Evolve Fluid and Imbalance quiz & answers
The nursing instructor is discussing peripherally implanted catheters (PICC) with a nursing student. Which nursing student statement would indicate a need for further teaching? "I will need to watch for phlebitis for up to 10 days after the PICC is inserted." "A PICC line is usually only used for access up to six months, but it can be left in longer." "I can safely take blood pressures in the arm with the PICC as long as the cuff is below the insertion site." "A PICC has fewer side effects than a central venous catheter, such as a lower infection rate and fewer insertion complications."
"I can safely take blood pressures in the arm with the PICC as long as the cuff is below the insertion site."
Which patient statement indicates the need for further education from the nurse regarding potassium supplementation prescribed to treat hypokalemia?
"I will chew my tablets."
Poor skin turgor is characterized by skin that takes _____________ seconds to return to normal after being pinched.
20 to 30
A patient is receiving intravenous albumin 5%. The nurse understands that albumin is commonly used to treat which metabolic alteration?
Hypovolemia
An _____________________ such as 0.9% sodium chloride is used to rapidly replace fluid volume. The solution 0.45% sodium chloride is hypotonic, 5% dextrose in 0.25% sodium chloride is isotonic, and 5% dextrose in 0.9% sodium chloride is hypertonic; therefore, these solutions should not be used for rapid fluid volume replacement
isotonic fluid
Which patient statements indicate the need for further education from the nurse regarding the use of potassium supplementation for the treatment of hypokalemia? Select all that apply.
"I will chew my tablets." "I will include licorice in my diet."
The family of a patient being treated for acute pancreatitis hears the nurse referring to "third spacing" during the assessment and asks the nurse what that means. Which explanation provides the best description for the family?
"The fluid normally in the cells becomes trapped in between the cells and has difficulty moving back into the cells."
A nurse is completing an assessment on a patient with suspected fluid volume excess. Which cardiovascular changes would support this diagnosis? Select all that apply.
- Full, bounding pulse - Distended neck veins - Presence of S3 heart sound
The emergency room nurse is caring for a patient with a severe fluid volume deficit who presented after several days of diarrhea secondary to C. difficile infection. Which intravenous (IV) fluid does the nurse anticipate will be used to rapidly replace the fluid volume?
0.9% sodium chloride
A patient had 5 liters of fluid removed during a paracentesis. What intravenous (IV) solution may be used to pull fluid into the intravascular space after the paracentesis?
25% albumin solution
The nurse is caring for a group of patients. Which patient is at greatest risk for increased extracellular fluid accumulation?
A patient with renal impairment
The nurse is caring for a patient diagnosed with heat stroke and with a urine output of 4000 mL per day. What is the most appropriate nursing action?
Administrating lactated Ringer's solution
The nurse is caring for a patient diagnosed with heat stroke and with a urine output of 4000 mL per day. What is the most appropriate nursing action? Transfusing blood Applying moisturizer regularly Administrating lactated Ringer's solution Administrating supplementary water in enteric formula
Administrating lactated Ringer's solution Heat stroke and an increased amount of urine output of about 4000 mL leads to a deficit in extracellular fluid volume, causing dehydration. Administering lactated Ringer's solution to maintain fluid and electrolyte balance is beneficial.
In the regulation of water balance, which system has a primarily antiinflammatory effect and increases serum glucose levels?
Adrenal-cortical
A patient reports numbness, tingling around the mouth and extremities, difficulty in swallowing, and a contraction of the patient's facial muscles in response to a tap over the facial nerve in front of the ear. The patient's electrocardiogram (ECG) shows a prolonged QT interval. Which electrolyte imbalance does the nurse suspect? Calcium Potassium Magnesium Phosphorous
Calcium Chvostek's sign is the contraction of facial muscles in response to a tap over the facial nerve in front of the ear. It is a test for hypocalcemia, which causes dysphagia, numbness, and tingling near the mouth and the extremities
When the nurse is caring for a patient with a central venous access device, which nursing interventions are important to maintain a safe, functioning device? Select all that apply.
Change the catheter dressing regularly. Cleanse around the catheter insertion site. Change the injection caps at regular intervals.
The nurse is preparing to cleanse the skin around a central venous access device. Which solution would the nurse select as the most effective means of killing harmful bacteria?
Chlorhexidine-based solution
The nurse is assessing the fluid balance of a patient being treated for heart failure. Which indicator is the best measure of fluid volume status?
Daily weighing
A patient has low levels of parathyroid hormone. What other laboratory finding does the nurse expect in the patient?
Decreased calcium levels Hypoparathyroidism causes hyperphosphatemia because of impaired renal phosphate excretion. Hypoparathyroidism can result in magnesium deficiency.
The nurse is caring for a patient with kidney failure who is experiencing severe hyperphosphatemia. Which treatment does the nurse anticipate for this patient to correct the electrolyte imbalance?
Dialysis
Which clinical manifestation should the nurse anticipate observing when assessing a patient with Cushing syndrome?
Dyspnea - because this condition can cause excess extracellular volume accumulation which blocks interstitial air and tissue spaces resulting in dyspnea, crackles, and peripheral edema.
A patient sustains a soft tissue injury to the ankle, and a large amount of edema develops. What nursing intervention will relieve edema associated with this injury? Elevating the extremity Massaging the ankle every 1-2 hours Applying a warm compress to the ankle Applying warm saline soaks to the extremity
Elevating the extremity
The nurse is reviewing the laboratory data of a patient admitted for evaluation of a fluid and electrolyte imbalance. The lab results show Na+ 132 mEq/L, BUN 5 mg/dL, and HCT 33%. What does the nurse infer from these findings? Hyperkalemia Hypernatremia Excess fluid volume Deficient fluid volume
Excess fluid volume A decreased sodium level (normal sodium ranges from 135 to 145 mEq/L), BUN (normal BUN ranges from 7-20 mg/dL), and HCT (normal level 35-47% for women and 39-50% for men) indicate fluid volume excess.
While caring for a patient who had a pituitary tumor removed, which finding should be reported immediately to the primary health care provider? Excessive thirst Calcium level of 8.6 mg/dL Potassium level of 3.5 mEq/L Urine output of 300 mL in eight hours
Excessive thirst A patient who has had surgery on the pituitary gland is at risk for diabetes insipidus. Excessive thirst is an indicator of inadequate antidiuretic hormone (ADH) synthesis or release
A patient is admitted to the emergency room with second-degree (partial-thickness) burns over 30% of the total body surface area with poor skin turgor, a urine output of less than 50 mL over the past two hours, a rapid and thready pulse, and restlessness. The nurse determines that these symptoms might indicate which type of imbalance? Hyperkalemia Metabolic acidosis Hyperphosphatemia Extracellular fluid volume deficit
Extracellular fluid volume deficit Extracellular fluid volume deficit is characterized by poor skin turgor, decreased urine output, a rapid and thready pulse, and restlessness. Hyperkalemia is characterized by weakness, irregular pulse, and paresthesias. Hyperphosphatemia is characterized by numbness and tingling, hyperreflexia, tetany, and seizures. Metabolic acidosis is characterized by drowsiness, confusion, decreased blood pressure, dysrhythmias, nausea, and vomiting.
When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit?
Fluid movement from the interstitial space into the blood vessels In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment.
The nurse is caring for a patient with heart failure. What assessment data indicates the patient is at risk for developing fluid volume excess? Full, bounding pulse Flattened neck veins Low blood pressure Easily obliterated pulse
Full, bounding pulse Any change in the fluid volume is reflected in changes in blood pressure, pulse rate force, and jugular venous distension. A fluid volume excess may cause a full bounding pulse, increased blood pressure, and distended neck veins. The pulse in this case is not easily obliterated. Flattened neck veins, low blood pressure, and a weak and thready pulse that can be easily obliterated indicate fluid volume deficit.
When assessing a patient admitted with nausea and vomiting, which finding supports a determination of deficient fluid volume?
General restlessness
When assessing a patient admitted with nausea and vomiting, which finding supports a determination of deficient fluid volume? Polyuria Decreased pulse Difficulty breathing General restlessness
General restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.
A patient is receiving intravenous albumin 5%. The nurse understands that albumin is commonly used to treat which metabolic alteration?
Hypovolemia Albumin is a colloid solution that pulls fluid into the blood vessels, which restores blood volume
The nurse is caring for a patient with sickle cell anemia. What common electrolyte imbalance should the nurse carefully assess the patient for that is commonly associated with this disease? Increased calcium levels Increased potassium levels Increased phosphate levels Increased magnesium levels
Increased phosphate levels Sickle cell anemia leads to increased concentration of phosphates in the body, thus causing hyperphosphatemia. Hypercalcemia, or increased calcium levels, is associated with hyperparathyroidism. Hyperkalemia, or increased potassium levels, is associated with tumor-lysis syndrome. Hypermagnesemia, or increased magnesium levels, is associated with diabetic ketoacidosis.
The nurse is completing an assessment of a patient with heart failure who is being treated for accidental overuse of diuretics. For which potential respiratory issue should the nurse monitor the patient?
Increased respiratory rate
Which clinical manifestation would the nurse anticipate observing when assessing a client with a body temperature of 103°F (39.4°C)?
Orthostatic hypotension
A patient with blood pressure of 160/90 mm Hg has pedal edema. Which process of transport of molecules would be in action?
Osmosis - A patient with blood pressure of 160/90 mm Hg has hypertension and develops pedal edema due to excess sodium in the blood. This leads to movement of water down the gradient. Therefore the water from the blood vessels moves from higher concentrations to lower concentration across the semipermeable membrane with the help of osmotic pressure and leads to accumulation of water in the extracellular spaces. This movement of water across a semi-permeable membrane to balance the solute is called Osmosis. Diffusion and facilitated diffusion involve molecules moving from a higher to lower concentrations, and active transport involves molecules moving from a lower to higher concentration.
A patient has been admitted for dehydration. What is a priority nursing intervention?
Perform daily weights.
A patient with heart failure is admitted for adjustments to the present medication regimen. As the nurse completes the assessment, which data would support a diagnosis of fluid volume excess? Select all that apply. Polyuria Dizziness Lung crackles Muscle spasms Peripheral edema Increased respiratory rate
Polyuria Lung crackles Muscle spasms Peripheral edema Dizziness and increased respiratory rate are clinical manifestations of fluid volume deficit, not excess.
For which clinical manifestations would the nurse monitor a patient with a serum calcium level of 11.2 mg/dL? Select all that apply.
Polyuria Nephrolithiasis (kidney stones)
A pregnant woman reports headaches and shortness of breath to the nurse. The nurse auscultates crackles and a bounding pulse. What is the appropriate nursing action?
Restricting the intake of dietary sodium
A pregnant woman reports headaches and shortness of breath to the nurse. The nurse auscultates crackles and a bounding pulse. What is the appropriate nursing action? Applying hot and cold compresses Restricting the intake of dietary sodium Asking the patient to sit and then stand Providing ice chips to hydrate the patient
Restricting the intake of dietary sodium A pregnant woman with increased extracellular fluid may develop hypertension and pregnancy-related complications. Restriction of dietary sodium helps to control the fluid accumulation and may help to maintain fluid balance
A nurse is caring for a patient with malignant lung cancer who experiences weakness, lethargy, depressed reflexes, and bone pain. Which changes in the electrocardiogram evaluated by the nurse may indicate suspected hypercalcemia? Select all that apply.
Shortened QT interval Shortened ST segment
A patient sustains multiple injuries in a motor vehicle accident and is hypovolemic due to hemorrhage. Blood transfusions are given to replace the lost blood. The nurse finds that the patient has now developed laryngeal stridor, dysphagia, and numbness and tingling around the mouth. What could be the reason for these new manifestations? The patient has developed anemia. The patient has developed hypocalcemia. The patient has developed fluid overload. The patient has developed a hemolytic reaction
The patient has developed hypocalcemia. Blood and blood products have citrate in them, which can bind with calcium in the body and make it unavailable. Multiple blood transfusions have thus caused hypocalcemia.
The nurse is caring for a patient with hyponatremia associated with heart failure and liver cirrhosis. What drug does the nurse anticipate administering to treat this patient?
Tolvaptan Tolvaptan is used to treat hyponatremia associated with heart failure and liver cirrhosis
The nurse is caring for a patient with a potassium level of 6.2 mEq/dl. What syndrome does the nurse suspect the patient may have?
Tumor lysis syndrome Tumor lysis syndrome causes movement of potassium from the intracellular fluid (ICF) to the extracellular fluid (ECF), resulting in hyperkalemia. Cushing syndrome may cause hypernatremia. Milk-alkali syndrome may cause hypercalcemia. Malabsorption syndrome may cause hypophosphatemia.
A patient's insensible water loss is estimated at 900 mL per day. The nurse understands that this fluid is lost via which mechanism? Excreted via urine Excreted in the feces Vaporized by the lungs and skin Secreted into the digestive tract
Vaporized by the lungs and skin Approximately 600-900 mL of water is lost each day via insensible water loss, which is vaporization by the lungs and skin. Approximately 1,500 mL is excreted in the urine and 100 mL in the feces. Approximately 8,000 mL of digestive fluids are secreted daily, but most is reabsorbed in the gastrointestinal tract.
Which assessment finding is consistent with a phosphate level of 1.8 mg/dL? Tetany Diarrhea Weakness Muscle cramps
Weakness Signs of hypophosphatemia include weakness, confusion, coma, and diminished reflexes. Tetany and muscle cramps are manifestations of hyperphosphatemia. Diarrhea is commonly seen with sodium and potassium imbalances.