Foundations Ch 39 Fluid Imbalance PrepU

What is the rate of administration for packed red blood cells? a) 1 unit over 2 to 3 hours, no longer than 4 hours b) IV push over 3 minutes c) As fast as the patient can tolerate d) 200 mL/hr

a) 1 unit over 2 to 3 hours, no longer than 4 hours

Which client has more extracellular fluid? a) Newborn b) Adolescent man c) Adult woman d) Female school-age child

a) Newborn

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) distended neck veins b) nausea and vomiting c) fingerprinting over sternum d) muscle twitching

a) distended neck veins

A child is eating a peanut butter sandwich. He is ingesting an excellent source of: a) magnesium. b) sulfate. c) calcium. d) potassium.

a) magnesium.

A decrease in arterial blood pressure will result in the release of: a) renin. b) thrombus. c) insulin. d) protein.

a) renin.

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

b) 3,000

What is the lab test commonly used in the assessment and treatment of acid-base balance? a) Chemistry I b) Arterial blood gas c) Complete blood count d) Urinalysis

b) Arterial blood gas

Potassium is needed for neural, muscle, and: a) optic function. b) cardiac function. c) auditory function. d) skeletal function.

b) cardiac function.

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? a) Chloride b) Phosphorous c) Sodium d) Potassium

d) Potassium

A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? a) 40 gtt/min b) 20 gtt/min c) 50 gtt/min d) 30 gtt/min

c) 50 gtt/min

Which is a common anion? a) Potassium b) Calcium c) Chloride d) Magnesium

c) Chloride

A nurse is required to initiate IV therapy for a client. Which of the following should the nurse consider before starting the IV? a) Select a primary tubing of about 37 inches (94 cm) long. b) Use half-instilled IV solutions before infusing a new one. c) Ensure that the prescribed solution is clear and transparent. d) Avoid replacing IV solution every 24 hours.

c) Ensure that the prescribed solution is clear and transparent.

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

a) 300 to 400 mL/day

The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients? a) Cardiac volume intolerance b) An increased sense of thirst c) Increased renal blood flow d) Increase in nephrons in the kidneys

a) Cardiac volume intolerance

Which of the following is not true regarding magnesium? a) The liver regulates magnesium levels by breaking down the ion when serum levels are low. b) Magnesium is important in regulating neuromuscular function and cardiac activity. c) Normal serum magnesium level ranges from 1.4 to 1.74 mEq/L. d) Up to 60% of magnesium is in bone.

a) The liver regulates magnesium levels by breaking down the ion when serum levels are low.

An intravenous hypertonic solution containing dextrose, proteins, vitamins, and minerals is known as a) Blood transfusion therapy b) Cellular hydration c) Volume expander d) Total parenteral nutrition

d) Total parenteral nutrition

A nurse monitoring a client's IV infusion auscultates the client's lung sounds and finds crackles in the bases of lungs that were previously clear. What would be the appropriate intervention in this situation? a) Notify the primary care provider immediately for possible fluid overload. b) Check all clamps on the tubing and check tubing for any kinking. c) No intervention is necessary as this is a normal finding with IV infusion. d) Notify the primary care provider immediately because these are signs of speed shock.

a) Notify the primary care provider immediately for possible fluid overload.

A woman age 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) replacement of fluids for those lost from vomiting and diarrhea. b) an access route to replace fluids in combination with blood products. c) intravenous fluids to be administered on an outpatient basis. d) an access route to administer medications intravenously.

a) replacement of fluids for those lost from vomiting and diarrhea.

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) Blood pressure 112/70 mm Hg b) Blood pressure 104/68 mm Hg c) Blood pressure 126/80 mm Hg d) Pulse rate 90 bpm e) Pulse rate 72 bpm

b) Blood pressure 104/68 mm Hg d) Pulse rate 90 bpm

The nurse is caring for a male client who has a diagnosis of heart failure. Today's laboratory results show a serum potassium of 3.2 mEq/L. For what complications should the nurse be aware, related to the potassium level? a) Tetany b) Cardiac dysrhythmias c) Pulmonary embolus d) Fluid volume excess

b) Cardiac dysrhythmias

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

b) Normal serum potassium ranges from 5.5 to 6.0 mEq/L.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms indicative of what? a) A systemic blood infection b) Phlebitis c) An infiltration d) Rapid fluid administration

b) Phlebitis

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a) a 47-year-old who had a colon resection yesterday and is reporting pain b) a newly admitted 88-year-old with a 2-day history of vomiting and loose stools c) a 60-year-old who is 3 days post-myocardial infarction and has been stable. d) a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today

b) a newly admitted 88-year-old with a 2-day history of vomiting and loose stools

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) output measurements b) daily weights c) daily BUN and serum creatinine monitoring d) daily electrolyte monitoring

b) daily weights

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) hypokalemia. d) hypoglycemia.

c) hypokalemia.

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

d) Acute Confusion related to cerebral edema

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

d) cardiac irregularities

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) decreased skin area. b) increase in muscle mass. c) smaller stomach capacity. d) increase in fat cells.

d) increase in fat cells.

The primary extracellular electrolytes are: a) phosphorous, calcium, and phosphate. b) potassium, phosphate, and sulfate. c) magnesium, sulfate, and carbon. d) sodium, chloride, and bicarbonate.

d) sodium, chloride, and bicarbonate.