Deck 44: Fluid,electrolyte,and Acid-Base Balance

Question 1

Mr.Isaac,a 24-year-old client,has had vomiting and diarrhea for 4 days due to a viral infection.Which electrolyte imbalance is the nurse most likely to see as a result of Mr.Isaac's vomiting and diarrhea?

A)Hypocalcemia
B)Hypophosphatemia
C)Hypermagnesemia
D)Hypokalemia

Answer 1

Hypokalemia

Question 2

The nurse is caring for Kimberly,a 3-month-old infant,who is receiving IV therapy at a rate of 10 mL/hour.The 500-mL IV bag was hung at 9 am Monday morning when the IV catheter was initiated.It is now 9 am on Tuesday morning.What nursing action should be taken?

A)Change the bag and tubing
B)Infuse the remaining IV fluid before hanging a new bag
C)Discard the remaining IV fluid and hang a new bag
D)Discontinue the IV site and restart an IV in the opposite hand

Answer 2

Discard the remaining IV fluid and hang a new bag

Question 3

The physician has ordered that Mr.Hammitz receive 50 mL of an IV solution to infuse over 20 minutes.In order to accurately infuse this solution,the electronic controller should be set to deliver how many mL/hr?

A)50 mL/hr
B)100 mL/hr
C)150 mL/hr
D)200 mL/hr

Answer 3

150 mL/hr

Question 4

The nurse is caring for Mrs.Lyall,a 30-year-old engineer,who is 3 days post-operative.Which intervention should the nurse implement to decrease Mrs.Lyall's possibility of developing hypercalcemia?

A)Measure vital signs every 4 hours
B)Ambulate Mrs.Lyall at least three times daily
C)Irrigate her nasogastric tube every 2 hours
D)Assist the client to turn,cough,and deep breathe every 2 hours

Question 5

Mr.Abraham is in the emergency room in renal failure.His potassium is 6.0 mmol/L.Which of the following nursing interventions is a priority?

A)Place patient on an electrocardiograph monitor (ECG)
B)Prepare patient for renal dialysis
C)Encourage foods rich in potassium
D)Measure and strain all urine

Question 6

Mr.Armando has just been started on a diuretic that is potassium wasting.Which of the following foods would the nurse encourage Mr.Armando to include in his diet?

A)Bananas and oranges
B)Lentils and peanuts
C)Dairy products
D)Apples and grapes

Question 7

Kelsey,a 1-month-old infant,was hospitalized with a gastroenteritis.She weighs 6.4 kg.Before discharging her home with her mother,what would the nurse advise is the minimum daily fluid intake for Kelsey?

A)1640 mL/day
B)640 mL/day
C)1320 mL/day
D)130 mL/day

Question 8

Mr.Isaac,a 24-year-old client,has had vomiting and diarrhea for 4 days due to a viral infection.Which arterial blood gas results would the nurse expect to find in this client?

A)pH 7.30; PaCO₂ 50; HCO₃ 27
B)pH 7.47; PaCO₂ 43; HCO₃ 28
C)pH 7.43; PaCO₂ 50; HCO₃ 28
D)pH 7.47; PaCO₂ 30; HCO₃ 23

Question 9

Mrs.Lyall asks why it has been necessary to measure her urine each time she voids.Which response about urine output should the nurse make?

A)Output should be lower than her fluid intake.
B)Output should be higher than her fluid intake.
C)Output should be approximately the same as her fluid intake.
D)Output over 24 hours will determine a urinary tract infection.

Question 10

Mr.Lee complains of burning along the vein in which a medicated IV is infusing.Upon assessment,the nurse finds the IV site is slightly reddened,but not warmer than the surrounding skin,and without swelling.What action should be taken by the nurse?

A)Call the physician for direction
B)Place a cool pack over the IV site and vein
C)Discontinue the IV and place a warm pack on the area
D)Slow the IV infusion and reassess the area in 15 minutes

Question 11

Mrs.Belker has just had a subclavian central venous catheter inserted.Which of the following signs may indicate complications from the placement?

A)Presence of bibasilar crackles
B)Sudden onset of shortness of breath
C)Bradycardia
D)Severe temporal headache

Question 12

Ten minutes after the transfusion of a unit of packed red blood cells was initiated,Mr.Ericson complained of a headache.The nurse assesses that Mr.Ericson has slight shortness of breath and feels warm to the touch.What action by the nurse is the priority?

A)Notify the physician
B)Discontinue the transfusion
C)Slow the rate of the transfusion
D)Prepare to resuscitate the client

Question 13

Ms.Ellsmere,23,is in the emergency room after an opiate overdose.What are expected blood gas results?

A)pH 7.30; PaCO₂ 54; HCO₃ 24
B)pH 7.47; PaCO₂ 43; HCO₃ 28
C)pH 7.30; PaCO₂ 43; HCO₃ 18
D)pH 7.50; PaCO₂ 32; HCO₃ 24

Question 14

Mr.Isaac,a 24-year-old client,has had vomiting and diarrhea for 4 days due to a viral infection.The nurse is assessing Mr.Isaac's acid-base balance.When blood levels of carbonic acid and carbon dioxide rise,how does the respiratory system respond?

A)The rate and depth of respirations increase and carbon dioxide is exhaled.
B)The rate and depth of respirations decrease and carbon dioxide is exhaled.
C)The rate and depth of respirations increase and carbon dioxide is retained.
D)The rate and depth of respirations decrease and carbon dioxide is retained.

Question 15

Mr.Isaac is a 24-year-old client who has had vomiting and diarrhea for 4 days due to a viral infection.The nurse is assessing his acid-base balance.Which statement correctly reflects the attempt by Mr.Isaac's body to restore acid-base balance?

A)Respiratory regulation is slow,but very efficient.
B)Primary regulation is through GI system losses.
C)Kidney regulation is powerfully effective.
D)Cardiovascular system is the major buffer.

Question 16

Skye,a 16-year-old high school student,is brought to the emergency department after passing out in a local department store.Skye reports dieting by fasting for the last 5 days.Which acid-base imbalance would Skye be at risk for?

A)Respiratory acidosis
B)Respiratory alkalosis
C)Metabolic acidosis
D)Metabolic alkalosis

Question 17

The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes to Chelsey who is 3 years old.The tubing has a drop factor of 20.How many drops per minute should the nurse set the controller to deliver?

A)25 drops per minute
B)50 drops per minute
C)75 drops per minute
D)100 drops per minute

Question 18

The mother of 1-month-old Kelsey calls the nurse who works in the health clinic.The mother is concerned because the infant has had vomiting and diarrhea for 2 days.What instruction should the nurse give this infant's mother?

A)Bring the infant to the clinic for evaluation
B)Give the infant at least 2 ounces of juice every 2 hours
C)Measure the infant's urine output for 24 hours
D)Provide the infant with 50 mL of glucose water

Question 19

A nurse is caring for Mr.Hammitz who is receiving intravenous fluids that are not regulated on an electronic controller.Where should the nurse look for the number of drops per millilitre of fluid the tubing delivers?

A)On the tubing package
B)The documentation when the infusion started
C)In the drug monograph
D)On the roller clamp of the tubing

Question 20

Mr.Isaac,a 24-year-old client,has had vomiting and diarrhea for 4 days due to a viral infection.The nurse is assessing Mr.Isaac's fluid balance.What physical assessment criteria would support a nursing diagnosis of fluid volume deficit?

A)Distended neck veins
B)Full bounding pulse
C)Increased blood pressure
D)Dry mucous membranes

Question 21

Mrs.Ami has been placed on a 1200 mL oral fluid restriction.How should the nurse plan for this restriction?

A)Offer Mrs.Ami softer,cold foods such as sherbet and custard
B)Remove fluids from diet trays and offer them only between meals
C)Plan for 600 mL from 7-3,400 mL from 3-11,and 200 mL from 11-7
D)Place 1200 mL of fluid at her bedside every 24 hours

Question 22

The nurse is caring for Mrs.Emmet,an elderly patient,who has been receiving intravenous fluids at 175 mL/hr.The nurse assesses that Mrs.Emmet has crackles,shortness of breath,and distended neck veins.The nurse would recognize these findings as which complication of IV fluid therapy?

A)Third space syndrome
B)Fluid volume excess
C)Pulmonary embolism
D)Allergic reaction to the antibiotics

Question 23

The nurse has initiated Mr.Ericson's blood transfusion.Which action is now a priority?

A)Assign an appropriate health care provider to sit with Mr.Ericson for 15 minutes
B)Return to the room and take a set of vital signs in 15 minutes
C)Stay with Mr.Ericson and closely observe him for the first 5 to 15 minutes of the transfusion
D)Advise Mr.Ericson to notify the nurse if he experiences any chilling,nausea,or rapid heart rate

Question 24

Mrs.Hislop,80 years old,has a diagnosis of heart failure.She has pitting edema,orthopnea,and confusion.Which nursing diagnosis is most appropriate for this client?

A)Heart failure related to edema,as evidenced by confusion
B)Fluid volume deficit related to loss of fluids as evidenced by edema
C)Excess fluid volume related to retention of fluids as evidenced by edema and orthopnea
D)Hyperosmolar fluid imbalance related to congestive heart failure as evidenced by edema and confusion

Question 25

Mrs.Charlson has an IV with an intermittent infusion lock in place for twice daily antibiotic infusions.She is requesting a shower.What action should be taken by the nurse?

A)Discontinue the lock
B)Cover the lock with an occlusive dressing
C)Place a piece of cloth tape under the lock,wrapping the top in a U shape
D)Encourage a bed bath until the IV is discontinued

Question 26

Mr.Singh has been admitted to hospital after a work explosion left him with third degree burns to 30% of his body.Considering his fluid loss,which of the following solutions may be considered for administration to him?

A)Albumin
B)Autologous transfusion
C)Dextrose and water
D)Fresh frozen plasma

Question 27

The nurse has obtained a unit of packed red blood cells from the laboratory blood bank to administer to Mr.Ericson.Upon returning to Mr.Ericson's room,the nurse discovers that he has been taken for an emergency CT scan and is expected to be gone from the unit for approximately 45 minutes.What action should the nurse take?

A)Place the blood in the unit refrigerator until Mr.Ericson returns
B)Return the blood to the laboratory blood bank until Mr.Ericson returns
C)Set up the blood with the IV fluid and y-tubing in his room and initiate immediately after the client returns
D)Set up the blood with the IV fluid and y-tubing and place it in the unit medication room until he returns

Question 28

The nurse is caring for Mr.Richards,who presented to the emergency department with fever,chills,nausea,and loss of appetite.How would the nurse test Mr.Richards for orthostatic hypotension?

A)Raise his legs above heart level and measure his blood pressure
B)Measure his blood pressure in both the sitting and standing position
C)Measure his blood pressure before and after a normal saline fluid challenge
D)Assess him for dependent edema and then reassess while supine

Question 29

The nurse is collecting equipment to administer a unit of packed red blood cells to Mr.Ericson.Which IV fluid should be used to initiate the IV for this transfusion?

A)1000 mL of lactated Ringer's solution
B)250 mL of normal saline
C)500 mL of 5% dextrose and water
D)100 mL of 5% dextrose and 1/2 normal saline