Deck 39: Fluid, Electrolyte, and Acid-Base Balance

Question 1

Cross-matching of blood is ordered for a client before major surgery. What does this process do?

A) Determines compatibility between blood specimens
B) Determines a person's blood type
C) Predicts the amount of needed blood replacement
D) Specifies the donor and the recipient of the blood

Answer 1

Determines compatibility between blood specimens

Question 2

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?

A) Impaired Skin Integrity
B) Risk for Deficient Fluid Volume
C) Impaired Urinary Elimination
D) Urinary Retention

Answer 2

Risk for Deficient Fluid Volume

Question 3

A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this?

A) The client's family members have been donors.
B) The client donates his or her own blood.
C) The client's blood has been rendered sterile.
D) The client will only need fluids, not blood.

Answer 3

The client donates his or her own blood.

Question 4

A client's PaCO₂ is abnormal on an ABG report. Which of is the most likely be the medical diagnosis?

A) Rheumatoid arthritis
B) Sexually transmitted infection
C) Chronic obstructive pulmonary disease
D) Infection of the bladder and ureters

Question 5

A specially trained nurse has inserted a PICC line. What would be done next?

A) Start administration of prescribed fluids.
B) Explain the procedure to the client and family.
C) Place the client on restricted oral fluids.
D) Send the client to the radiology department.

Question 6

Which body fluid is the fluid within the cells, constituting about 70% of the total body water?

A) Extracellular fluid (ECF)
B) Intracellular fluid (ICF)
C) Intravascular fluid
D) Interstitial fluid

Question 7

A nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body fluid is lost via the gastrointestinal tract?

A) 300 mL
B) 1,000 mL
C) 1,300 mL
D) 2,600 mL

Question 8

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?

A) Compare the client's intake with the normal range of adult fluid intake.
B) Report the exact milliliter of intake to the physician's office nurse.
C) Compare the total intake and output of fluids for the 24 hours.
D) Ensure that the information is included in the verbal end-of-shift report.

Question 9

A nurse reads the laboratory report and notes that the client has hyponatremia. What physical assessment should be made?

A) Observe skin color and texture.
B) Auscultate bowel sounds.
C) Percuss lung density.
D) Monitor for GI symptoms.

Question 10

A student is learning how to administer intravenous fluids, including accessing a vein. Although all of the following may occur, which is the most potentially harmful risk posed for the client when accessing the vein?

A) Discomfort
B) Pain
C) Minor bleeding
D) Infection

Question 11

Which location might the nurse use to assess the condition of an insertion site for a central venous access device?

A) Below the sternum
B) Over the fourth intercostal space
C) Over the jugular vein
D) The back of the hand

Question 12

What is the average adult fluid intake and loss in each 24 hours?

A) 500 to 1,000 mL
B) 1,000 to 1,500 mL
C) 1,500 to 2,000 mL
D) 1,500 to 3500 mL

Question 13

Which question about fluid balance would be appropriate when conducting a health history for a client?

A) "Describe your usual urination habits."
B) "Describe your problems with constipation."
C) "How did you feel when your calcium was low?"
D) "Do you eat fruits and vegetables each day?"

Question 14

Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this?

A) Infants have less total body fluid and ECF than adults.
B) Infants have more total body fluid and ECF than adults.
C) Infants drink less fluid than adults.
D) Infants lose more fluids through output than adults.

Question 15

A physician writes an order to "force fluids." What will be the first action the nurse will take in implementing this order?

A) Explain to the client why this is needed.
B) Tell the client and family to increase oral intake.
C) Decide how much fluid to increase each eight hours.
D) Divide the intake so the largest amount is at night.

Question 16

A client is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than four hours. What should the nurse do next?

A) Continue with the transfusion and document the drip rate.
B) Report to the next shift the amount of blood left to infuse.
C) Take and record vital signs more often.
D) Discontinue the blood transfusion.

Question 17

A client asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond?

A) "There is only a very small chance; I know you will be safe."
B) "Although hepatitis is possible, AIDS is not."
C) "If I were you, I would request special handling of my blood."
D) "There is no way you can contract a disease by giving blood."

Question 18

A nurse is administering a potassium supplement to a client. What will the nurse do to disguise the taste and decrease gastric irritation?

A) Dilute it
B) Give it after meals
C) Mix it with food
D) Freeze it

Question 19

A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request?

A) The nurse is concerned that the client's diet has caused sodium loss.
B) The nurse recognizes these symptoms of hypokalemia.
C) The client is actively seeking increased attention.
D) The client had bananas and orange juice for breakfast.

Question 20

A client has an order to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem?

A) Back rubs
B) Chewing gum
C) Hair care
D) Oral hygiene

Question 21

Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion?

A) Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea
B) Congestive heart failure related to edema
C) Fluid volume excess related to loss of sodium and potassium
D) Fluid volume deficit related to congestive heart failure, as evidenced by shortness of breath

Question 22

A nurse assessing the IV site of a client observes swelling and pallor around the site, and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What IV complication does this describe?

A) Infiltration
B) Sepsis
C) Thrombus
D) Speed shock

Question 23

A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider?

A) The nurse should use new tubing when attaching additional IV solutions.
B) As one bag is infusing, the nurse should prepare the next bag so it is ready for a change when less than 10 mL of fluid remains in the original container.
C) It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician's order.
D) Generally, the nurse should change the administration sets of simple IV solutions every 24 hours.

Question 24

A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation?

A) Swab the line with sterile saline and gently reinsert the line.
B) Sedate the client, remove the PICC line, and then notify the physician.
C) Set up a sonogram for the client to determine the end point of the line.
D) Reapply the dressing and notify the physician for further instructions.

Question 25

A client has a physician's order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?

A) Replace fluid and electrolytes
B) Administer blood products
C) Provide protein supplements
D) Treat the client's infection

Question 26

A nurse is caring for a client with phlebitis. The nurse notices that the client's forearm, which has the tubing, has become red and slightly warm. Which of the following actions should the nurse perform to avoid further complications and provide relief to the client?

A) Administer oxygen.
B) Call for help.
C) Discontinue the IV promptly.
D) Elevate the affected arm.

Question 27

A nurse is initiating a peripheral venous access IV infusion ordered for a client presurgically. In what position would the nurse place the client to perform this skill?

A) High-Fowler's
B) Low-Fowler's
C) Sims'
D) Dorsal recumbent

Question 28

Which of the following individuals with diarrhea for three days is more likely to suffer from fluid and electrolyte imbalance?

A) Infant
B) School-age child
C) Adolescent
D) Young adult

Question 29

A nurse is changing a peripheral venous access dressing for a client. Which of the following is a recommended step in this procedure?

A) Observe clean technique to minimize the possibility of contamination.
B) Cleanse site thoroughly with sterile saline, or according to facility policy.
C) Apply chlorhexidine using a back and forth friction scrub for at least 30 seconds.
D) Wipe or blot the site dry and allow to dry completely before covering.

Question 30

A nurse is caring for a client with dehydration. Which of the following signs is observed in a client with dehydration? Select all that apply.

A) Decreased skin turgor over sternum
B) Decreased blood pressure
C) Low urine output
D) Increased pulse rate
E) Increased respiratory rate

Question 31

A nurse flushing a capped, peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation?

A) If infiltration or phlebitis is present, apply a sterile dressing to the site.
B) Aspirate and attempt to flush the line again.
C) If resistance remains after aspirating and flushing, forcefully flush the line.
D) If catheter has pulled out a short distance, push back in and flush line again.

Question 32

A client with dehydration is being administered IV fluids. During her rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?

A) Phlebitis
B) Thrombus formation
C) Pulmonary embolus
D) Air embolism

Question 33

Which client will have more adipose tissue and less fluid?

A) A woman
B) A man
C) An infant
D) A child

Question 34

Which client would be the most likely candidate for the administration of total parenteral nutrition?

A) A client with severe pancreatitis
B) A client with a myocardial infarction
C) A client with hepatitis B
D) A client with mild malnutrition

Question 35

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is which of the following?

A) Fluid volume deficit
B) Myocardial Infarction
C) Fluid volume excess
D) Atelectasis