Deck 8: Fluid and Electrolyte Management

Question 1

The nurse is providing care to an adult patient admitted with dehydration and hyponatremia.Which medical condition supports the current nursing diagnosis of Electrolyte Imbalance?

A) Osmotic pressure
B) Hydrostatic pressure
C) Isotonic dehydration
D) Hypotonic dehydration

Answer 1

Hypotonic dehydration

Question 2

The nurse is providing care to a patient whose serum calcium levels have increased since a surgical procedure performed three days prior.Which intervention should the nurse implement to decrease the risk for the development of hypercalcemia?

A) Monitor vital signs every eight hours
B) Encourage ambulation three times a day
C) Irrigate the Foley catheter one time a day
D) Recommend turning,coughing,and deep breathing every two hours

Answer 2

Encourage ambulation three times a day

Question 3

A patient is admitted to the emergency department (ED)for dehydration.The patient is 154 lbs.Which urine output indicate the rehydration efforts for this patient have been effective?

A) 20 mL/hr
B) 25 mL/hr
C) 30 mL/hr
D) 35 mL/hr

Answer 3

35 mL/hr

Question 4

Which data collected by the nurse during the assessment process places the older adult patient at risk for dehydration?

A) Poor skin turgor
B) Body mass index of 20.5
C) Blood pressure of 140/98 mmHg
D) Water intake of 2 glasses per day

Question 5

A patient is prescribed 20 mEq of potassium chloride due to excessive vomiting.Which is the rationale for this drug the nurse should provide to the patient?

A) It controls and regulates water balance in the body.
B) It is used in the body to synthesize ingested protein.
C) It is vital in regulating muscle contraction and relaxation.
D) It is needed to maintain skeletal,cardiac,and neuromuscular activity.

Question 6

The nurse is caring for a patient with a potassium level of 5.9 mEq/L.The health-care provider prescribes both glucose and insulin for the patient.The patient's spouse asks,"Why is insulin needed?" Which response by the nurse is the most appropriate?

A) "The insulin will help his kidneys excrete the extra potassium."
B) "The insulin is safer than other medications that can lower potassium levels."
C) "The insulin lowers his blood sugar levels and this is how the extra potassium is excreted."
D) "The insulin will cause his extra potassium to move into his cells,which will lower potassium in the blood."

Question 7

An older adult patient,who appears intermittently confused,is admitted to the hospital after a fall.Based on the current data,which is the patient at an increased risk for developing?

A) Brain attack
B) Dehydration
C) Hemorrhage
D) Kidney damage

Question 8

The nurse is caring for a patient who is receiving intravenous fluids postoperatively following cardiac surgery.The nurse is aware that this patient is at risk for fluid volume excess.The family asks why the patient is at risk for this condition.Which response by the nurse is the most appropriate?

A) "Fluid volume excess is caused by inactivity."
B) "Fluid volume excess is caused by the intravenous fluids."
C) "Fluid volume excess is caused by new onset liver failure caused by the surgery."
D) "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery."

Question 9

The nurse is analyzing the intake and output record for a patient being treated for dehydration.The patient weighs 176 lbs.and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL.Based on this data,which conclusion by the nurse is the most appropriate?

A) Treatment has not been effective.
B) Treatment needs to include a diuretic.
C) Treatment is effective and should continue.
D) Treatment has been effective and should end.

Question 10

An older adult patient,who lives in a long-term care facility,presents in the emergency department (ED)due to fever,nausea,and vomiting over the past two days.The patient denies thirst.The urine dipstick indicates a decreased urine specific gravity.Which medical diagnosis should the nurse anticipate when planning care for this patient?

A) Dehydration
B) Hypertension
C) Fluid overload
D) Congestive heart failure

Question 11

The nurse receives shift report on a pediatric medical-surgical unit.The nurse has been assigned four patients for the shift.Which child does the nurse plan to assess first based on the increased risk for dehydration?

A) A 4-year-old child with a broken leg
B) A 15-month-old child with tachypnea
C) A 16-year-old child with migraine headaches
D) A 10-year-old child with cellulitis of the left leg

Question 12

The nurse is reviewing laboratory values for a female patient suspected of having a fluid imbalance.Which laboratory value evaluated by the nurse supports the diagnosis of dehydration?

A) Hematocrit 30%
B) Hematocrit 53%
C) Serum potassium 3.8 mEq/L
D) Serum osmolality 230 mOsm/kg

Question 13

The nurse is providing care to a patient who is prescribed furosemide as part of the treatment for congestive heart failure (CHF).The patient's serum potassium level is 3.4 mEq/L.Which food should the nurse encourage the patient to eat based on this data?

A) Peas
B) Iced tea
C) Bananas
D) Baked fish

Question 14

The nurse is providing care to a patient following hemodialysis.The patient is experiencing tachycardia and decreased urine output along with skin that is pale and cool to the touch.Which goal of hemodialysis does the nurse determine the patient has not met based on the current data?

A) Cardiac decompensation
B) A reduction of extracellular fluid
C) The effects of rapidly infused intravenous fluids
D) The pharmacological effects of a diuretic infused in the dialysate

Question 15

Which intervention should the nurse implement for a patient whose serum phosphorus level is 2.0 mg/dL?

A) Enforce contact precautions
B) Strain all urine for kidney stones
C) Encourage consumption of milk and yogurt
D) Discourage the consumption of a high-calorie diet

Question 16

The nurse is providing care to a patient who seeks emergency treatment for headache and nausea.The patient works in a mill without air conditioning.The patient states,"I drink water several times each day but I seem to sweat more than I am able to replace." Which suggestions should the nurse provide to this patient?

A) Drink juices and carbonated sodas.
B) Eat something salty when drinking water.
C) Eat something sweet when drinking water.
D) Double the amount of water being ingested.

Question 17

The nurse is providing care to a patient who is diagnosed with multisystem fluid volume deficit.The patient is currently experiencing tachycardia and decreased urine output along with skin that is pale and cool to the touch.The patient has a decreased urine output.Which probable cause to the patient's symptoms should the nurse include when educating the family?

A) Congestive heart failure
B) Rapidly infused intravenous fluids
C) Natural compensatory mechanisms
D) Pharmacological effects of a diuretic

Question 18

The nurse is providing care to an older adult patient who is receiving intravenous (IV)fluids at 150 mL/hr.The patient is currently exhibiting crackles in the lungs,shortness of breath,and jugular vein distention.Which complication of IV fluid therapy does the nurse suspect the patient is experiencing?

A) Speed shock
B) Fluid volume excess
C) Anaphylactic reaction
D) Pulmonary embolism

Question 19

The nurse is caring for a patient with congestive heart failure who is admitted to the medical-surgical unit with acute hypokalemia.Which prescribed medication may have contributed to the patient's current hypokalemic state?

A) Cortisol
B) Demerol
C) Skelaxin
D) Nonsteroidal anti-inflammatory drugs (NSAIDs)

Question 20

The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise.Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the teaching session?

A) "My child only needs to hydrate at the end of an exercise session."
B) "Water is the drink of choice to replenish fluids that are lost during exercise."
C) "I will have my child stop every 15-20 minutes during the activity for fluids."
D) "It is important for my child to wear dark clothing while exercising in the heat."

Question 21

A patient is admitted to the emergency department (ED)for fluid volume deficit.Which body system should the nurse focus to determine the cause of this imbalance when assessing this patient?

A) Genitourinary
B) Cardiovascular
C) Gastrointestinal
D) Musculoskeletal

Question 22

A patient with acute renal failure has jugular vein distention,lower extremity edema,and elevated blood pressure.Based on this data,which nursing diagnosis is the most appropriate?

A) Risk for Infection
B) Excess Fluid Volume
C) Ineffective Renal Tissue Perfusion
D) Risk for Altered Cardiac Perfusion

Question 23

The nurse is planning care for the patient with acute renal failure.The nurse plans the patient's care based on the nursing diagnosis of Excess Fluid Volume.Which assessment data supports this nursing diagnosis?

A) Wheezing in the lungs
B) Generalized weakness
C) Bowel sounds positive in four quadrants
D) Pitting edema in the lower extremities

Question 24

The nurse is instructing a patient with heart failure about a prescribed sodium-restricted diet.Which patient statement indicates that additional teaching is required?

A) "I can use as much salt substitute as I want."
B) "I have to read the labels on foods to find out the sodium content."
C) "I have to limit the intake of food with baking soda or baking powder."
D) "I can use spices and lemon juice to add flavor to food when cooking."

Question 25

The nurse is caring for a patient admitted with hypertension and chronic renal failure who receives hemodialysis three times per week.The nurse is assessing the patient's diet and notes the use of salt substitutes.When teaching the patient to avoid salt substitute,which rationale supports this teaching point?

A) They can potentiate hyperkalemia.
B) They will cause the client to retain fluid.
C) They will increase the risk of AV fistula infection.
D) They will interact with the client's antihypertensive medications.