F&E
The process of filtration begins at the: (a) glomerulus. (b) Loop of Henle. (c) Bowman's capsule. (d) collecting ducts.
a
A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? (a) "I need to drink no more than 1,000 mL/day" (b) "I should drink 1,500 mL/day of fluid." (c) "I should drink 2,500 mL/day of fluid." (d) "I should drink more than 3,500 mL/day of fluid."
c
During a blood transfusion, a client displays signs of immediate onset facial flushing, hypotension, tachycardia, and chills. Which transfusion reaction should the nurse suspect? (a) allergic reaction: allergy to transfused blood (b) febrile reaction: fever develops during infusion (c) hemolytic transfusion reaction: incompatibility of blood product (d) bacterial reaction: bacteria present in the blood
c
The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? (a) 1,000 mL/day (b) 1,500 mL/day (c) 2,500 mL/day (d) 3,500 mL/day
c
The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? (a) excessive use of laxatives (b) diaphoresis (c) renal failure (d) increased cardiac output
c
When an older adult client receiving a blood transfusion presents with an elevated blood pressure, distended neck veins, and shortness of breath, the client is most likely experiencing: (a) allergic reaction. (b) pulmonary embolism. (c) fluid overload. (d) anaphylaxis.
c
Which is a common anion? (a) magnesium (b) potassium (c) chloride (d) calcium
c
Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? (a) Constipation related to immobility (b) Pain related to surgical incision (c) Acute Confusion related to cerebral edema (d) Risk for Infection related to inadequate personal hygiene
c
Which nursing interventions would be appropriate for a client diagnosed with deficient fluid volume? Select all that apply. (a) Hypervolemia management (b) Fluid restriction (c) Intravenous therapy (d) Electrolyte management (e) Monitoring edema (f) Nutrition management
c,d,f
Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? (a) hypertonic (b) colloid (c) isotonic (d) hypotonic
c--Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.
A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: (a) hypocalcemia. (b) hypothyroidism. (c) hypoglycemia. (d) hypokalemia.
d
After surgery, a client is on IV therapy for the next 4 days. How often should the nurse change the IV tubing for this client? (a) every 12 hours (b) every 24 hours (c) every 36 hours (d) every 72 hours
d
When capping a primary line for intermittent use, a nurse notices local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. Which complication has most likely occurred? (a) sepsis (b) infiltration (c) speed shock (d) thrombus
d
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? (a) calcium and phosphorus (b) potassium and sodium (c) chloride and magnesium (d) potassium and chloride
a
The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client? (a) Apply pressure to insertion site for at least 3 minutes. (b) Ask client to perform Valsalva maneuver. (c) Instruct client to remain flat for 30 minutes. (d) Apply petroleum-based ointment and sterile occlusive dressing.
a
A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? Select all that apply. (a) blood pressure 100/48 mmHg (b) crackles in the lungs (c) distended neck veins (d) poor skin turgor (e) heart rate 128/bpm
a,d,e
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? (a) "I was breathing so fast because I was so anxious and in so much pain." (b) "I've been taking antacids almost every 2 hours over the past several days." (c) "I've had a fever for the past 3 days that just doesn't seem to go away." (d) "I've had a GI virus for the past 3 days with severe diarrhea."
b
When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? (a) Elevate the client's head. (b) Apply a warm compress. (c) Position the client on the left side. (d) Apply antiseptic and a dressing.
b--Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV.
A client is diagnosed with hypovolemia after significant blood loss. Which action will the nurse take? (a) Allow nothing by mouth. (b) Give the client a glass of orange juice with added sugar. (c) Encourage fluid intake. (d) Start an IV of normal saline as prescribed.
d
A nurse is changing a client's peripheral venous access dressing. The nurse finds that the site is bleeding and oozing. Which type of dressing should the nurse use for this client? (a) Transparent semipermeable membrane dressing (b) Occlusive dressing (c) Sealed IV dressing (d) Gauze dressing
d
The nurse is caring for Mrs. Roberts, an 86-year-old client, who fell at home and was not found for 2 days. Mrs. Roberts is severely dehydrated. The nurse is aware that older adults are at increased risk for fluid imbalance due to: (a) increase in muscle mass. (b) smaller stomach capacity. (c) decreased skin area. (d) increase in fat cells.
d
The nursing instructor hears students discussing fluid and electrolyte balance. Which statement would warrant further instruction? (a) "The lungs remove water though exhalation." (b) "The heart circulates water and nutrients through the body." (c) "The lungs regulate metabolic acid-base disturbances by controlling carbon dioxide." (d) "The kidneys store and release antidiuretic hormone to increase water retention."
d
The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system? (a) Abdominal distention (b) Vomiting (c) Paralytic ileus (d) Diarrhea
d--Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia.
The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? (a) a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today (b) a 60-year-old who is 3 days post-myocardial infarction and has been stable. (c) a 47-year-old who had a colon resection yesterday and is reporting pain (d) a newly admitted 88-year-old with a 2-day history of vomiting and loose stools
d--The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).
A client admitted with heart failure requires careful monitoring of his fluid status. Which method will provide the nurse with the best indication of the client's fluid status? (a) daily weights (b) daily BUN and serum creatinine monitoring (c) output measurements (d) daily electrolyte monitoring
a
A client has been diagnosed with stage II breast cancer and will require 8 weeks of chemotherapy. Which intravenous access would the nurse anticipate? (a) Groshong catheter tunneled under the subclavian vein (b) PICC catheter inserted in the axillary vein (c) 18 gauge peripheral IV port in the left forearm (d) percutaneous catheter in the jugular vein
a
A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? (a) decreased blood volume and intracellular dehydration (b) increased blood volume and intracellular dehydration (c) increased blood volume and extracellular overhydration (d) decreased blood volume and extracellular overhydration
a
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? (a) cardiac irregularities (b) muscle weakness (c) increased intracranial pressure (ICP) (d) metabolic acidosis
a
A dialysis unit nurse caring for a client with renal failure will expect the client to exhibit which fluid and electrolyte imbalances? (a) fluid volume excess and acidosis (b) fluid volume deficit and alkalosis (c) fluid volume excess and alkalosis (d) fluid volume deficit and acidosis
a
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? (a) Avoid salty or excessively sweet fluids. (b) Use regular gum and hard candy. (c) Eat crackers and bread. (d) Use an alcohol-based mouthwash to moisten your mouth.
a
A nurse inspecting the IV site of a client notices signs of phlebitis (inflammation). What would be the appropriate nursing intervention for this situation? (a) Discontinue the IV and relocate it to another spot. (b) Call the physician and ask if anti-inflammatory drugs should be administered. (c) Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV. (d) Cleanse the site with alcohol and apply transparent polyurethane dressing over the entry site.
a
A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? (a) Stop the transfusion and infuse normal saline using a new administration set. (b) Check the client's vital signs. (c) Stop the transfusion and infuse normal saline using the blood tubing. (d) Notify the health care provider of the client's response.
a
During a blood transfusion of a client, the nurse observes the appearance of rash and flushing in the client, although the vital signs are stable. Which intervention should the nurse perform for this client first? (a) Stop the transfusion immediately. (b) Infuse saline at a rapid rate. (c) Prepare to give an antihistamine. (d) Administer oxygen.
a
How is control over the extracellular concentration of potassium within the human body is exerted? (a) aldosterone. (b) albumin. (c) progesterone. (d) testosterone.
a
The nurse is assessing a client's intravenous line and notes small air bubbles within the tubing. What is the priority nursing action? (a) Tighten the roller clamp to stop the infusion. (b) Twist the tubing around a pencil. (c) Tap the tubing below the air bubbles. (d) Milk the air in the direction of the drip chamber.
a
The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? (a) The client has anti-A antibodies. (b) The client has anti-B antibodies. (c) The client has both anti-A and anti-B antibodies. (d) The client is a universal donor.
a
The nurse is teaching a nursing student how to record strict I&O for a client who wears adult absorbent undergarments. Which nursing teaching is appropriate? (a) "Weigh the wet undergarment, subtract the weight of a similar dry item, and fluid loss is based on the equivalent of 1 lb (0.47 kg) = 1 pint (475 mL)." (b) "We do not record fluids absorbed into undergarments." (c) "Estimate the amount of fluid that you think was excreted into the undergarment." (d) "You only record urine output in an adult undergarment; you do not record diarrhea output."
a
Which statement most accurately describes the process of osmosis? (a) Water moves from an area of lower solute concentration to an area of higher solute concentration. (b) Solutes pass through semipermeable membranes to areas of lower concentration. (c) Water shifts from high-solute areas to areas of lower solute concentration. (d) Plasma proteins facilitate the reabsorption of fluids into the capillaries.
a
A client has been diagnosed with a gastrointestinal bleed and the health care provider has ordered a transfusion. At what rate should the nurse administer the client's packed red blood cells? (a) As fast as the client can tolerate (b) 1 unit over 2 to 3 hours, no longer than 4 hours (c) 75 mL/hr for the first 15 minutes, then 200 mL/hr (d) 200 mL/hr
b
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? (a) Slow the rate of IV fluids. (b) Remove the IV. (c) Apply a warm compress. (d) Elevate the arm.
b
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? (a) Dairy products (b) Apricots (c) Processed meat (d) Bread products
b
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: 5.75 mg/dL (1.8 mEq/L) Based on these levels, the nurse would identify which imbalance? (a) Hyponatremia (b) Hypokalemia (c) Hypercalcemia (d) Hypermagnesemia
b
A nurse monitoring a client's IV infusion auscultates the client's lung sounds and detects crackles in the bases in lungs that were previously clear. What would be the most appropriate intervention in this situation? (a) Notify the primary care provider immediately because these are signs of speed shock. (b) Notify the primary care provider immediately for possible fluid overload. (c) Check all clamps on the tubing and check tubing for any kinking. (d) Place the client in the Trendelenburg position to keep the client's airway open.
b
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? (a) muscle twitching (b) distended neck veins (c) fingerprinting over sternum (d) nausea and vomiting
b
A woman aged 58 years is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires: (a) an access route to administer medications intravenously. (b) replacement of fluids for those lost from vomiting and diarrhea. (c) an access route to replace fluids in combination with blood products. (d) intravenous fluids to be administered on an outpatient basis.
b
A young man has developed gastric esophageal reflux disease. He is treating it with antacids. Which acid-base imbalance is he at risk for developing? (a) Respiratory alkalosis (b) Metabolic alkalosis (c) Respiratory acidosis (d) Metabolic acidosis
b
An infant is brought to the emergency room with dehydration due to vomiting. After several failed attempts to start an IV, the nurse observes a scalp vein. When accessing the scalp vein, the nurse should use: (a) an 18-gauge needle. (b) a winged infusion needle. (c) an intermittent infusion device. (d) a central venous access.
b
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? (a) hypervolemia (b) hypovolemia (c) edema (d) circulatory overload
b
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? (a) The secretion of aldosterone and antidiuretic hormone is stimulated due to a lowered blood pressure, which results in extracellular fluid volume and water excess. (b) Increased plasma levels of antidiuretic hormone lead to water excess. (c) 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. (d) 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.
b
Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? (a) Normal serum sodium levels range from 145 to 155 mEq/L (145 to 155 mmol/L). (b) Sodium is regulated by the renin-angiotensin-aldosterone system. (c) If sodium is low, it means that there is not enough water. (d) Sodium is not regulated by natriuretic peptides.
b
The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? (a) "Unfortunately, your own blood cannot be reinfused during surgery." (b) "Let me refer you to the blood bank so they can provide you with information." (c) "This surgery has a very low chance of hemorrhage, so you will not need blood." (d) "We now have artificial blood products, so giving your own blood is not necessary."
b
The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths per minute. Which arterial blood gas data does the nurse anticipate finding? (a) pH: 7.32; PaCO2: 28; HCO3: 24 (b) pH: 7.60; PaCO2: 64; HCO3: 42 (c) pH: 7.28; PaCO2: 52; HCO3: 32 (d) pH: 7.32; PaCO2: 26; HCO3: 18
b
The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present? (a) The client has a decreased sensation of thirst. (b) The renal system retains more water. (c) Urine becomes more diluted. (d) The frequency of voiding increases.
b
The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? (a) "I have never given blood before." (b) "I received a blood transfusion in the United Kingdom." (c) "My blood type is B positive." (d) "My spouse would also like to donate blood."
b
A nurse is caring for a client who requires intravenous (IV) therapy. The nurse understands that which actions are the nurse's responsibilities related to this therapy? Select all that apply. (a) Prescribing the kind of IV solution. (b) Deciding the location of the IV catheter. (c) Deciding the size of the IV catheter. (d) Administering the IV solution. (e) Determining the amount of IV solution.
b,c,d
A nurse is caring for a client who is on total parenteral nutrition (TPN). Which clients are candidates for TPN? Select all that apply. (a) clients who have not eaten for a day (b) clients with major trauma or burns (c) clients with liver and renal failure (d) clients who are recovering from cataract surgery (e) clients with inflammatory bowel disease
b,c,e
A nurse is assessing a client after surgery and obtains the client's vital signs: pulse rate is 65 bpm, blood pressure is 122/76 mm Hg in the supine position. The nurse then obtains the client's vital signs on standing. Which finding would alert the nurse to the possibility of a an ECF volume deficit? Select all that apply. (a) Pulse rate 72 bpm (b) Pulse rate 90 bpm (c) Blood pressure 126/80 mm Hg (d) Blood pressure 112/70 mm Hg (e) Blood pressure 104/68 mm Hg
b,e
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? (a) Isotonic (b) Hypertonic (c) Hypotonic (d) Osmolar
b--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 nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? (a) Select a primary tubing of about 37 inches (94 cm) long. (b) Ensure that the prescribed solution is clear and transparent. (c) Use half-instilled IV solutions before infusing a new one. (d) Avoid replacing IV solutions every 24 hours.
b--Before preparing the solution, the nurse should inspect the container and determine that the solution is clear and transparent, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.
A client is receiving a peripheral IV infusion and the electronic pump is alarming frequently due to occluded flow. What is the nurse's most appropriate action? (a) Assess the area distal to the IV site for signs and symptoms of deep vein thrombosis. (b) Flush the IV with 3 mL of normal saline. (c) Change from infusion with an electronic pump to infusion by gravity. (d) Flush the IV with 2 mL of 100 U/mL heparin.
b--If fluid is slow to infuse, the nurse should reposition the client's arm and/or flush the IV
A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? (a) Hypernatremia (b) Hyperchloremia (c) Hypokalemia (d) Hypomagnesemia
c
A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? (a) Metabolic acidosis (b) Respiratory acidosis (c) Metabolic alkalosis (d) Respiratory alkalosis
c
An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as: (a) cellular hydration. (b) volume expander. (c) total parenteral nutrition. (d) blood transfusion therapy.
c
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? (a) interstitial (b) extracellular (c) intracellular (d) intravascular
c
The primary extracellular electrolytes are: (a) potassium, phosphate, and sulfate. (b) magnesium, sulfate, and carbon. (c) sodium, chloride, and bicarbonate. (d) phosphorous, calcium, and phosphate.
c
What is the lab test commonly used in the assessment and treatment of acid-base balance? (a) Complete blood count (b) Basic metabolic panel (c) Arterial blood gas (d) Urinalysis
c
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? (a) isotonic (b) hypotonic (c) hypertonic (d) plasma
c--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
Which client would be a candidate for total parenteral nutrition? (a) a client with diabetic ketoacidosis (b) a postoperative appendectomy client (c) a client with colitis and bloody diarrhea (d) a client receiving intravenous antibiotics
c--Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing. A client with bloody diarrhea and colitis requires complete bowel rest.