Chapter 4 Questions: Fluid, Electrolyte, and Acid-Base Balance Problems
The nursing care plan for an older client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? Select all that apply. 1. Reminding the client to avoid commercial mouthwashes. 2. Encouraging mouth rinsing with warm saline. 3. Assess skin turgor by pinching the skin over the back of the hand. 4. Observing the lips, tongue, and mucous membranes. 5. Providing mouth care every 2 hours while the client is awake. 6. Seeking a dietary consult to increase fluids on meal trays.
1, 2, 4, 5
The nurse is completing a history for an older client at risk for an acidosis imbalance. Which questions would the nurse be sure to ask? Select all that apply. 1. "Which drugs to you take on a daily basis?" 2. "Do you have any problems with breathing?" 3. "When was your last bowel movement?" 4. "Have you experienced any activity intolerance or fatigue in the past 24 hours?" 5. "Over the past month have you had any dizziness or tinnitus?" 6. "Do you have episodes of drowsiness or decreased alertness?"
1, 2, 4, 6
The client has an order for HCTZ 10 mg orally every day. What should the nurse be sure to include in a teaching plan for this drug? Select all that apply. 1. "Take this medication in the morning." 2. "This medication should be taken in two divided doses when you get up and when you go to bed." 3. "Eat foods with extra sodium every day." 4. "Inform your prescriber if you notice weight gain or increased swelling." 5. "You should expect your urine output to increase." 6. "Your health care provider may also prescribe a potassium supplement."
1, 4, 5, 6
The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to a new-graduated RN. Which actions can the new-graduate RN delegate to the UAP? Select all that apply. 1. Providing oral care every 3 or 4 hours. 2. Monitoring for indications of dehydration. 3. Administering 0.45% saline by IV line. 4. Record urine output when client voids. 5. Assessing daily weights for trends. 6. Help the client change position every 2 hours.
1, 4, 6
The student nurse, under the supervision of an RN, is reviewing a client's arterial blood gas results and notes an acute increase in arterial partial pressure of carbon dioxide to 51 mm Hg compared with the previous results. Which statement by the student nurse indicates accurate understanding of acid-base balance for this client? 1. "When the PaCO2 is acutely elevated, the blood pH should be lower than normal." 2. "This client should be taught to breathe and rebreathe in a paper bag." 3. An elevated paCO2 always means that a client has an acidosis." 4. "When a client's paCO2 is increased, the respiratory rate should decrease to compensate."
1. "When the PaCO2 is acutely elevated, the blood pH should be lower than normal."
The nurse is providing care for several clients who are at risk for acid-base imbalance. Which client is most at risk for respiratory acidosis? 1. A 68-year-old client with chronic emphysema. 2. A 58-year-old client who uses antacids every day. 3. A 48-year-old client with an anxiety disorder. 4. A 28-year-old client with salicylate intoxication.
1. A 68-year-old client with chronic emphysema.
A client's potassium level is 6.7 mEq/L. Which intervention should the nurse delegate to the first-year student nurse whom he or she is supervising? 1. Administer sodium polystyrene sulfonate 15 g orally. 2. Administer spironolactone 25 mg orally. 3. Assess the ECG strip tall T waves. 4. Administer potassium 10 mEq.
1. Administer sodium polystyrene sulfonate 15 g orally.
This client is at risk for poor perfusion related to decreased plasma volume. Which assessment finding supports this risk? 1. Flattened neck veins when the client is in the supine position. 2. Full and bounding pedal and post-tibial pulses. 3. Pitting edema located in the feet, ankles, and calves. 4. Shallow respirations with crackles on auscultation.
1. Flattened neck veins when the client is in the supine position.
The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should the nurse expect to correct this problem? 1. Increase in ventilator rate from 6 to 10 breaths/min 2. Decrease in ventilator rate from 10 to 6 breaths/min 3. Increase in oxygen concentration from 30% to 40% 4. Decrease in oxygen concentration from 40% to 30%
1. Increase in ventilator rate from 6 to 10 breaths/min
A client is admitted to the oncology unit for chemotherapy. To prevent an acid-base problem, which finding would the nurse instruct the UAP to report? 1. Repeated episodes of nausea and vomiting. 2. Reports of pain associated with exertion. 3. Failure to eat all the food on the breakfast tray. 4. Client hair loss during the morning bath.
1. Repeated episodes of nausea and vomiting.
A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assess the client, which finding would the nurse instruct the student to report immediately? 1. Respiratory rate of 8 to 10 breaths/min. 2. Decrease in pain level from 6 to 2. 3. Request by the client that the room door be closed. 4. Heart rate of 90 to 100 beats/min
1. Respiratory rate of 8 to 10 breaths/min.
Which actions should the nurse delegate to an UAP for the client with diabetic ketoacidosis? Select all that apply. 1. Checking fingerstick glucose results every hour. 2. Recording intake and output every hour. 3. Measuring vital every 15 minutes. 4. Assessing for indicators of fluid imbalance. 5. Notifying the provider of changes in glucose level. 6. Assisting the client to reposition every 2 hours.
2, 3, 6
The client has a NG tube connected to intermittent wall suction. The student nurse asks why the client's respiratory rate and depth has decreased. What is the nurse's best response? 1. "It's common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing." 2. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism." 3. "Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem." 4. "The client is hypoventiliating because of anxiety, and we will have to stay alert for the development of respiratory acidosis."
2. "The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism."
Which client would the charge nurse assign to the step-down unit nurse who was floated to the ICU for the day? 1. A 68-year-old client on a ventilator with acute respiratory failure and respiratory acidosis. 2. A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent. 3. A newly admitted 56-year-old client with diabetic ketoacidosis receiving an insulin drip. 4. A 38-year-old client on a ventilator with narcotic overdose and respiratory.
2. A 72-year-old client with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent.
Which specific instruction does the charge nurse give the UAP helping to provide care for a client who is at risk for metabolic acidosis? 1. Check to see that the client keeps his oxygen in place at all times. 2. Inform the nurse immediately if the client's respiratory rate and depth increases. 3. Record any episodes of reflux or constipation. 4. Keep the client's ice water pitcher filled at all times.
2. Inform the nurse immediately if the client's respiratory rate and depth increases.
The nurse has been floated to the telemetry unit for the day. The monitor technician informs the nurse that the client has developed prominent U waves. Which laboratory value should be checked immediately? 1. Sodium 2. Potassium 3. Magnesium 4. Calcium
2. Potassium
Which blood test result would the nurse be sure to monitor for the client taking HCTZ? 1. Sodium level 2. Potassium level 3. Chloride level 4. Calcium level
2. Potassium level
The client has fluid volume deficit related to excessive fluid loss. Which action related to fluid management should be delegated by the RN to UAP? 1. Administering IV fluids as prescribed by the physician. 2. Providing straws and offering fluids between meals. 3. Developing a plan for added fluid intake over 24 hours. 4. Teaching family members to assist the client with fluid intake.
2. Providing straws and offering fluids between meals.
The UAP reports to the nurse that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should the nurse suspect? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis
2. Respiratory alkalosis
An experiences LPN/LVN reports to the RN that a client's blood pressure and heart rate have decreased, and when his face was assessed, one side twitches. What action should the RN take at this time? 1. Reassess the client's blood pressure and heart rate. 2. Review the client's morning calcium level. 3. Request a neurologic consult today. 4. Check the client's pupillary reaction to light.
2. Review the client's morning calcium level.
Which statement by a client with hypovolemia related to dehydration is the best indicator to the nurse of the need for additional teaching? 1. "I will drink 2 to 3 L of fluids every day." 2. "I will drink a glass of water whenever I feel thirsty." 3. "I will drink coffee and cola drinks throughout the day." 4. "I will avoid drinks containing alcohol."
3. "I will drink coffee and cola drinks throughout the day."
The UAP asks the nurse why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is the RN's best response? 1. "The client's low phosphorus is probably due to malnutrition." 2. "The client is just worn out form not getting enough rest." 3. "The client's skeletal muscles are weak because of the low phosphorus." 4. "The client will do more for himself when his phosphorus level is normal."
3. "The client's skeletal muscles are weak because of the low phosphorus."
A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone section (SIADH). For which electrolyte abnormality would the nurse be sure to monitor? 1. Hypokalemia 2. Hyperkalemia 3. Hyponatremia 4. Hypernatremia
3. Hyponatremia
The RN is admitting a client with benign prostatic hyperplasia (BPH) to an acute care unit. The client describes an oral intake of about 1400 mL/day. What is the RN's priority concern? 1. Ask the client about his or her bowel movements. 2. Have the client complete a diet diary for the past 2 days. 3. Instruct the client to increase oral intake to 2 or 3 L/day. 4. Ask the client to describe his urine output.
3. Instruct the client to increase oral intake to 2 or 3 L/day.
The nurse is preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL). Which statement by the client indicates the need for additional teaching? 1. "I will call my doctor if I experience muscle twitching or seizures." 2. "I will make sure to take my vitamin D with my calcium each day." 3. "I will take my calcium citrate pill every morning before breakfast." 4. "I will avoid dairy products, broccoli, and spinach when I eat."
4. "I will avoid dairy products, broccoli, and spinach when I eat."
The health care provider has written these orders for a client with a diagnosis of pulmonary edema. The client's morning assessment reveals bounding peripheral pulses, weight gain of 2 lbs, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? 1. Weight the client every morning. 2. Maintain accurate intake and output records. 3. Restrict fluids to 1500 mL/day. 4. Administer furosemide 40 mg IV push.
4. Administer furosemide 40 mg IV push.
The nurse is admitting an older adult client to the acute care medical unit. Which assessment factor alerts the nurse that this client has a risk for acid-base imbalances? 1. History of myocardial infarction 1 year ago. 2. Antacid use for occasional indigestion. 3. Shortness of breath with extreme exertion. 4. Chronic renal insufficiency.
4. Chronic renal insufficiency.
The UAP reports to the nurse that a client's urine output for the past 24 hours has been only 360 mL. What is the nurse's priority action at this time? 1. Place an 18-gauge IV in the non-dominant arm. 2. Elevate the client's head of bed at least 45 degrees. 3. Instruct the UAP to provide the client with a pitcher of ice water. 4. Contact and notify the health care provider immediately.
4. Contact and notify the health care provider immediately.
Which order prescribed for a client with hypercalcemia would the nurse be sure to question? 1. 0.9% saline at 50 mL/hr IV 2. Furosemide 20 mg orally each morning 3. Apply cardiac telemetry monitoring 4. Hydrocholorthiazide (HCTZ) 25 mg orally each morning
4. Hydrocholorthiazide (HCTZ) 25 mg orally each morning
The RN is providing care for a client diagnosed with dehydration and hypovolemic shock. Which prescribed intervention from the health care provider should the RN question? 1. Blood pressure every 15 minutes. 2. Place two 18-gauge IV lines. 3. Oxygen at 3 L via nasal cannula. 4. IV 5% dextrose in water to run at 250 mL/hr.
4. IV 5% dextrose in water to run at 250 mL/hr.
The nurse is caring for a client who experiences frequent generalized tonic-clonic seizures associated with periods of apnea. The nurse must be alert for which acid-base imbalance? 1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Metabolic acidosis
4. Metabolic acidosis
The RN is reviewing the client's morning laboratory results. Which of these results is of most concern? 1. Serum potassium level of 5.3 mEq/L 2. Serum sodium level of 134 mEq/L 3. Serum calcium level of 10.6 mg/dL 4. Serum magnesium level of 0.8 mEq/L
4. Serum magnesium level of 0.8 mEq/L
