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Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances Test Bank MULTIPLE CHOICE 1. The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which

assessment data will be of most concern to the nurse? Blood pressure is 90/40 mm Hg. Urine output is 30 mL over the last hour. Oral fluid intake is 100 mL for the last 8 hours. There is prolonged skin tenting over the sternum.

a. b. c. d.

ANS: A

The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient’s fluid intake but not as urgently as the hypotension. DIF: Cognitive Level: Apply (application) REF: 292 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate

antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours ANS: C

Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention. DIF: Cognitive Level: Apply (application) REF: 295-296 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. A patient is admitted for hypovolemia associated with multiple draining wounds. Which

assessment would be the most accurate way for the nurse to evaluate fluid balance? Skin turgor Daily weight Presence of edema Hourly urine output

a. b. c. d.

ANS: B

Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds. DIF: Cognitive Level: Apply (application) REF: 292 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 4. The home health nurse cares for an alert and oriented older adult patient with a history of

dehydration. Which instructions should the nurse give to this patient related to fluid intake? “Increase fluids if your mouth feels dry. “More fluids are needed if you feel thirsty.” “Drink more fluids in the late evening hours.” “If you feel lethargic or confused, you need more to drink.”

a. b. c. d.

ANS: A

An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur. DIF: Cognitive Level: Apply (application) REF: 293 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 5. A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains

of generalized weakness. It is most appropriate for the nurse to take which action? Assess for facial muscle spasms. Ask the patient about loose stools. Suggest that the patient avoid orange juice with meals. Ask the health care provider to order a basic metabolic panel.

a. b. c. d.

ANS: D

Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are associated with hyperkalemia. DIF: Cognitive Level: Apply (application) REF: 297-298 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which

statement by the patient indicates that the teaching about this medication has been effective? a. “I will try to drink at least 8 glasses of water every day.” b. “I will use a salt substitute to decrease my sodium intake.” c. “I will increase my intake of potassium-containing foods.” d. “I will drink apple juice instead of orange juice for breakfast.” ANS: D

Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium. DIF: Cognitive Level: Apply (application) REF: 298 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 7. A newly admitted patient is diagnosed with hyponatremia. When making room assignments,

the charge nurse should take which action? Assign the patient to a room near the nurse’s station. Place the patient in a room nearest to the water fountain. Place the patient on telemetry to monitor for peaked T waves. Assign the patient to a semi-private room and place an order for a low-salt diet.

a. b. c. d.

ANS: A

The patient should be placed near the nurse’s station if confused in order for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. This patient needs sodium replacement, not restriction. DIF: Cognitive Level: Apply (application) REF: 295-296 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 8. IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe

hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion. ANS: B

IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias. DIF: Cognitive Level: Apply (application) REF: 298 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. A postoperative patient who had surgery for a perforated gastric ulcer has been receiving

nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

ANS: A

Because the patient’s gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer’s solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction. DIF: Cognitive Level: Apply (application) REF: 291 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 10. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow

for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: D

The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory cause. The other responses are incorrect based on the pH and the normal HCO3. DIF: Cognitive Level: Apply (application) REF: 306 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 11. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep

respirations. Which action should the nurse take? Give the prescribed PRN lorazepam (Ativan). Start the prescribed PRN oxygen at 2 to 4 L/min. Administer the prescribed normal saline bolus and insulin. Encourage the patient to take deep, slow breaths with guided imagery.

a. b. c. d.

ANS: C

The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis. DIF: Cognitive Level: Apply (application) REF: 302 | 304-305 | 309 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 12. An older adult patient who is malnourished presents to the emergency department with a

serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? Pallor Edema Confusion Restlessness

a. b. c. d.

ANS: B

The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels. DIF: Cognitive Level: Apply (application) REF: 289 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 13. A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is

most important for the nurse to monitor for while the patient is receiving this infusion? Lung sounds Urinary output Peripheral pulses Peripheral edema

a. b. c. d.

ANS: A

Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation. DIF: Cognitive Level: Apply (application) REF: 308 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 14. The long-term care nurse is evaluating the effectiveness of protein supplements for an older

resident who has a low serum total protein level. Which assessment finding indicates that the patient’s condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg ANS: C

Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient’s protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status. DIF: Cognitive Level: Apply (application) REF: 288-289 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 15. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood

gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A

The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses. DIF: Cognitive Level: Apply (application) REF: 304-306 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. A patient who has been receiving diuretic therapy is admitted to the emergency department

with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every evening ANS: A

Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level. DIF: Cognitive Level: Apply (application) REF: 296-297 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 17. The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action

should the nurse include on the care plan? Maintain the patient on bed rest. Auscultate lung sounds every 4 hours. Monitor for Trousseau’s and Chvostek’s signs. Encourage fluid intake up to 4000 mL every day.

a. b. c. d.

ANS: D

To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau’s and Chvostek’s signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift. DIF: Cognitive Level: Apply (application) REF: 299 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 18. When caring for a patient with renal failure on a low phosphate diet, the nurse will inform

unlicensed assistive personnel (UAP) to remove which food from the patient’s food tray? Grape juice Milk carton Mixed green salad Fried chicken breast

a. b. c. d.

ANS: B

Foods high in phosphate include milk and other dairy products, so these are restricted on lowphosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted. DIF: Cognitive Level: Apply (application)

REF:

301

OBJ: Special Questions: Delegation MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

19. A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3

mg/dL. Which assessment would be most important for the nurse to make? Daily alcohol intake Intake of dietary protein Multivitamin/mineral use Use of over-the-counter (OTC) laxatives

a. b. c. d.

ANS: A

Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels. DIF: Cognitive Level: Apply (application) REF: 302 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse

why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a. “There is a decreased risk for infection when 25% dextrose is infused through a central line.” b. “The prescribed infusion can be given much more rapidly when the patient has a central line.” c. “The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.” d. “The required blood glucose monitoring is more accurate when samples are obtained from a central line.” ANS: C

The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly. DIF: Cognitive Level: Apply (application) REF: 309 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. The nurse is caring for a patient who has a central venous access device (CVAD). Which

action by the nurse is appropriate? Avoid using friction when cleaning around the CVAD insertion site. Use the push-pause method to flush the CVAD after giving medications. Obtain an order from the health care provider to change CVAD dressing. Position the patient’s face toward the CVAD during injection cap changes.

a. b. c. d.

ANS: B

The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting. To decrease infection risk, friction should be used when cleaning the CVAD insertion site. The dressing should be changed whenever it becomes damp, loose, or visibly soiled. The patient should turn away from the CVAD during cap changes. DIF: Cognitive Level: Apply (application) REF: 312 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 22. An older patient receiving iso-osmolar continuous tube feedings develops restlessness,

agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L) ANS: C

The elevated serum sodium level is consistent with the patient’s neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal. DIF: Cognitive Level: Apply (application) REF: 295 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 23. The nurse assesses a patient who has been hospitalized for 2 days. The patient has been

receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1° F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Gradually decreasing level of consciousness (LOC) d. Weight gain of 2 pounds (1 kg) above the admission weight ANS: C

The patient’s history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause...