Fundamentals: Chapter 41: Fluid, Electrolyte, and Acid-Base Balance
A nurse is preparing to administer a blood transfusion. Which assessment finding would the nurse report immediately? a. Blood pressure 120/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats per minute
ANS: B
The physician asks the nurse to monitor the fluid volume status of a congestive heart failure patient and a patient at risk for clinical dehydration. What is the most effective nursing interven-tion for monitoring both of these patients? a. Weigh the patients every morning before breakfast. b. Ask the patients to record their intake and output. c. Measure the patients' blood pressure every 4 hours. d. Assess the patients for edema in extremi-ties.
A
Which fluid order should the nurse question for a patient with a traumatic brain injury? a. 0.45% sodium chloride b. 0.9% sodium chloride c. Lactated Ringer's d. Dextrose 5% in 0.9% sodium chloride
A
Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl? A. Auscultate dependent portions of lungs B. Check color of urine C. Assess muscle strength D. Check skin turgor over sternum or shin
A
The nurse understands that administering a hypertonic solution to a patient will shift water from the _____ to the _____ space. a. Intracellular; extracellular b. Extracellular; intracellular c. Intravascular; intracellular d. Intravascular; interstitial
A .
A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. What is the minute flow rate (drops per minute)? a. 12 gtt/min b. 24 gtt/min c. 125 gtt/min d. 150 gtt/min
ANS: C
Which of the following assessments would indicate that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Skin discolored or bruised in appearance c. Pain and warmth at the insertion site d. Skin cool to the touch e. Reddish streak proximal to the insertion site f. Numbness or loss of sensation g. Palpable venous cord
A, B, D, F
Which of the following activities can you delegate to nursing assistive personnel (NAP)? (Select all that apply.) A. Measuring oral intake and urine output B. Preparing intravenous (IV) tubing for routine change C. Reporting an IV container that is low in fluid D. Changing an IV fluid container
A, C
Assessment findings consistent with intravenous (IV) fluid infiltration include: (Select all that apply.) A. Edema and pain B. Streak formation C. Pain and erythema D. Pallor and coolness E. Numbness and pain Rationale Inadvertent fluid leakage into the interstitial compartment around an IV site can cause swelling, pain from the pressure, pale color, and coolness of the infiltrated area.
A, D
The nurse knows that edema in a patient who has venous congestion from right heart failure is facilitated by an imbalance with regard to _____ pressure. a. Hydrostatic b. Osmotic c. Oncotic d. Concentration
A
The nurse knows that intravenous fluid therapy has been effective for a patient with hyper-natremia when a. Serum sodium concentration returns to normal. b. Systolic and diastolic blood pressure de-crease. c. Large amounts of emesis and diarrhea de-crease. d. Urine output increases to 150 mL/hr.
A
The nurse knows that the most abundant cation in the blood is a. Sodium. b. Potassium. c. Chloride. d. Magnesium.
A
The nurse would expect a patient with respiratory acidosis to have an excessive amount of a. Carbon dioxide. b. Bicarbonate. c. Oxygen. d. Phosphate.
A
The nurse would select the dorsal venous plexus of the foot as an IV site for which patient? a. A 2-year-old child b. A 22-year-old adult c. A 50-year-old patient d. An 80-year-old patient
A
A 2-year-old child was brought into the emergency department after ingesting several morphine tablets from a bottle in his mother's purse. The nurse knows that the child is at greatest risk for which acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
A
A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, elevated white blood cell count, and oral candidiasis. The nurse knows that the purpose of starting total parenteral nutrition (TPN) is to a. Replace fluid, electrolytes, and nutrients in the patient. b. Stimulate the patient's appetite to eat. c. Provide medication to raise the patient's blood pressure. d. Deliver antibiotics to fight off infection.
A
A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 4 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300 mL output. The patient has voided 400 mL of urine. After reporting these values to the physician, what orders does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Discontinue the nasogastric suctioning. d. Administer a diuretic to prevent fluid volume excess.
A
A patient informs the nurse that he has the type of diabetes that does not require insulin. The nurse advises the patient to make which dietary change? a. Drink plenty of fluids throughout the day to stay hydrated. b. Avoid food high in acid to avoid meta-bolic acidosis. c. Reduce the quantity of carbohydrates in-gested to lower blood sugar. d. Include a serving of dairy in each meal to elevate calcium levels.
A
A patient presents to the emergency department with the complaint of vomiting and diarrhea for the past 48 hours. The nurse anticipates which fluid therapy initially? a. 0.9% sodium chloride b. Dextrose 10% in water c. Dextrose 5% in water d. 0.45% sodium chloride
A
A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis
A
Approximately two thirds of the body's total water volume exists in the _____ fluid. a. Intracellular b. Interstitial c. Intravascular d. Transcellular
A
The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most concerned about? a. Potassium imbalance b. Sodium imbalance c. Calcium imbalance d. Phosphate imbalance
A
The nurse is caring for a diabetic patient in renal failure. Which laboratory findings would the nurse expect? a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L c. pH 7.3, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L
A
The nurse knows that an imbalance of which ion causes acid-base impairment? a. Hydrogen b. Calcium c. Magnesium d. Sodium
A
A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia. Which assessment finding would the nurse expect? a. Thready peripheral pulses b. Abdominal distention c. Dry mucous membranes d. Flushed skin
B
A patient had an acute intravascular hemolytic reaction to a blood transfusion. After discontinu-ing the blood transfusion, what is the nurse's next action? a. Run normal saline through the existing tubing. b. Start normal saline at TKO rate using new tubing. c. Discontinue the IV catheter. d. Return the blood to the blood bank.
B
A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. The patient's respiratory rate has decreased to 12 breaths per minute. The nurse would expect the patient to have which of the following arterial blood gas values? a. pH 7.78, PaCO2 40 mm Hg, HCO3- 30 mEq/L b. pH 7.52, PaCO2 48 mm Hg, HCO3- 28 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3- 26 mEq/L d. pH 7.25, PaCO2 47 mm Hg, HCO3- 29 mEq/L
B
In which patient would the nurse expect to see a positive Chvostek sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a bro-ken hip related to osteoporosis
B
The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate do you program into the infusion pump? A. 125 mL/hr B. 167 mL/hr C. 200 mL/hr D. 1000 mL/hr
B
The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 17.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L
B
The nurse would expect a patient with increased levels of serum calcium to also have _____ levels. a. Increased potassium b. Decreased phosphate c. Decreased sodium d. Increased magnesium
B
The nurse would not expect full compensation to occur for which acid-base imbalance? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
B
The process of passively moving water from an area of lower particle concentration to an area of higher particle concentration is known as a. Hydrolysis. b. Osmosis. c. Filtration. d. Active transport.
B
Which organ system is responsible for compensation of respiratory acidosis? a. Respiratory b. Renal c. Gastrointestinal d. Endocrine
B
You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid? A. Tap water or bottled water B. Fluid that has sodium (salt) in it C. Fluid that has K+ and HCO3- in it D. Coffee or tea, whichever they prefer
B
Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient's breathing? A. Notify her health care provider that she is hyperventilating B. Provide frequent oral care to keep her mucous membranes moist C. Ask her to breathe slower and help her to calm down and relax D. Assess her for pain and request anour patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record? A. 700 mL B. 900 mL C. 1000 mL D. 1100 mL order for a sedative
B
Which of these patients do you expect will need teaching regarding dietary sodium restriction? A. An 88-year-old with a fractured femur scheduled for surgery B. A 65-year-old recently diagnosed with heart failure C. A 50-year-old recently diagnosed with asthma and diabetes D. A 20-year-old with vomiting and diarrhea from gastroenteritis
B .
When discontinuing a peripheral IV access, the nurse should (Select all that apply.) a. Use scissors to remove the IV site dressing and tape. b. Keep the catheter parallel to the skin while removing it. c. Apply firm pressure with sterile gauze during removal. d. Stop the infusion before removing the IV catheter. e. Wear sterile gloves and a mask. f. Apply pressure to the site for 2 to 3 minutes after removal.
B, D, F
When selecting a site to insert an intravenous catheter on an adult, the nurse should (Select all that apply.) a. Start proximally and move distally on the arm. b. Choose a vein with minimal curvature. c. Choose the patient's dominant arm. d. Check for contraindications to the extrem-ity. e. Select a vein that is rigid. f. Avoid areas of flexion.
B, D, F
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 20 mL/hr. At what time should the infusion be completed? a. 0645 Tuesday b. 0675 Tuesday c. 0715 Tuesday d. 0735 Tuesday
C
A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. The nurse recognizes that the patient is experi-encing which transfusion complication? a. Anaphylactic shock b. Septicemia c. Fluid volume overload d. Hemolytic reaction
C
A patient was admitted for hypovolemia and has intravenous fluid running at 250 mL/hr. The patient complains of burning at the IV insertion site. Upon assessment, the nurse does not find redness, swelling, heat, or coolness. The nurse suspects that the a. IV has infiltrated. b. IV has caused phlebitis. c. Fluid is infusing too quickly. d. Patient is allergic to the fluid.
C
A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 55 mm Hg, and HCO3- of 20 mEq/L. The physician has been notified. Which is the priority nursing intervention for this patient? a. Check the color of the patient's urine output. b. Place the patient in Trendelenburg posi-tion. c. Encourage the patient to increase respira-tions. d. Place the patient in high Fowler's position.
C
The nurse is caring for a patient with hyperkalemia. Which body system would be most important for the nurse plan to monitor closely? a. Gastrointestinal b. Neurological c. Cardiac d. Respiratory
C
The nurse is caring for a patient with sepsis. The plan of care for the patient is to administer antibiotics 3 times a day for 4 weeks. What device will be used to administer these antibiotics? a. A continuous infusion b. A heparin locked peripheral catheter c. A PICC line d. An implanted port catheter
C
Which assessment finding would the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Lightheadedness when standing up b. Weak quadriceps muscles c. Tingling of the extremities and tetany d. Decreased deep tendon reflexes
C
Which laboratory value should the nurse examine when evaluating uncompensated respiratory alkalosis? a. PaO2 b. Anion gap c. PaCO2 d. HCO3-
C
Which of the following defining characteristics is consistent with fluid volume deficit? A. A 1-lb (0.5 kg) weight loss, pale yellow urine B. Engorged neck veins when upright, bradycardia C. Dry mucous membranes, thready pulse, tachycardia D. Bounding radial pulse, fl at neck veins when supine
C
You assess four patients. Which patient is at greatest risk for the development of hypocalcemia? A. 56-year-old with acute kidney renal failure B. 40-year-old with appendicitis C. 28-year-old who has acute pancreatitis D. 65-year-old with hypertension and asthma
C
Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record? A. 700 mL B. 900 mL C. 1000 mL D. 1100 mL
C
A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. "Are you having difficulty sleeping at night?" b. "How many calories a day do you con-sume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"
D
A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patient's peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Notify the physician. b. Administer pain medication. c. Discontinue the IV. d. Start a new IV line.
D
A nurse just received a bag of packed red blood cells The nurse knows that the blood must not remain at room temperature for longer than
D
A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first? A. Serum albumin B. Serum sodium C. Hematocrit D. Serum potassium
D
The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid? A. Flat neck veins B. Tachycardia C. Hypotension D. Oliguria
D
The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has a. Two-way valves to allow the patient's blood to mix and warm the blood trans-fusing. b. An injection port to mix additional elec-trolytes into the blood. c. An air vent to let bubbles in the blood es-cape. d. A filter to ensure that clots do not enter the patient.
D
Which assessment finding should cause a nurse to question administering a sodium-containing isotonic intravenous fluid? a. Blood pressure 102/58 b. Dry mucous membranes c. Poor skin turgor d. Pitting edema
D
Which patient is most at risk for sensible water loss? a. A 7-year-old child with asthma b. A 24-year-old adult with constipation c. A 56-year-old patient with gastroenteritis d. An 80-year-old patient with pneumonia
D
While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action? A. Notify a health care provider B. Insert an indwelling catheter C. Alert the blood bank D. Stop the transfusion
D
