3: EAQ Fluid & Electrolytes

How much fluid is lost daily through feces in a healthy adult? Record your answer using a whole number. _______ mL

100 mL Rationale: The gastrointestinal system plays a major role in fluid and electrolyte balance in the body. Approximately 3 to 6 L of fluid enters the gastrointestinal system and is absorbed back into the body. Approximately 100 mL of fluid is excreted through feces daily.

The primary health care provider ordered 2 L of saline over 10 hours to a patient with diarrhea. What should be the flow rate of infusion? Record your answer in mL/hour using a whole number. __________ mL/hr

200 mL/hr Rationale: The flow rate is calculated by dividing the total infusion volume by the hours of administration. Therefore, 2 L or 2000 mL is divided by 10 hours to obtain the infusion flow rate: 2000/10 = 200 mL/hour.

The primary health care provider orders the nurse to infuse 1,000 mL of intravenous fluid to a patient with diarrhea over 4 hours using gravity-flow tubing with a drop factor of 10. Calculate the minute flow rate in drops/minute. Record your answer to a whole number. ____________ drops/minute

42 drops/minute Rationale: The flow rate of the intravenous fluid is 1,000 mL over 4 hours or 250 mL per hour. Then 250 mL/hr divided by 60 min/hr to get 4.167 mL/minute. Therefore, the minute flow rate is 4.167 mL/min x 10 = 41.67 drops/min, which rounds to 42 drops/min.

What is the normal range of values of phosphate in human blood? a. 1.5 to 2.5 mEq/L b. 2.7 to 4.5 mg/dL c. 3.5 to 5.0 mEq/L d. 4.5 to 5.3 mg/dL

b. 2.7 to 4.5 mg/dL Rationale: The normal range of values of phosphate in human blood is 2.7 to 4.5 mg/dL. The normal value of potassium is 3.5 to 5.0 mEq/L, the normal value of ionized calcium is 4.5 to 5.3 mg/dL, and the normal value of magnesium is 1.5 to 2.5 mEq/L.

A nurse teaches a patient with dehydration about maintaining safe intravenous therapy at home. Which statement made by the patient indicates a need for further learning? a. "I should perform isometric exercises daily for 30 minutes." b. "I should cover the injection site with plastic to prevent the site from getting wet during a shower." c. "I should apply pressure to the injection site with sterile gauze if the catheter falls out." d. "I should immediately report inflammation and itching at the injection site."

a. "I should perform isometric exercises daily for 30 minutes." Rationale: A patient who is undergoing intravenous therapy should not perform isometric exercises because it may lead to bleeding and injury at the injection site. During a shower, the patient should protect the injection site and dressing from getting wet by covering it with plastic. Applying pressure with sterile gauze at the injection site if the catheter falls out helps to reduce bleeding. Inflammation and itching at the injection site may be an indication of infection and phlebitis; the patient should report these manifestations immediately.

The nurse is caring for a patient diagnosed with chronic heart failure. The nurse understands that the patient is at risk of developing extracellular fluid volume (ECF) excess. Which clinical findings would the nurse observe in this patient? (Select all that apply). a. Ankle edema b. Postural hypotension c. Overnight weight loss d. Overnight weight gain e. Neck veins full when upright

a. Ankle edema d. Overnight weight gain e. Neck veins full when upright Rationale: Chronic heart failure can cause extracellular fluid volume (ECF) excess due to decreased renal output caused by elevated aldosterone. It can result in fluid retention manifested as ankle edema and weight gain, and the neck veins may feel full on palpation when the patient is in an upright position. Postural hypotension and weight loss occur when there is extracellular fluid volume deficit, not extracellular fluid volume excess.

A patient develops an anaphylactic reaction following initiation of a blood transfusion. Which primary drug should the nurse use for the patient? a. Epinephrine b. Vasopressor c. Antihistamine d. Glucocorticoid

a. Epinephrine Rationale: Blood transfusions may cause anaphylactic reactions. Epinephrine is the drug of choice, because it relieves all of the clinical features of anaphylaxis. Vasopressors do not control the dyspnea and wheezing of anaphylaxis. They are used to control blood pressure. Antihistamines and glucocorticoids may be used as adjuvants to epinephrine, but they are not the primary drugs for anaphylaxis.

Which factor can be a risk for causing extracellular volume deficit (ECV)? a. Hemorrhage b. Sodium-rich diet c. Intravenous therapy d. Oliguric renal disease

a. Hemorrhage Rationale: There are many risk factors for fluid, electrolyte, and acid-base imbalances. Hemorrhage causes a deficit in the ECV. A sodium-rich diet is an environmental factor that causes ECV excess. Intravenous therapy and oliguric renal disease also cause ECV excess.

The physician orders parenteral nutrition and orders use of a hyperosmolar solution. How should the nurse administer the solution to the patient? a. Use central IV catheter. b. Use peripheral IV catheter. c. Use gastrostomy tube. d. Use jejunostomy tube.

a. Use central IV catheter. Rationale: If the parenteral nutrition fluids to be administered are hyperosmolar, then they must be administered through a central intravenous (IV) catheter. Hyperosmolar solutions tend to cause irritation of tissues and may lead to tissue necrosis if extravasation happens. If the fluids are hypoosmolar, then they must be given through peripheral veins. Gastrostomy and jejunostomy tubes are not parenteral routes; these are used for enteral feeding.

The nurse is teaching a team of student nurses about acid-base balance. Which statements by the nurse are appropriate? (Select all that apply). a. "The kidneys excrete all acids produced in the patient's body." b. "Patients with obstructive lung diseases may have more acid in the blood." c. "Patients experience deeper respirations when the carbon dioxide level in the blood rises." d. "Patients experience shallow respirations when the carbon dioxide level in the blood rises." e. "Patients with kidney disease have difficulty excreting metabolic acids."

b. "Patients with obstructive lung diseases may have more acid in the blood." c. "Patients experience deeper respirations when the carbon dioxide level in the blood rises." Rationale: Patients with obstructive lung diseases may have more acid in their blood. This can be due to a difficulty in normal excretion of carbonic acid. When the level of carbon dioxide in the blood rises, the chemoreceptors are triggered quickly. The patient hyperventilates in order to excrete the excess carbonic acid. The excretion of metabolic acids occurs in the renal tubules of the kidneys. This is one of the major contributing factors for difficulty in normally excreting metabolic acids. The kidneys excrete all acids except carbonic acid. When the carbon dioxide level in the blood rises, the chemoreceptors trigger hyperventilation to facilitate excretion of excess carbonic acid. The patient also experiences shallow respirations in response to decreased levels of carbon dioxide in the blood to enable the cells to produce more carbon dioxide and make up for the deficit.

Which conditions are common in a patient with chronic diarrhea? (Select all that apply). a. Hyperkalemia b. Hypocalcemia c. Hypernatremia d. Hypomagnesemia e. Hyperphosphatemia

b. Hypocalcemia c. Hypernatremia d. Hypomagnesemia Rationale: Chronic diarrhea may lead to hypernatremia and result in clinical dehydration. It also leads to hypocalcemia and hypomagnesemia because diarrhea decreases electrolyte absorption. Hypokalemia occurs due to an increase in fluid output, not hyperkalemia. Hyperphosphatemia is uncommon during chronic diarrhea.

A patient with chronic diarrhea shows Chvostek's sign. What might be the reason behind the patient's condition? (Select all that apply). a. Hypokalemia b. Hypocalcemia c. Hyponatremia d. Hypomagnesemia e. Hypophosphatemia

b. Hypocalcemia d. Hypomagnesemia Rationale: A patient with chronic diarrhea who has hypocalcemia and hypomagnesemia may show Chvostek's sign which is contraction of facial muscles when the facial nerve is tapped. Hypokalemia, hyponatremia, and hypophosphatemia manifest in other signs and symptoms.

Which body fluid is considered an intravascular fluid? a. Synovial fluid b. Plasma of the blood c. Fluid outside the cells d. Fluid outside the blood vessels

b. Plasma of the blood Rationale: Blood plasma is considered an intravascular fluid. Synovial fluid is considered a transcellular fluid. Extracellular fluid is located outside the cells. Interstitial fluid is located outside the blood vessels.

What is the normal concentration of ionized calcium in human blood? a. 2.7 to 4.5 mg/dL b. 3.5to 5.0 mEq/L c. 4.5 to 5.3 mg/dL d. 8.4 to 10.5 mg/dL

c. 4.5 to 5.3 mg/dL Rationale: The normal concentration of ionized calcium in human blood ranges from 4.5 to 5.3 mg/dL. The normal value of phosphate in human blood ranges from 2.7 to 4.5 mg/dL. The normal value of potassium in human blood ranges from 3.5 to 5.0 mEq/L. The normal value of total calcium in human blood ranges from 8.4 to 10.5 mg/dL.

A patient has had chronic diarrhea for 3 months. He also is experiencing repeated bouts of vomiting. The laboratory reports indicate hypokalemia. Which signs is the nurse likely to find during examination? (Select all that apply). a. Positive Chvostek's sign b. Hyperactive reflexes c. Numbness of circumoral region d. Bilateral muscle weakness e. Signs of digoxin toxicity at normal digoxin levels

d. Bilateral muscle weakness e. Signs of digoxin toxicity at normal digoxin levels Rationale: In hypokalemia, the patient experiences bilateral muscle weakness that begins in the quadriceps and ascends to the respiratory muscles. Signs of digoxin toxicity at normal digoxin levels are also seen. Positive Chvostek's sign, hyperactive reflexes, and numbness of the circumoral region are signs of hypocalcemia.

The nurse finds redness, heat, and swelling at the catheter-skin entry point and purulent drainage in a patient on intravenous infusion. Which complication does the nurse suspect? a. Phlebitis b. Bleeding c. Extravasation d. Local infection

d. Local infection Rationale: A local infection is characterized by redness, heat, and swelling at the catheter-skin entry point, and possible purulent drainage. Fresh blood evident at the venipuncture site and sometimes pooling under the extremity are the assessment findings of bleeding at the venipuncture site. The assessment findings of phlebitis are redness, tenderness, pain, and warmth along the course of the vein. Edematous, blanched skin that is cool to the touch indicates extravasation.

Which electrolyte controls the function of neuromuscular junctions? a. Calcium b. Potassium c. Phosphate d. Magnesium

d. Magnesium Rationale: Magnesium controls the function of neuromuscular junctions and is a cofactor for many enzymes. Calcium influences the excitability of nerve and muscle cells. Potassium maintains normal muscle function by stabilizing the resting membrane potential of skeletal, smooth, and cardiac muscles. Phosphate facilitates the production of adenosine triphosphate.

Which electrolyte influences the function of the neuromuscular junctions? a. Calcium (Ca 2+) b. Potassium (K +) c. Phosphate (PO 4 3-) d. Magnesium (Mg 2+)

d. Magnesium (Mg 2+) Rationale: Magnesium (Mg 2+) influences the function of the neuromuscular junctions. Potassium (K +) is necessary for normal muscle function. Calcium (Ca 2+) is necessary for muscle contraction. Phosphate (PO 4 3-) is necessary for the production of adenosine triphosphate.

The primary health care provider orders the nurse to infuse 500 mL normal saline over 4 hours to a patient with a blood pressure of 100/70 mm Hg. What is the flow rate of infusion? Record your answer in mL per hour. ___________mL/hr

125 mL/hr Rationale: A patient with a blood pressure of 100/70 mm Hg is hypotensive. Normal saline solution is used to maintain the patient's sodium level. The formula used to calculate the flow rate is the total infusion volume (mL) divided by the hours of infusion. Therefore, 500 mL of normal saline is divided by 4 hours to calculate the infusion rate, which is 125 mL per hour.

Which fluid electrolyte imbalance may develop in a patient who consumes spironolactone? a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypomagnesemia

b. Hyperkalemia Rationale: Spironolactone is a potassium-sparing diuretic that may cause hyperkalemia. Hypokalemia and hypomagnesemia may be caused by potassium-wasting diuretics such as furosemide. Hyponatremia is caused by antidepressants such as fluoxetine.

A patient with blood type A is in need of packed red cells on an emergency basis, but none of the donors of this type are available. How can the nurse provide better health care to the patient? a. Arrange to provide red blood cells of group O. b. Arrange to provide red cells of group AB. c. Arrange for an autologous blood transfusion. d. Wait until the donor of blood type A becomes available.

a. Arrange to provide red blood cells of group O. Rationale: The patient requires red blood cells on an emergency basis, and none of the donors of this blood type are available. Therefore, the patient may be managed by transfusion of red cells of blood group O, because this carries minimum risk. Red blood cells of blood group AB should not be given to patients with blood group A, because they cause mismatching. Autologous transfusion takes a few weeks; therefore, it is not suitable on an emergency basis. If the patient did not require blood on an emergency basis, then it would be appropriate to wait until a blood group A donor is found.

Which electrolyte influences excitability of nerve and muscle cells and is necessary for muscle contraction? a. Calcium (Ca 2+) b. Potassium (K +) c. Phosphate (PO 4) d. Magnesium (Mg 2+)

a. Calcium (Ca 2+) Rationale: Calcium influences the excitability of nerve and muscle cells and is necessary for muscle contraction. Potassium maintains the resting membrane potential of skeletal, smooth, and cardiac muscle, allowing for normal muscle function. Electrolyte phosphate is necessary for the production of adenosine triphosphate (ATP), the energy source for cellular metabolism. Electrolyte magnesium influences the function of neuromuscular junctions and is a cofactor for numerous enzymes.

After reviewing a patient's laboratory test reports, the nurse documents excessive extracellular fluid volume. Which diseases may have caused the condition? (Select all that apply). a. Cirrhosis b. Heart failure c. Hemorrhage d. Adrenal insufficiency e. Acute oliguric renal disease

a. Cirrhosis b. Heart failure e. Acute oliguric renal disease Rationale: An excess of extracellular fluid volume occurs when there is too much isotonic fluid in the extracellular compartment. This condition occurs when there is sodium and water retention in the kidney, which occurs in patients with cirrhosis, heart failure, and acute oliguric renal disease. Hemorrhage and adrenal insufficiency will cause an extracellular fluid volume deficit.

A patient is dehydrated and needs an infusion of isotonic fluids to correct dehydration. Which intravenous fluid is appropriate for this patient? a. Dextrose 5% in water (D 5W) b. Dextrose 10% in water (D 10W) c. Dextrose 5% in lactated Ringer's (D 5LR) d. Dextrose 5% in 0.9% sodium chloride (D 5NS; D 50.9% NaCl)

a. Dextrose 5% in water (D 5W) Rationale: Dextrose 5% in water (D5W) is an isotonic fluid. It enters cells rapidly, leaving free water, which dilutes extracellular fluid; most of the water then enters cells by osmosis. This mechanism helps correct dehydration. Dextrose 10% in water (D 10W), dextrose 5% in lactated Ringer's (D 5LR), and dextrose 5% in 0.9% sodium chloride (D 5NS; D 50.9% NaCl) are hypertonic solutions; hence, these are not suitable for this patient. Hypertonic solutions have an osmolality that is greater than that of body fluids and tend to extract water from cells.

The nurse is teaching a group of patients about the importance of fluid and electrolyte balance in a health awareness program. About which common causes of hypokalemia would the nurse educate the patients? (Select all that apply). a. Diarrhea b. Acute oliguria c. Repeated vomiting d. Calcium-deficient diet e. Glucocorticoid therapy

a. Diarrhea c. Repeated vomiting e. Glucocorticoid therapy Rationale: Hypokalemia is a low potassium concentration in the blood that results from the loss of potassium. This can occur in patients with diarrhea or repeated vomiting. Glucocorticoid therapy can also result in potassium loss from the body and cause hypokalemia. Acute oliguria decreases the loss of potassium from the body and results in increased concentration of potassium or hyperkalemia. A calcium-deficient diet can cause decreased intake and absorption of calcium, thus resulting in hypocalcemia.

A patient has a pH value of 7.25. Which possible pathological and physiological changes may occur in this patient? (Select all that apply). a. Enzyme dysfunction b. Pruritis c. Anemia d. Impaired hemoglobin function e. Death

a. Enzyme dysfunction d. Impaired hemoglobin function e. Death Rationale: A pH of 7.25 indicates acidosis in the patient. The normal pH value ranges between 7.35 and 7.45. Any deviation from this range will lead to improper functioning of cellular enzymes because enzymes are active only at a certain pH level. A low pH level also interferes with the normal functions of hemoglobin, including oxygen carrying capacity, and may even result in death. Anemia and pruritis are usually not the direct consequences of acidosis. Anemia may have multifactorial causes. Pruritis is usually a result of allergic reactions.

The nurse works at a blood bank. For which diseases should the nurse screen in blood donors? (Select all that apply). a. Human immunodeficiency virus (HIV) b. Syphilis c. Hepatitis C d. Gonorrhea e. Cytomegalovirus

a. Human immunodeficiency virus (HIV) b. Syphilis c. Hepatitis C e. Cytomegalovirus Rationale: Human immunodeficiency virus (HIV), syphilis, hepatitis C, and cytomegalovirus are blood-borne infections and may spread from the donor blood to the recipient. Therefore, the donor blood must be screened for these infections to reduce transmission. Gonorrhea is not routinely screened, because it is not transmitted through blood and blood products.

Which electrolyte abnormality is least likely to be caused by the use of laxatives? a. Hyponatremia b. Hypokalemia c. Hypocalcemia d. Hypomagnesemia

a. Hyponatremia Rationale: Hyponatremia can be caused by the use of antidepressants. Hypokalemia, hypocalcemia, and hypomagnesemia can be caused by the use of laxatives. Therefore, in the patients with these conditions laxatives are contraindicated.

A patient's laboratory reports indicate a sodium level of 120 mEq/L in the blood. Which drug is most likely responsible for this condition? a. Ibuprofen b. Carbenicillin c. Spironolactone d. Magnesium hydroxide

a. Ibuprofen Rationale: The normal level of sodium in the blood ranges from136 to 145 mEq/L. A level of 120 mEq/L indicates hyponatremia. This condition is caused by nonsteroidal antiinflammatory drugs such as ibuprofen. Carbenicillin will cause hypokalemia if large doses are administered. Spironolactone is a potassium-sparing diuretic that causes hyperkalemia. Magnesium hydroxide may cause hypermagnesemia.

After assessing a patient with gastroenteritis, the nurse documents nausea related to gastric irritation. Which symptom supports the nurse's documentation? (Select all that apply). a. Increased salivation b. Decreased skin turgor c. Little interest in eating d. Heart rate of 102 bpm e. Dry oral mucous membranes

a. Increased salivation c. Little interest in eating Rationale: Increased salivation and little interest in eating in a patient with gastroenteritis are symptoms of nausea related to gastric irritation. Decreased skin turgor indicates impaired skin integrity and deficient fluid volume. A heart rate of 102 bpm and dry oral mucous membranes are symptoms of a deficient fluid volume related to vomiting and diarrhea.

The nurse is caring for a patient who is suffering from diarrhea due to intestinal inflammation. Upon assessment, the nurse notes that the patient has had watery stools with abdominal cramping 10 times since the previous day. Which appropriate actions should the nurse take? (Select all that apply). a. Measure stool output. b. Advise high-fiber food. c. Advise easily digestible food. d. Advise reduced fluid intake. e. Administer antidiarrheal as ordered.

a. Measure stool output. c. Advise easily digestible food. e. Administer antidiarrheal as ordered. Rationale: Measuring stool output will help to identify the total loss of fluids and to plan further medical management. Easily digested food helps to ease the gastrointestinal tract and provide nutrition. Antidiarrheal medications should be administered as ordered to control watery stools and abdominal cramping. High-fiber food may increase gastrointestinal motility and should be avoided. Fluid intake should be increased to compensate for the fluid loss due to diarrhea.

A patient has more than six episodes of diarrhea a day, associated with intestinal cramping, hyperactive bowel sounds on auscultation, and brown stools. Which nursing interventions are appropriate in this situation? (Select all that apply). a. Measure stool output. b. Administer antiemetics. c. Discourage use of high-fiber foods. d. Encourage easily digestible food. e. Withhold antidiarrheal agents.

a. Measure stool output. c. Discourage use of high-fiber foods. d. Encourage easily digestible food. Rationale: Intestinal cramping, hyperactive bowel sounds on auscultation, and brown stools of more than six episodes per day are suggestive of inflammatory diarrhea. Measuring stool output helps to assess the volume loss through stools. Avoiding intake of high-fiber foods helps reduce the inflammation. The intake of easily digestible food allows the bowels to rest. Antiemetics are not helpful in a patient with inflammatory diarrhea, because the patient is not vomiting. Antidiarrheal agents should be administered as prescribed.

Which activities can the nurse 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 e. Reporting an electronic infusion device alarm

a. Measuring oral intake and urine output c. Reporting an IV container that is low in fluid e. Reporting an electronic infusion device alarm Rationale: The nurse is able to delegate measuring oral intake and urine output, reporting an IV container that is low in fluid, and reporting an electronic infusion device alarm.The registered nurse cannot delegate working with intravenous (IV) tubing or changing an IV infusion to nursing assistive personnel (NAP).

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; PaCO 2, 21 mm Hg; PaO 2, 92 mm Hg; and HCO 3 -, 8. What do these laboratory values indicate? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

a. Metabolic acidosis Rationale: The low pH indicates acidosis. The low PaCO 2 is caused by the hyperventilation, either from primary respiratory alkalosis (not compatible with the measured pH) or as a compensation for metabolic acidosis. The low HCO 3 - indicates metabolic acidosis or compensation for respiratory alkalosis (again, not compatible with the measured pH). Thus, metabolic acidosis is the correct interpretation.

The nurse is assessing a group of patients for the risk of fluid and electrolyte imbalance. Which patients are considered to be at an increased risk? (Select all that apply). a. Older adult patients b. Overweight patients c. Healthy adult patients d. Patients with skin lesions e. Patients with low platelet count

a. Older adult patients d. Patients with skin lesions e. Patients with low platelet count Rationale: Older adults have proportionately less body water and are at increased risk of fluid and electrolyte imbalance. Skin lesions or infection near potential venipuncture sites increase the likelihood of fluid and electrolyte imbalance. Low platelet count increases risk for bleeding and seepage of blood from the puncture site during venipuncture. Overweight patients are not considered to be at increased risk unless there is an underlying disease process. Healthy adult patients have a stable fluid and electrolyte balance unless there is an underlying disease process.

A patient has developed circulatory overload. Which therapies should the nurse expect to be prescribed for this patient? (Select all that apply). a. Oxygen b. Morphine c. Diuretics d. Vasopressors e. Glucocorticoids

a. Oxygen b. Morphine c. Diuretics Rationale: Oxygen and morphine are helpful in reducing the dyspnea, cough, crackles, and rales associated with circulatory volume overload. Diuretics are helpful in reducing circulatory volume overload by facilitating salt and water excretion in the kidneys. Vasopressors and glucocorticoids are not useful in circulatory overload and may aggravate symptoms of circulatory overload.

A patient with gastroenteritis experiences light-headedness on sitting upright. On assessment, the blood pressure is 90/50 mm Hg in the supine position, pulse rate is 110 beats/minute, and the oral mucous membranes are dry. How should the nurse promote fluid and electrolyte balance in the patient? (Select all that apply). a. Provide oral fluids. b. Administer ordered 0.9% NaCl. c. Promote excess fluid intake. d. Administer antidiarrheal agents. e. Provide a comfortable environment.

a. Provide oral fluids. b. Administer ordered 0.9% NaCl. Rationale: The patient is exhibiting signs and symptoms of extracellular fluid depletion due to fluid loss related to gastroenteritis. The management involves providing oral fluids at the preferred temperature to replenish the lost fluids. To prevent hypokalemia, 0.9% NaCl is administered with KCl supplementation. Fluids should not be given beyond the patient's tolerability. Antidiarrheal agents should be given only on receiving prescription from the primary health care provider. A comfortable environment is helpful to patients with nausea due to gastric irritation; however, it may not help to correct the fluid and electrolyte imbalance in the patient.

A patient on intravenous fluids develops shortness of breath and edema of the extremities. Upon auscultation, the nurse hears crackles in the dependent parts of the lungs. Which nursing intervention is beneficial in this condition? a. Reducing the flow rate b. Starting a new line in another extremity c. Applying a warm and moist compress at the site d. Removing the catheter and applying sterile dressing

a. Reducing the flow rate Rationale: A patient with a circulatory overload of intravenous fluids may develop crackles in the dependent parts of the lungs, shortness of breath, and edema of the extremities. Therefore, the nurse should reduce the intravenous flow rate and notify the health care provider. Starting a new line in another extremity may aggravate the patient's condition. The nurse should apply a warm and moist compress when the patient experiences phlebitis. Removal of the catheter and the application of a sterile dressing is suggested in the case of local infection.

A patient develops acute intravascular hemolytic transfusion reaction following transfusion with incompatible blood. Which treatment strategies should be included in the patient's management? (Select all that apply). a. Stop the transfusion immediately. b. Maintain the blood pressure (BP) at the normal range. c. Avoid keeping the intravenous (IV) line connected. d. Administer diuretics. e. Insert an indwelling urinary catheter.

a. Stop the transfusion immediately. b. Maintain the blood pressure (BP) at the normal range. d. Administer diuretics. e. Insert an indwelling urinary catheter. Rationale: When a patient develops acute intravascular hemolytic transfusion reaction due to a mismatched transfusion, the transfusion should be stopped immediately to prevent further worsening of the condition. The blood bag and transfusion set should be saved for further investigation. The blood pressure (BP) should be maintained to the normal range to ensure perfusion to vital organs. To maintain urinary flow, the nurse may administer diuretics if prescribed. An indwelling urinary catheter may be inserted for hourly monitoring of urine output. The intravenous (IV) line must be kept open by infusing normal saline through new tubing.

A patient has been brought to the hospital in an unconscious state. On assessment, the nurse learns that the patient has engaged in binge drinking, and the lab reports reveal a high anion gap level. What can the nurse interpret about the patient's metabolic status? a. The patient has metabolic acidosis. b. The patient has metabolic alkalosis. c. The patient has respiratory acidosis. d. The patient has respiratory alkalosis.

a. The patient has metabolic acidosis. Rationale: The patient is at risk of metabolic acidosis due to formation of ketoacids in the blood as a result of excessive alcohol intake. A high anion gap also indicates that the patient has metabolic acidosis. Metabolic alkalosis usually occurs either due to conditions associated with bicarbonate excess or increased excretion of metabolic acids. Respiratory acidosis is seen in conditions associated with alveolar hypoventilation. Respiratory alkalosis occurs as a result of alveolar hyperventilation.

Which patient would most likely need teaching regarding dietary sodium restriction? a. An 88-year-old scheduled for surgery for a fractured femur 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. A 65-year-old recently diagnosed with heart failure Rationale: Heart failure commonly causes extracellular fluid volume (ECF) excess because diminished cardiac output reduces kidney perfusion and activates the renin-angiotensin-aldosterone system, causing the kidneys to retain Na + and water. Dietary sodium restriction is important with heart failure because Na + holds water in the extracellular fluid, making the ECF excess worse.

The nurse is caring for a patient with generalized body edema. Which hormones directly influence renal fluid excretion? (Select all that apply). a. Renin b. Aldosterone c. Angiotensin II d. Antidiuretic hormone e. Atrial natriuretic peptide

b. Aldosterone d. Antidiuretic hormone e. Atrial natriuretic peptide Rationale: Aldosterone promotes reabsorption of sodium and water from the kidneys and also facilitates excretion of potassium and hydrogen ions. Antidiuretic hormone is responsible for reabsorption of water from the kidneys. Atrial natriuretic peptide facilitates the urinary excretion of sodium and water. Renin and angiotensin have no direct action on renal fluid excretion and absorption; however, they indirectly exert their actions through aldosterone.

The nurse finds fresh blood at a venipuncture site in a patient and pooling of fluids under the extremity. Which should be the immediate nursing action? a. Culture the blood at the venipuncture site. b. Assess for intactness of the intravenous (IV) system. c. Start a new line even if the catheter is in place. d. Apply a pressure dressing if the catheter is dislodged.

b. Assess for intactness of the intravenous (IV) system. Rationale: The patient has bleeding at the venipuncture site, which could be due to dislodgement of the intravenous (IV) catheter. Therefore, the nurse should check for intactness of the IV system. Because the patient has fresh blood, it does not require culturing. Purulent discharges require cultures. If the catheter is found within the vein, then a pressure dressing must be applied over the site. If the catheter is dislodged, then a new IV line must be set up.

A patient reports nausea, has little interest in eating, and has increased salivation. How would the nurse relieve nausea in the patient? (Select all that apply). a. Administer antiemetics. b. Avoid sudden position changes. c. Provide a comfortable environment. d. Provide oral care every 2 hours. e. Promote excessive intake of oral fluids.

b. Avoid sudden position changes. c. Provide a comfortable environment. d. Provide oral care every 2 hours. Rationale: Nausea, little interest in eating, and increased salivation suggest gastric irritation. Sudden changes in the position of the patient should be avoided, because this can worsen the nausea. A comfortable, clean environment that is free from odors, noise, and vibrations helps relieve nausea. Providing oral care every 2 hours promotes oral hygiene. Antiemetics should be administered only if prescribed by the primary health care provider. Oral fluids should not be given beyond the tolerability of the patient, because they may cause vomiting.

Which assessment findings in a patient on intravenous therapy indicate infiltration? (Select all that apply). a. Bleeding b. Blanched skin c. Edematous skin d. Purulent drainage e. Redness of the skin

b. Blanched skin c. Edematous skin Rationale: The assessment findings in a patient on intravenous therapy that indicate extravasation are blanched skin and edematous skin. Purulent drainage is a sign of a local infection. Redness of the skin is a sign of phlebitis. Pooling under an extremity is an assessment finding of bleeding at the venipuncture site.

How can the nurse prevent the development of febrile nonhemolytic reactions in the patient during blood transfusions? (Select all that apply). a. By adjusting the transfusion volume b. By pretreating with antipyretics c. By pretreating with antihistamine d. By implementing blood-banking standards e. By considering leukocyte-poor blood products

b. By pretreating with antipyretics e. By considering leukocyte-poor blood products Rationale: Blood transfusions may result in febrile nonhemolytic reactions. They can be prevented by pretreatment with antipyretics, especially if the patient has a previous history of febrile nonhemolytic reactions. Leukocytes in the blood are responsible for febrile reactions; therefore, the use of leukocyte-poor blood products (filtered, washed, or frozen) can prevent febrile reactions to blood transfusions. Adjusting the transfusion volume is useful in reducing the circulatory overload and has no role in reducing nonhemolytic reactions. Antihistamines are helpful for allergic reactions but not for febrile reactions. The implementation of blood-banking standards is helpful in reducing the incidence of sepsis.

Which acute condition will place the patient at a high risk for hyperkalemia? a. Cancer b. Crush injuries c. Chronic heart failure d. Bacterial pneumonia

b. Crush injuries Rationale: Crush injuries place a patient at risk for hyperkalemia. Patients with cancer may develop hypercalcemia. Patients with chronic heart failure will be at risk for hypokalemia. Bacterial pneumonia will cause respiratory acidosis.

While caring for a patient on intravenous therapy, the nurse elevates the patient's extremity. What is the rationale behind this intervention? a. Phlebitis b. Extravasation c. Local infection d. Circulatory overload

b. Extravasation Rationale: Elevating the extremity would benefit a patient with extravasations (tissue damage). Applying warm and moist compresses would benefit a patient with phlebitis. A new intravenous line should be started in another extremity if a patient develops a local infection. Circulatory overload of intravenous solutions occurs when a patient receives fluids too rapidly or receives an excessive amount of fluids. This condition can lead to excessive fluid volume deficit; raising the head of the bed is an appropriate intervention in this case.

The skin of a patient taking intravenous fluids appears blanched, cool to the touch, and edematous. Upon touch, the patient reports pain. Which complication does this represent? a. Phlebitis b. Extravasation c. Local infection d. Circulatory overload

b. Extravasation Rationale: Extravasation and infiltration are manifested by painful and blanched skin that is cool to the touch and edematous. Phlebitis is manifested by redness, tenderness, pain, and warmth along the course of the vein starting at the access site. Redness, heat, and swelling indicate a local infection at the catheter entry site. Circulatory overload is manifested by crackles in the dependent parts of the lungs, shortness of breath, and dependent edema.

A patient is experiencing the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). For which electrolyte disturbance should the nurse evaluate the patient? a. Hypernatremia b. Hyponatremia c. Hemoconcentration d. Increased serum osmolality

b. Hyponatremia Rationale: Patients with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) have excess antidiuretic hormone (ADH) secretion. Therefore, the patient is most likely to have hyponatremia due to excess retention of water from the kidney, which is disproportionate to salt retention. SIADH is not related to hypernatremia. SIADH is most likely found in diabetes insipidus (deficiency of ADH). Hemoconcentration is seen in conditions associated with extracellular water depletion. In conditions associated with excess ADH, there is a decrease in serum osmolality.

The nurse is examining a patient with hypocalcemia. For which clinical findings should the nurse look during the assessment? (Select all that apply). a. Abdominal distension b. Positive Chvostek's sign c. Positive Trousseau's sign d. Muscle twitching and cramping e. Bilateral muscle weakness in quadriceps

b. Positive Chvostek's sign c. Positive Trousseau's sign d. Muscle twitching and cramping Rationale: Hypocalcemia occurs due to low serum calcium level. It increases neuromuscular excitability and can cause a positive Chvostek's sign. Chvostek's sign refers to the contraction of facial muscles when a facial nerve is tapped. Trousseau's sign refers to the carpal spasm in response to hypoxia. This sign is positive in hypocalcemia. In addition, muscle twitching and cramping can be noted. Abdominal distension is noted in case of hypokalemia, along with muscle weakness. Bilateral muscle weakness in the quadriceps is noted in the case of imbalances of serum potassium levels.

A nurse finds circulatory overload in a patient on intravenous infusion. Which intervention would benefit this patient? a. Elevating the extremity b. Raising the head of the bed c. Applying a warm and moist compress d. Starting a new intravenous line in another extremity

b. Raising the head of the bed Rationale: Circulatory overload of intravenous solution occurs due to infusion at a too rapid rate or an infusion of too much solution. Circulatory overload causes excessive extracellular volume. Raising the head of the bed will help a patient in this case. Elevating the extremity of the patient reduces extravasations. A warm, moist compress is applied for phlebitis. Starting a new intravenous line in another extremity is considered appropriate when the patient's extremity develops local infection.

A patient has a partial pressure of carbon dioxide (PaCO 2) of 30 mm Hg. What does this value indicate about the patient's condition? a. CO 2 has accumulated in the blood. b. The PaCO 2 is lower than normal. c. The patient is hypoventilating. d. The patient has impaired renal function.

b. The PaCO 2 is lower than normal. Rationale: PaCO2 is the measure of the partial pressure of carbon dioxide in the blood; it measures how well the lungs are excreting carbon dioxide produced during cellular metabolism. Normal values range from 35 to 45 mm Hg. This patient has a value lower than normal. A high PaCO 2 indicates accumulation of carbon dioxide in the blood, caused by hypoventilation. The PaCO 2 value denotes lung function; the bicarbonate (HCO 3-) indicates kidney function.

Which physical findings can be seen in a patient with extracellular fluid volume (ECV) deficit? (Select all that apply). a. Edema b. Thready pulse c. Crackles in lungs d. Postural hypotension e. Dry mucous membranes

b. Thready pulse d. Postural hypotension e. Dry mucous membranes Rationale: A thready pulse, postural hypotension, and dry mucous membranes are the physical findings of an extracellular fluid volume deficit. Edema in dependent areas and crackles in the lungs are the physical findings of extracellular fluid volume excess.

On assessment, a patient is found to have extracellular fluid volume (ECF) depletion associated with dehydration of cells. Which fluids might the nurse choose to correct both extracellular fluid volume depletion and cellular dehydration? (Select all that apply). a. 5% dextrose in lactated Ringer's b. 0.9% sodium chloride c. 0.45% sodium chloride d. 0.225% sodium chloride e. 3% and 5% sodium chloride

c. 0.45% sodium chloride d. 0.225% sodium chloride Rationale: Sodium chloride solutions of 0.225% and 0.45% are hypotonic in nature and are used to correct both extracellular fluid volume depletion and cellular dehydration. These solutions have an effective osmolality less than body fluids, which helps to move water into cells. Lactated Ringer's (LR) and 0.9% sodium chloride are isotonic and correct only extracellular volume depletion. Solutions of 3% and 5% sodium chloride are hypertonic and they aggravate cellular dehydration.

The nurse assesses 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 with acute pancreatitis d. 65-year-old with hypertension and asthma

c. 28-year-old with acute pancreatitis Rationale: People who have acute pancreatitis frequently develop hypocalcemia because calcium binds to undigested fat in their feces and is excreted. This process decreases absorption of dietary calcium and also increases calcium output by preventing resorption of calcium contained in gastrointestinal fluids. The presence of abnormal levels of fat in feces is called steatorrhea.

A patient develops a mild allergic reaction during a blood transfusion. Which should the nurse administer to manage this allergic reaction? a. Sympathomimetics b. Corticosteroids c. Antihistamines d. Vasoconstrictors

c. Antihistamines Rationale: Mild allergic reactions during blood transfusion are managed by administering antihistamines. Antihistamines prevent the release of histamine from the cells, thereby preventing the allergic reaction from getting worse. Epinephrine (a sympathomimetic) is used only in patients with anaphylaxis. Corticosteroids usually do not have an immediate action and are usually not required for mild allergic reactions. Vasopressors are required only during sepsis related to blood transfusion.

A patient suffering from gastroenteritis has tachycardia, hypotension, oliguria, and dark-colored urine. The lab reports reveal increased hematocrit, elevated blood urea nitrogen, and increased specific gravity of the urine. What is the probable electrolyte disturbance in the patient? a. Low levels of sodium in the body b. Low levels of potassium in the body c. Decreased extracellular fluids with normal tonicity d. Combined hypernatremia and extracellular volume depletion

c. Decreased extracellular fluids with normal tonicity Rationale: Patients with gastroenteritis may have tachycardia, hypotension, oliguria, and dark-colored urine. In addition, increased hematocrit, elevated blood urea nitrogen, and increased specific gravity indicate extracellular volume depletion with isotonicity. Patients with low levels of sodium, or hyponatremia, usually present with confusion, nausea, vomiting, seizures, and lab reports indicating lower serum osmolality. Patients with low levels of potassium, or hypokalemia, present with bilateral muscle weakness, abdominal distention, decreased bowel sounds, and constipation. If the patient had coexisting increased serum osmolality and serum sodium levels above 145 mEq/L, then the patient would have symptoms of both hypernatremia and extracellular volume depletion.

While caring for a patient with gastroenteritis, the nurse finds a supine blood pressure of 90/58 mm Hg and a heart rate of 102 bpm. What condition does the nurse suspect? a. Risk for impaired skin integrity b. Nausea related to gastric irritation c. Deficient fluid volume related to vomiting d. Diarrhea related to intestinal inflammation

c. Deficient fluid volume related to vomiting Rationale: A supine blood pressure of 90/58 mm Hg and a heart rate of 102 bp in a patient with gastroenteritis indicate deficient fluid volume related to vomiting. The symptoms of impaired skin integrity in a patient with gastroenteritis are intact skin, redness, and decreased skin turgor. Little interest in eating and increased salivation are symptoms of nausea related to gastric irritation. Abdominal cramping and hyperactive bowel sounds are symptoms of diarrhea related to intestinal inflammation.

A patient with blood type O needs platelets. What should the nurse consider when choosing a donor for platelet transfusion? a. Rh compatibility is excluded. b. Donor can be of any blood group. c. Donor should be of blood group O. d. Donor can be exempted from screening for infections.

c. Donor should be of blood group O. Rationale: For platelet transfusion to a patient with blood group O, the donor must be of blood group O only. Any other blood type may cause a mismatch and lead to a transfusion reaction. Rh compatibility should be checked before transfusion, because it can also lead to a transfusion reaction. Donor specifications exist for platelet transfusions; not just any blood group is acceptable. The donor must be screened for all communicable diseases, including human immunodeficiency virus (HIV).

The nurse understands that various mechanisms in the body help move fluid from one compartment to another. Which transport mechanism is governed by oncotic and hydrostatic pressures? a. Osmosis b. Diffusion c. Filtration d. Active transport

c. Filtration Rationale: A filtration process determines fluid movement in and out of capillaries and is governed by hydrostatic and oncotic pressure within the vascular and interstitial space. Osmosis is the movement of water molecules across semipermeable membranes. Diffusion is the passive movement of electrolytes down the concentration gradient. Active transport refers to the transportation of electrolytes against the concentration gradient via adenosine triphosphate (ATP).

A patient on antidepressant therapy has developed hyponatremia. Which drug might have led to this condition? a. Losartan b. Captopril c. Fluoxetine d. Furosemide

c. Fluoxetine Rationale: Fluoxetine is an antidepressant that leads to hyponatremia. Losartan is an angiotensin II receptor blocker that causes hyperkalemia. Captopril is an angiotensin-converting enzyme inhibitor that also causes hyperkalemia. Furosemide is a diuretic that causes hypokalemia and hypomagnesemia.

While performing a general examination of a patient, the nurse finds that the patient has tetany and is positive for Chvostek's sign and Trousseau's sign. Which electrolyte disturbance is responsible for this clinical presentation? a. Hypokalemia b. Hyponatremia c. Hypocalcemia d. Hypermagnesemia

c. Hypocalcemia Rationale: Positive Chvostek's sign, Trousseau's sign, and presence of tetany indicate hypocalcemia. Low levels of calcium may affect the excitability of the nerve and muscle cells, causing cramps and abnormal muscle movements. Hypokalemia presents with muscular weakness and cardiac rhythm disturbances. Hyponatremia usually presents with nausea, vomiting, confusion, and seizures. Hypermagnesemia is an abnormally high magnesium concentration in the blood. Chvostek's sign and Trousseau's sign are associated with hypomagnesemia.

A patient's electrocardiogram report indicates a prolonged QT interval. Which electrolyte imbalance does the nurse suspect? a. Hyperkalemia b. Hypocalcemia c. Hypomagnesemia d. Hypermagnesemia

c. Hypomagnesemia Rationale: Prolongation of the QT interval on the electrocardiogram report can be seen in patients with hypomagnesemia. PR prolongation can be seen in patients with hyperkalemia. Prolonged ST segments can be seen in patients with hypercalcemia. A prolonged PR interval is seen in patients with hypermagnesemia.

A patient with gastroenteritis is experiencing dehydration due to vomiting and diarrhea. Which nursing intervention requires correction? a. Initiating ordered peripheral IV and administering 1,000 mL 0.9% NaCl with 10 mEq KCl b. Providing oral fluids at a temperature the patient prefers c. Offering fluid frequently in large amounts as tolerated d. Providing antiemetics as ordered

c. Offering fluid frequently in large amounts as tolerated Rationale: Because the patient with vomiting and diarrhea is likely experiencing nausea and lightheadedness, he or she may not be able to tolerate large amounts of fluid; it is more effective to offer this patient small amounts of fluid as tolerated. The other nursing interventions are correct. The nurse should initiate an ordered peripheral IV and administer 1,000 mL 0.9% NaCl with 10 mEq KCl to maintain fluid and electrolyte balance. Providing fluids at the temperature the patient prefers will encourage the patient to consume more than if the temperature is too cold or too warm. Antiemetics will decrease the patient's nausea.

Which patient is most at risk of developing hypokalemia? a. Patient with cancer b. Patient with oliguria c. Patient with diarrhea d. Patient with acute pancreatitis

c. Patient with diarrhea Rationale: A patient with diarrhea loses fluids and potassium, which can lead to hypokalemia. A patient with cancer develops hypercalcemia because some cancer cells secrete chemicals into the blood that are related to the parathyroid hormone. Oliguria causes decreased potassium output resulting in hyperkalemia. A patient with acute pancreatitis develops hypocalcemia because calcium binds with the undigested fat in the feces and is excreted.

The nurse works in an acute care facility. Which patients should the nurse monitor for development of hypokalemia? (Select all that apply). a. Patients with adrenal insufficiency b. Patients with end-stage renal disease c. Patients with diarrhea d. Patients with vomiting e. Patients using potassium-wasting diuretics

c. Patients with diarrhea d. Patients with vomiting e. Patients using potassium-wasting diuretics Rationale: Hypokalemia is common when potassium output is increased. Diarrhea and vomiting can increase potassium loss through the gastrointestinal tract. Potassium-wasting diuretics may increase potassium loss in urine. Adrenal insufficiency leads to hyperkalemia by decreasing excretion of potassium. Oliguria in end-stage renal disease may cause decreased excretion of potassium in the urine, leading to hyperkalemia.

Which electrolyte is necessary for the production of adenosine triphosphate? a. Calcium (Ca 2+) b. Potassium (K +) c. Phosphate (PO 4 3-) d. Magnesium (Mg 2+)

c. Phosphate (PO 4 3-) Rationale: Phosphate (PO 4 3-) is necessary for the production of adenosine triphosphate. Calcium (Ca 2+) is necessary for muscle contractions. Potassium (K +) is necessary for normal muscle function. Magnesium (Mg 2+) influences the function of neuromuscular junctions.

A patient with chronic infective diarrhea has skin redness on the perianal area due to constant exposure to stool. The patient also has reduced skin turgor and reports dizziness. Which interventions would be helpful to promote patient comfort? (Select all that apply). a. Avoid foods high in fiber. b. Provide easily digestible food. c. Position the patient off the inflamed area. d. Apply moisture barriers to the skin. e. Provide the bedpan carefully.

c. Position the patient off the inflamed area. d. Apply moisture barriers to the skin. e. Provide the bedpan carefully. Rationale: The nursing interventions should aim at providing comfort to the patient and keeping the patient safe until the dizziness subsides. Positioning the patient off the inflamed area can promote patient comfort. Providing skin care by applying moisture barriers prevents further breakdown. Providing safe access to a bedpan until the dizziness resolves promotes patient safety. Avoiding high-fiber foods and ingestion of easily digestible food is helpful in diarrhea related to inflammation.

A patient has had chronic diarrhea for 3 months and also suffers from repeated bouts of vomiting. The nurse is reviewing the patient's laboratory report. Which are likely findings in the laboratory report? a. Serum K + levels are more than 5 mEq/L. b. Total serum Ca 2+ is greater than 10.5 mg/dL. c. Serum K + levels are less than 3.5 mEq/L. d. Serum Mg 2+ levels are greater than 2.5 mEq/L.

c. Serum K + levels are less than 3.5 mEq/L. Rationale: Chronic diarrhea and vomiting can cause electrolyte imbalances in the body. Diarrhea and vomiting can result in the loss of electrolytes from the body, resulting in decreased potassium levels. Potassium, magnesium, and calcium levels may increase in the case of increased intake and absorption of these electrolytes.

A patient with vomiting and diarrhea reports lightheadedness while standing from a sitting position. The patient's blood pressure is 90/58 mm Hg. Which intervention would best treat this patient? a. Administering diuretics b. Monitoring the patient's 24-hour fluid intake and urine output c. Limiting the patient's intake of fluids and foods rich in sodium d. Administering 1000 mL of 0.9% normal saline solution with 10 mEq of potassium chloride

d. Administering 1000 mL of 0.9% normal saline solution with 10 mEq of potassium chloride Rationale: A patient with vomiting and diarrhea may experience lightheadedness due to fluid and electrolyte imbalance. The blood pressure may also be altered to 90/58 mm Hg while changing positions, resulting in postural hypotension. Administering 1000 mL of 0.9% normal saline solution with 10 mEq of potassium chloride may accelerate the improvement of the patient's condition. Diuretics such as furosemide and thiazide may lead to hyponatremia and hypokalemia, which may aggravate the patient's condition. Monitoring the patient's 24-hour fluid intake and urine output is important, but it may not directly comfort the patient. Limiting the patient's intake of fluids and foods rich in sodium may worsen the condition.

The primary health care provider orders the nurse to administer potassium chloride to a patient with 10 episodes of vomiting in two days. Which complication does the nurse anticipate from the potassium chloride? a. Cancer b. Seizures c. Respiratory acidosis d. Cardiac dysrhythmia

d. Cardiac dysrhythmia Rationale: Potassium chloride is an intravenous solution that should be carefully administered to a patient with severe emesis because hyperkalemia may cause fatal cardiac dysrhythmias. Patients with cancer often develop hypocalcemia. Hyponatremia or hypernatremia may cause confusion and seizures. An increased partial pressure of carbon dioxide leads to respiratory acidosis.

Which can cause an excess of extracellular fluid volume? a. Vomiting b. Diarrhea c. Hemorrhage d. Chronic heart failure

d. Chronic heart failure Rationale: Chronic heart failure results in an excess of extracellular fluid volume, because there is a decrease in urine output due to elevated aldosterone. Vomiting and diarrhea cause a loss of fluids and electrolytes, which results in extracellular volume deficit. Hemorrhage also decreases the extracellular volume due to loss of fluids.

A patient needs a blood transfusion but is apprehensive due to fear of developing sepsis. Which nursing interventions are helpful in preventing transfusion-related sepsis? a. Administer antibiotics. b. Educate patient about blood transfusion. c. Wear gloves during the procedure. d. Follow blood-banking standards.

d. Follow blood-banking standards. Rationale: The infusion of infected blood and blood products may lead to sepsis, which can be prevented by following blood-banking standards. Blood-banking standards include appropriate collection, processing, storage, and transfusion. Antibiotics have no preventive role in transfusion-related sepsis. Educating the patient about blood transfusion may alleviate anxiety. However, it is not a preventive action against transfusion-related sepsis. Wearing gloves may prevent spread of microorganisms but may not be helpful in preventing sepsis.

What condition may be suspected in a patient with end-stage renal disease? a. Hypokalemia b. Hypercalcemia c. Hypomagnesemia d. Hypermagnesemia

d. Hypermagnesemia Rationale: Hypermagnesemia is an abnormally high magnesium concentration in the blood; this can be caused by end-stage renal disease. Excessive fluid loss can cause hypokalemia. Malignant neoplasms or increased levels of parathyroid hormone can cause hypercalcemia. Chronic diarrhea can cause hypomagnesemia.

The nurse advises a patient to consume dark green, leafy vegetables and whole grains. What might be the patient's condition? a. Muscle weakness b. Cardiac dysrhythmia c. End-stage renal disease d. Neuromuscular excitability

d. Neuromuscular excitability Rationale: Dark green leafy vegetables and whole grains are rich in magnesium. The consumption of food containing magnesium is required in patients with hypomagnesemia because this condition increases neuromuscular excitability. Muscle weakness and cardiac dysrhythmia are caused by hypokalemia. A patient with hypokalemia should consume a diet rich in potassium. Hypermagnesemia causes end-stage renal disease; therefore, the patient should be advised to avoid a magnesium-rich diet.

A patient has extracellular volume deficit due to diarrhea. How should the nurse correct the volume deficit in the patient? a. Provide caffeinated fluids. b. Provide low-sodium fluids. c. Provide fluids that contain lactose. d. Provide fluids that contain sodium.

d. Provide fluids that contain sodium. Rationale: The nurse should use fluids such as an electrolyte replacement, which contains sodium to correct extracellular volume deficit. The sodium in the fluids helps to prevent fluid loss through retention. Caffeinated fluids, low-sodium fluids, and fluids containing lactose are not ideal to correct the extracellular volume deficit of diarrhea. These fluids tend to promote fluid loss and cause dehydration.

Which symptom can be seen in a patient with phlebitis? a. Blanched skin b. Edematous skin c. Purulent drainage d. Redness of the skin

d. Redness of the skin Rationale: Inflammation of the inner layer of a vein is known as phlebitis. In this condition, the patient will have redness of the skin. Blanched skin and edematous skin are associated with extravasation. Purulent drainage is a sign of a local infection.

A patient with a cardiac history is taking the diuretic furosemide and is seen in the emergency department for muscle weakness. Which laboratory value should the nurse assess first? a. Serum albumin b. Serum sodium c. Hematocrit d. Serum potassium

d. Serum potassium Rationale: Potassium-wasting diuretics such as furosemide increase potassium urinary output and can cause hypokalemia unless potassium intake also increases. Hypokalemia causes muscle weakness.