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

Question 1

The nurse is caring for a patient who has a central venous catheter (CVC). Which nursing intervention is the most important for the nurse to include in the patient's plan of care?

A) Carefully document all assessments of the catheter site.
B) Use strict sterile procedure when performing dressing changes.
C) Label each new dressing with the date, time, and nurse's initials.
D) Ensure that the CVC is discontinued as soon as possible.

Answer 1

Use strict sterile procedure when performing dressing changes.

Question 2

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient in order to correct the patient's fluid imbalance?

A) 0.33% normal saline
B) 0.45% normal saline
C) 0.9% normal saline
D) 3% normal saline

Answer 2

3% normal saline

Question 3

The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient's albumin level is critically low. What assessment finding will the nurse expect to note when meeting with the patient?

A) The patient has generalized 3+ pitting edema.
B) The patient is confused and disoriented.
C) The patient's urine is dark and very concentrated.
D) The patient lung sounds are very diminished.

Answer 3

The patient has generalized 3+ pitting edema.

Question 4

The nurse is caring for a patient who is to receive intermittent bolus doses of phenytoin (Dilantin) through the IV line. Which intervention has the highest priority when administering this medication?

A) Check for blood return and compatibility prior to administration.
B) Use a new IV tubing set each time the medication is administered.
C) Document the date, time, and nurse's initials after each dose is administered.
D) Use sterile gloves when drawing up and administering the medication.

Question 5

The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform?

A) Perform regular neurologic checks and institute seizure precautions.
B) Encourage the patient to eat foods that are high in sodium.
C) Administer hypotonic IV solutions as ordered by the physician.
D) Assess for signs and symptoms of digoxin (Lanoxin) toxicity.

Question 6

The nurse is caring for a patient who is at risk for fluid overload as a result of a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?

A) "Check to make sure that your urine is a bright yellow color."
B) "Weigh yourself every morning before breakfast."
C) "Count your heart rate every evening before you go to bed."
D) "Drink plain water rather than soda, coffee, or fruit juice."

Question 7

The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO₂ 32 mm Hg, HCO₃ 42 mEq/L, PaO₂ 90 mm Hg. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results?

A) Gastroenteritis with severe nausea, vomiting, and diarrhea
B) Widespread tissue ischemia caused by cardiogenic shock
C) Respiratory failure caused by pneumonia with pleural effusions
D) Hyperventilation after a panic attack

Question 8

The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. Which is the most likely cause of the patient's collapse?

A) Orthostatic hypotension
B) Circulatory overload
C) Hemolytic reaction
D) Catheter embolism

Question 9

The nurse is caring for a patient who was brought to the ER after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect to see?

A) pH 7.56, PaCO₂ 32 mm Hg, HCO₃ 32 mEq/L, PaO₂ 90 mm Hg
B) pH 7.35, PaCO₂ 45 mm Hg, HCO₃ 26 mEq/L, PaO₂ 70 mm Hg
C) pH 7.45, PaCO₂ 38 mm Hg, HCO₃ 28 mEq/L, PaO₂ 80 mm Hg
D) pH 7.27, PaCO₂ 58 mm Hg, HCO₃ 24 mEq/L, PaO₂ 60 mm Hg

Question 10

The nurse is caring for a patient who is receiving a blood transfusion. One hour into the transfusion, the patient's blood pressure decreases significantly and the patient complains of a severe headache. What is the priority action of the nurse?

A) Check the patient's temperature and administer acetaminophen (Tylenol) if higher than 101° F.
B) Recheck the patient's blood pressure in 15 minutes after administering pain medication.
C) Stop the blood transfusion and administer 0.9% normal saline through new IV tubing.
D) Double-check that the transfusion blood type is an exact match to the patient.

Question 11

The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank?

A) Identify the blood group, type, and expiration date with another nurse.
B) Insert an 18- or 20-gauge angiocatheter into the patient's other arm.
C) Program the IV infusion pump so that the transfusion will complete within 4 hours.
D) Obtain a new microdrip tubing and extension tubing from the clean utility room.

Question 12

The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur as a result of this therapy?

A) Hypocalcemia
B) Hypernatremia
C) Hypokalemia
D) Hyperphosphatemia

Question 13

The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis fluid volume excess in the patient's care plan. Which goal statement has the highest priority for the patient and nurse?

A) The patient's lung sounds will remain clear.
B) The patient will have urine output of at least 30 mL/hr.
C) The patient will verbalize understanding of fluid restrictions.
D) The patient's pitting pedal edema will resolve within 72 hours.

Question 14

The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is the nurse's best action?

A) Discontinue the IV and start another line in the other arm.
B) Aspirate to check for blood return and flush the IV with sterile saline.
C) Clean the IV site with chlorhexidine and apply a new sterile dressing.
D) Change the IV tubing and administer prescribed pain medication.

Question 15

The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of her three meals and had another 150 mL with her medications. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume in order to stay within the prescribed fluid restriction?

A) 100 mL
B) 150 mL
C) 250 mL
D) 300 mL

Question 16

The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus doses of furosemide (Lasix) for a few days to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert in order to administer the patient's medication?

A) Peripherally inserted central catheter
B) Midline inside-the-needle catheter
C) Central venous catheter
D) Over-the-needle catheter

Question 17

The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) in order to prevent fluid overload and pulmonary edema. The patient tells the nurse that she has stopped taking the medication because she has to urinate frequently during the night. What is the nurse's best response?

A) "You should ask your doctor to decrease the dose."
B) "Take the diuretic early in the morning before breakfast."
C) "Eat foods high in potassium and limit your salt intake."
D) "Restrict your fluid intake after dinner and in the evening."

Question 18

The nurse is caring for a patient who is very dehydrated. Which goal best indicates that the nursing diagnosis of Deficient fluid volume has been corrected and that the patient's fluid balance has been restored?

A) The patient had 1300 mL of light yellow urine in the last 24 hours.
B) The patient's lung sounds are clear bilaterally.
C) The patient has no jugular venous distention.
D) The patient verbalizes need for adequate daily fluid intake.

Question 19

The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient's body to correct the pH?

A) The patient's respirations are very deep and rapid.
B) The patient's urine is dark and concentrated.
C) The patient's skin is pale, cool, and diaphoretic.
D) The patient is sleepy and difficult to arouse.

Question 20

The nurse is reviewing the patient's laboratory results. Which result must be communicated to the physician immediately?

A) Serum chloride level 85 mEq/L
B) Serum sodium level 134 mEq/L
C) Serum potassium level 6.8 mEq/L
D) Serum magnesium level 2.3 mEq/L

Question 21

The nurse is caring for a patient with a history of hyperparathyroidism who presents with a serum calcium level of 14.5 mg/dL. What is the highest priority nursing diagnosis for this patient?

A) Risk for injury related to weakened bones that may easily fracture
B) Deficient knowledge related to need for supplemental calcium in diet
C) Risk for constipation caused by decreased gastrointestinal motility
D) Activity intolerance related to muscle cramping and spasms

Question 22

The nurse is caring for a patient who has B-positive blood. The patient is severely anemic and requires a blood transfusion. Which types of blood can the patient receive? (Select all that apply.)

A) AB positive
B) AB negative
C) B negative
D) B positive
E) O positive
F) O negative

Question 23

The nurse is caring for a patient with renal failure who has a serum potassium level of 7.1 mEq/L and serum magnesium level of 3.5 mEq/L. The nurse prepares to administer 10 units of insulin and an ampule of 50% dextrose to the patient. The patient asks why he will be receiving insulin when he is not diabetic. What is the nurse's best answer?

A) "The doctor has prescribed these medications for you to help heal your kidneys."
B) "These medications will lower your potassium level and prevent an irregular heart rate."
C) "These medications will prevent you from having a seizure from too little magnesium."
D) "These medications will increase your urine output until your kidneys recover."

Question 24

The nurse is caring for a patient who has a serum magnesium level of 0.8 mEq/L. Which is the highest priority goal to include in the patient's plan of care?

A) The patient will maintain urine output of at least 30 mL/hr.
B) The patient will verbalize the importance of sufficient dietary intake of magnesium.
C) The patient's oral mucous membranes will remain free of ulceration and pain.
D) The patient will remain alert and oriented x3 with no confusion or seizure activity.

Question 25

The nurse is caring for a hospitalized patient with hyperparathyroid disease and a serum calcium level of 14.2 mg/dL. What is the priority intervention of the nurse?

A) Instruct the patient to always call for assistance before getting out of bed.
B) Assist the patient to change into dry clothing after episodes of diaphoresis.
C) Teach stress-relieving techniques, including progressive muscle relaxation.
D) Measure urine output hourly and notify physician if urine output is less than 30 mL/hr.