE. Pulmonary edema can occur very quickly and can lead to death. Option 4: Insertion of an indwelling catheter, although appropriate, should not be the nurse's priority.)

Question 2. A nurse in an emergency department is caring for a client who has lost a significant amount of blood secondary to upper gastrointestinal bleeding. Which vital signs should the nurse anticipate during the assessment of this client? 1. Heart rate: 60 bpm; blood pressure: 112/64 mm Hg; respiratory rate: 12/min 2. Heart rate: 75 bpm; blood pressure: 120/80 mm Hg; respiratory rate: 12/min 3. Heart rate: 118 bpm; blood pressure: 76/52 mm Hg; respiratory rate: 16/min 4. Heart rate: 125 bpm; blood pressure: 145/86 mm Hg; respiratory rate: 20/min

3 (Rationale Option 1: These vital signs are within normal limits. Option 2: These vital signs are within normal limits. Option 3: The nurse should anticipate an increase in heart rate, a decrease in blood pressure, and a normal respiratory rate because blood loss results in a decrease in circulating blood volume, creating a profound fluid volume deficit. The client's heart will attempt to compensate for decreased blood volume by increasing the rate to maintain perfusion to vital organs. The client's respiratory rate may be normal or increased. Option 4: These vital signs show an increased heart rate, increased blood pressure, and a slightly increased respiratory rate. Significant blood loss would result in a decrease in blood pressure.)

Question 9. A nurse is caring for a patient admitted to the hospital with a diagnosis of congestive heart failure. For what clinical indicator should the nurse assess the patient that supports the presence of this condition? 1. Weight loss 2. Hypotension 3. Bounding pulse 4. Hemoconcentration

3 (Rationale Option 1: Weight loss is associated with fluid volume deficit, not fluid volume excess. Congestive heart failure is associated with excess fluid volume (hypervolemia). Option 2: Hypotension is associated with fluid volume deficit, not fluid volume excess. Congestive heart failure is associated with excess fluid volume (hypervolemia). Option 3: Bounding pulse is associated with fluid volume excess. Congestive heart failure is associated with excessive fluid volume (hypervolemia). Option 4: Hemoconcentration is associated with fluid volume deficit, not fluid volume excess. Congestive heart failure is associated with excessive fluid volume (hypervolemia).)

Question 17. Which client information should a nurse associate with a nursing diagnosis of Deficient Fluid Volume Secondary to Dehydration? 1. Decreased pulse rate 2. Decreased hemoglobin and hematocrit levels 3. Jugular venous distention 4. Blood pressure of 96/54 mm Hg

4 (Rationale Option 1: An increased, not a decreased, pulse rate is associated with FVD. Option 2: Clients with isotonic and hypotonic dehydration with plasma volume deficits show hemoconcentration, or increased hemoglobin and hematocrit levels; decreased hemoglobin and hematocrit values may be indicative of hemorrhage or FVE. Option 3: Jugular venous distention would be present with FVE, not FVD. Option 4: The nurse should associate a blood pressure of 96/54 mm Hg with a nursing diagnosis of Deficient Fluid Volume Secondary to Dehydration. Common manifestations of dehydration include an increased pulse rate, a thready pulse, and decreased blood pressure.)

Question 3. A nurse is caring for a patient who reports having severe diarrhea and vomiting for the last few days. The patient's laboratory results indicate that the patient has a serum sodium level of 146 mEq/L. For which clinical indicator unique to this serum sodium level should the nurse assess the patient? Course Topic: Fluids and Electrolytes Concept(s): Assessment; Critical Thinking; Fluid and Electrolyte BalanceCognitive Level: Analysis [Analyzing] 1. Confusion 2. Headache 3. Agitation 4. Thirst

4 (Rationale Option 1: Increased and decreased serum sodium levels can cause confusion because of interference with nerve impulse conduction and cellular chemical reactions. Option 2: The patient's serum sodium level is higher than the expected range of 135 to 145 mEq/L. Decreased, not increased, serum sodium levels cause a headache due to cerebral edema. Option 3: Decreased and increased serum sodium levels can cause agitation because of interference with nerve impulse conduction and cellular chemical reactions. Option 4: The sensation of thirst is triggered when plasma osmolarity increases due to inadequate fluid intake in the presence of excessive fluid loss.)

Question 9. A nurse is caring for a patient who has a reduced fluid intake. What will this reduced fluid intake contribute to? 1. Urinary retention 2. Frequent urination 3. Incontinence of urine 4. Decreased urine output

4 (Rationale Option 1: The accumulation of urine in the bladder with an inability to empty the bladder (urinary retention) is unrelated to a decreased fluid intake. Option 2: Frequent urination occurs with increased, not decreased, fluid intake. Option 3: Involuntary urination (incontinence) is not associated with a reduced fluid intake. Option 4: When the serum osmolarity increases because of insufficient fluid intake, antidiuretic hormone increases the permeability of the collecting tubules in the kidneys, which increases the reabsorption of water and decreases urine output.)

Question 18. When evaluating a client being treated for FVE, a nurse determines that the FVE has not resolved based on which finding? 1. Level of consciousness improved to alert and oriented 2. Decrease in urine specific gravity and increase in urine output 3. Bilateral lower extremity edema decreased to scant 4. Crackles increased bilaterally in anterior and posterior lung fields

4 (Rationale Option 1: The return to a normal level of consciousness reflects the resolution of FVE. Option 2: A decrease in urine specific gravity and an increase in urine output indicate the resolution of FVD, not FVE. Option 3: Reduction to scant peripheral edema indicates the resolution of FVE. Option 4: The nurse should determine that the presence of bilateral crackles indicates that FVE has not resolved. The client's lungs should be clear bilaterally after the excess fluid has been removed or excreted.)