Deck 39: Fluid, electrolyte, and Acid-base Balances

Question 1

Which of the following is an example of a hypertonic solution?

A) Dextrose 5% in water
B) Dextrose 10% in water
C) 0.9% Sodium chloride
D) Lactated Ringer's solution

Answer 1

B

Question 2

A patient complains of a headache and chills during a blood transfusion.Which one of the following actions should the nurse take immediately?

A) Check the vital signs.
B) Stop the blood transfusion.
C) Slow the rate of blood flow.
D) Notify the physician and blood bank personnel.

Answer 2

B

Question 3

An IV of 125 mL is to be infused over a one-hour period.A microdrip infusion set will be used.Which of the following is the nurse's calculation of the infusion rate?

A) 32 gtt/minute
B) 60 gtt/minute
C) 125 gtt/minute
D) 250 gtt/minute

Answer 3

C

Question 4

Which of the following is of great importance for the nurse to check before administering an IV solution with potassium that is prescribed for the patient?

A) Check for weakness.
B) Assess renal function.
C) Evaluate deep tendon reflexes.
D) Initiate seizure precautions.

Question 5

Among the following four patients,the nurse recognizes that which one is most at risk for a fluid volume deficit?

A) A 6-month-old learning to drink from a cup
B) A 12-year-old who is moderately active in 27°C weather
C) A 42-year-old with severe diarrhea
D) A 90-year-old with frequent headaches

Question 6

The nurse is looking after a patient who has abdominal cramps,dizziness,and a rapid and thready pulse.The patient's laboratory results indicate hyponatremia.Which of the following additional signs can the nurse expect?

A) Postural hypotension
B) Tetany
C) Dry skin and dry mucous membranes
D) Elevated temperature and flushed skin

Question 7

Which of the following is the most common electrolyte imbalance?

A) Hypokalemia
B) Hyperkalemia
C) Hyponatremia
D) Hypernatremia

Question 8

When a deficit of body fluid exists in the intravascular compartment,which of the following signs can be expected?

A) Crackles
B) Hypertension
C) Neck vein distension
D) An elevated hematocrit

Question 9

A homeless person is brought into the emergency department with indications of extremely poor nutrition.Arterial blood gases are assessed,and the nurse anticipates that this patient will demonstrate which of the following results?

A) pH 7.3, PaCO₂ 38 mm Hg, HCO₃- 19 mmol/L
B) pH 7.5, PaCO₂ 34 mm Hg, HCO₃- 20 mmol/L
C) pH 7.35, PaCO₂ 35 mm Hg, HCO₃- 24 mmol/L
D) pH 7.52, PaCO₂ 48 mm Hg, HCO₃- 28 mmol/L

Question 10

The nurse knows that older adults are more prone to fluid volume alterations for which of the following reasons?

A) They have decreased thirst sensation.
B) Their kidneys have an increase in glomerular filtration.
C) They are at risk for increased excretion of medications.
D) They have decreased stomach-emptying time.

Question 11

A child having an asthma attack has presented to the emergency department.He is breathing rapidly and has a blood pH of 7.47,signs and symptoms that the nurse suspects are consistent with which of the following conditions?

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

Question 12

The single best indicator of a patient's fluid status is the nurse's assessment of which one of the following?

A) The patient's skin turgor
B) The patient's intake and output
C) The patient's serum electrolyte levels
D) The patient's daily body weight

Question 13

A rapid infusion of blood has been given to the patient.The nurse assesses the patient for which one of the following?

A) Diaphoresis
B) Anxiety
C) Hypertension and tachycardia
D) Nausea and vomiting

Question 14

Arterial blood gases are obtained for the patient.The patient's results (pH 7.48,PaCO₂ 42 mm Hg,HCO₃⁻ 32 mmol/L)indicate which one of the following acid-base imbalances?

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

Question 15

The nurse will be starting a new IV infusion and needs to select the site for the insertion.In selecting a site,the nurse should do which of the following?

A) Start with the most distal site.
B) Look for hard, cordlike veins.
C) Use the dominant arm.
D) Vigorously rub and tap the chosen vein.

Question 16

On the infiltration scale for assessing a peripheral intravenous (IV)site,what grade would the nurse document when the assessment indicates the skin is blanched with 4.5 cm of edema,and the area is cool to touch?

A) 1
B) 2
C) 3
D) 4

Question 17

An 8-year-old is admitted to the pediatric unit with pneumonia.On assessment,the nurse notes that the child is warm and flushed,is lethargic,has difficulty breathing,and has moist crackles.The nurse determines that the child has which one of the following?

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

Question 18

The physician orders 1000 mL of D5RL with 20 mmol KCl to run for eight hours.With an infusion set with a drop factor of 15 gtt/mL,which of the following flow rates will the nurse calculate?

A) 11 gtt/minute
B) 22 gtt/minute
C) 31 gtt/minute
D) 42 gtt/minute

Question 19

A patient has IV therapy for the administration of antibiotics and is stating that the IV site "hurts and is swollen." Which one of the following items of information assessed on the patient indicates the presence of phlebitis,as opposed to infiltration?

A) Intensity of the pain
B) Warmth of integument surrounding the IV site
C) Amount of subcutaneous edema
D) Skin discoloration of a bruised nature

Question 20

For a patient with a nursing diagnosis of "Fluid volume excess," the nurse is alert to which one of the following signs and symptoms?

A) Tachycardia
B) Hypertension
C) Dry mucous membranes
D) Fever

Question 21

Which of the following is an unexpected value that the nurse,in reviewing the results of the patient's blood work,should report to the physician?

A) Calcium 1.9 mmol/L
B) Sodium 140 mmol/L
C) Potassium 3.5 mmol/L
D) Magnesium 0.8 mmol/L

Question 22

According to the phlebitis scale,pain and erythema at the access site with streak formation would be documented as which of the following grades?

A) 1
B) 2
C) 3
D) 4

Question 23

When initiating peripheral IV therapy,where does the nurse place the tourniquet in relation to the proposed insertion site?

A) 5 to 10 cm above
B) 5 to 10 cm below
C) 10 to 15 cm above
D) 10 to 15 cm below

Question 24

When inserting a butterfly needle to initiate peripheral IV therapy in a patient,at what angle,in relation to the patient's skin,would the nurse place the needle before insertion?

A) 5 to 10 degrees
B) 10 to 30 degrees
C) 30 to 45 degrees
D) 45 to 60 degrees