Chapter 16 Fluid, Electrolyte, and Acid-Base Imbalances PDF

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TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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Chapter16: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? a.

Bloodpressureis90/40mmHg.

b.

Urineoutputis30mLoverthelasthour.

c.

Oralfluidintakeis100mLforthelast8hours.

d.

Thereisprolongedskintentingoverthesternum.

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patientsfluidintakebutnotasurgentlyasthehypotension. DIF:CognitiveLevel:Apply(application)REF:277 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:280 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?

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

a.

Skinturgor

b.

Dailyweight

c.

Presenceofedema

d.

Hourlyurineoutput

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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:277 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? a.

Increasefluidsifyourmouthfeelsdry.

b.

Morefluidsareneededifyoufeelthirsty.

c.

Drinkmorefluidsinthelateeveninghours.

d.

Ifyoufeellethargicorconfused,youneedmoretodrink.

ANS:A Analert,olderpatientwillbeabletoself-assessforsignsoforaldrynesssuchasthickoralsecretionsordryappearing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:278 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? a.

Assessforfacialmusclespasms.

b.

Askthepatientaboutloosestools.

c.

Suggestthatthepatientavoidorangejuicewithmeals.

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

d.

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Askthehealthcareprovidertoorderabasicmetabolicpanel.

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stool areassociatedwithhyperkalemia. DIF:CognitiveLevel:Apply(application)REF:282 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:283 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? a.

Assignthepatienttoaroomnearthenursesstation.

b.

Placethepatientinaroomnearesttothewaterfountain.

c.

PlacethepatientontelemetrytomonitorforpeakedTwaves.

d.

Assignthepatienttoasemi-privateroomandplaceanorderforalow-saltdiet.

ANS:A Thepatientshouldbeplacednearthenurses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

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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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:280 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:283 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patientsgastricsuctionhasbeendepletingelectrolytes,theIVsolutionshouldincludeelectrolyte replacement.SolutionssuchaslactatedRingers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:276 TOP:NursingProcess:PlanningMSC:NCLEX:PhysiologicalIntegrity

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

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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:291 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? a.

GivetheprescribedPRNlorazepam(Ativan).

b.

StarttheprescribedPRNoxygenat2to4L/min.

c.

Administertheprescribednormalsalinebolusandinsulin.

d.

Encouragethepatienttotakedeep,slowbreathswithguidedimagery.

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:287 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? a.

Pallor

b.

Edema

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

c.

Confusion

d.

Restlessness

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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:274 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? a.

Lungsounds

b.

Urinaryoutput

c.

Peripheralpulses

d.

Peripheraledema

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:293 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patientsconditionhas improved? a.

Hematocrit28%

b.

Absenceofskintenting

c.

Decreasedperipheraledema

d.

Bloodpressure110/72mmHg

ANS:C

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Edemaiscausedbylowoncoticpressureinindividualswithlowserumproteinlevels.Thedecreaseinedema indicatesanimprovementinthepatients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:273 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:289 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:281 TOP:NursingProcess:AssessmentMSC:NCLEX:PhysiologicalIntegrity

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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? a.

Maintainthepatientonbedrest.

b.

Auscultatelungsoundsevery4hours.

c.

MonitorforTrousseausandChvostekssigns.

d.

Encouragefluidintakeupto4000mLeveryday.

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. TrousseausandChvosteks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:284 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patientsfoodtray? a.

Grapejuice

b.

Milkcarton

c.

Mixedgreensalad

d.

Friedchickenbreast

ANS:B Foodshighinphosphateincludemilkandotherdairyproducts,sothesearerestrictedonlow-phosphate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:286 OBJ:SpecialQuestions:DelegationTOP:NursingProcess:Implementation MSC:NCLEX:PhysiologicalIntegrity 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? a.

Dailyalcoholintake

b.

Intakeofdietaryprotein

TestBank-Medical-SurgicalNursing:AssessmentandManagementofClinicalProblems10e

c.

Multivitamin/mineraluse

d.

Useofover-the-counter(OTC)laxatives

156

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:287 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:294 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? a.

AvoidusingfrictionwhencleaningaroundtheCVADinsertionsite.

b.

Usethepush-pausemethodtoflushtheCVADaftergivingmedications.