Deck 39: Fluids,electrolytes, Acidbase Balance

Question 1

The nurse examines the electrocardiogram (ECG)tracing of a client and notes tall T waves.What electrolyte imbalance should the nurse suspect?

A) Hypokalemia
B) Hypophosphatemia
C) Hyperkalemia
D) Hypercalcemia

Answer 1

Hyperkalemia

Question 2

A patient's arterial blood gas results are pH = 7.30; PCO₂ = 40; HCO₃ = 19 mEq/L; PO₂ = 80.What would be an appropriate nursing diagnosis for the patient?

A) Impaired Gas Exchange
B) Metabolic Acidosis
C) Risk for Impaired Gas Exchange
D) Risk for Acid-Base Imbalance

Answer 2

Impaired Gas Exchange

Question 3

A patient with a history of alcoholism is disoriented and vacillates between being calm and disruptive and loud.Vital signs are BP 138/84 mm Hg; pulse 135 beats/min,regular and strong; respiratory rate 22 breaths/min; temperature 37.1°C (98.1°F).What electrolyte imbalance might the nurse suspect this patient is experiencing?

A) Hypomagnesemia
B) Hypocalcemia
C) Hyperkalemia
D) Hypernatremia

Answer 3

Hypomagnesemia

Question 4

The nurse suspects that a patient's intravenous solution has infiltrated into the tissues.What action should the nurse take first?

A) Aspirate,then inject 0.5 mL normal saline.
B) Restart the IV line in a different vein.
C) Stop the infusion immediately.
D) Notify the primary care provider.

Question 5

Chloride,bicarbonate,phosphate,and sulfate are examples of what type of charged particles and why?

A) Cations,because they carry a positive charge
B) Cations,because they carry a negative charge
C) Anions,because they carry a positive charge
D) Anions,because they carry a negative charge

Question 6

A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours.A microdrip infusion set is being used.What is the drip rate (drops/min)that the nurse should monitor?

A) 60
B) 75
C) 125
D) 250

Question 7

Which is the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume?

A) Electrolyte balance restored,as evidenced by improved levels of alertness and cognitive orientation
B) Electrolyte balance restored,as evidenced by sodium returning to normal range
C) Patient demonstrates effective coughing and deep-breathing techniques.
D) Maintains fluid balance,as evidenced by moist mucous membranes and urinating every 4 hours

Question 8

Which body fluid lies in the spaces between the body cells?

A) Interstitial
B) Intracellular
C) Intravascular
D) Transcellular

Question 9

A client is admitted to the emergency department (ED)in respiratory distress.The results of his arterial blood gases are pH = 7.30; PCO₂ = 40; HCO₃ = 19 mEq/L; PO₂ = 80.How should the nurse interpret these results?

A) Respiratory acidosis with normal oxygen levels
B) Respiratory alkalosis with hypoxia
C) Metabolic acidosis with normal oxygen levels
D) Metabolic alkalosis with hypoxia

Question 10

When a patient has metabolic acidosis,which body system influences the acid-base imbalance to produce the compensatory changes in the arterial blood gases?

A) Respiratory system
B) Renal system
C) Vascular system
D) Neurological system

Question 11

A 6-year-old child becomes upset after learning that a blood sample is needed.The child's mother scolds the child and tells him to "act your age." How should the nurse proceed?

A) Request that the mother leave the room immediately.
B) Request the help of a coworker to hold the child down.
C) Inform the child that "this won't hurt a bit."
D) Calmly approach the child and tell him what is going to happen.

Question 12

Which is the principal system for regulation of fluid and electrolyte balance?

A) Cardiac
B) Vascular
C) Pulmonary
D) Renal

Question 13

Which electrolyte is the primary regulator of fluid volume?

A) Potassium
B) Calcium
C) Sodium
D) Magnesium

Question 14

Which laboratory result should alert the nurse to a potential problem?

A) Na⁺ = 137 mEq/L
B) K⁺ = 5.2 mEq/L
C) Ca²⁺ = 9.2 mg/dL
D) Mg²⁺ = 1.8 mg/dL

Question 15

A patient in respiratory distress has the following arterial blood gases (ABGs)results: pH = 7.30; PCO₂ = 40; HCO₃ = 19 mEq/L; PO₂ = 80.After treatment,repeat ABGs results are pH = 7.38; PCO₂ = 32; HCO₃ = 19 mEq/L.What should the nurse conclude from this information?

A) Respiratory acidosis; the treatment plan is ineffective.
B) Metabolic alkalosis; the treatment plan is effective.
C) Partial compensation; the treatment plan is ineffective.
D) Full compensation; the treatment plan is effective.

Question 16

Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?

A) Diffusion
B) Osmosis
C) Filtration
D) Active transport

Question 17

The nurse notes that a patient's intravenous catheter site is painful,edematous,red,and warm to the touch.There is a palpable cord along the vein and the fluid infusion is sluggish.What should the nurse suspect is occurring with this patient?

A) Infiltration
B) Extravasation
C) Hematoma
D) Phlebitis

Question 18

Which describes the passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration?

A) Osmosis
B) Filtration
C) Hydrostatic pressure
D) Diffusion

Question 19

The nurse is caring for a patient with a medical diagnosis of hypernatremia.The following prescriptions are written in the client's electronic health record.Which one should the nurse question?

A) Administer an IV of D₅W at 125 mL/hr.
B) Strict I&O monitoring.
C) Restrict oral intake to 900 mL every 24 hr.
D) Monitor serum electrolytes every 4 hr.

Question 20

A patient's vital signs prior to a blood transfusion were T = 97.6°F (36.4°C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg.Twenty minutes after the transfusion started,the patient began complaining of feeling "itchy and hot" and a new rash is present on the patient's trunk.Vital signs are now T = 100.8°F (38.2°C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg.Based on these findings,what is the priority intervention?

A) Administer an antihistamine (anti-allergenic)medication.
B) Flush the blood tubing with D₅W immediately.
C) Prepare for emergency resuscitation.
D) Stop the blood transfusion immediately.

Question 21

When assisting with bedside central venous catheter (CVC)placement,which nursing intervention is appropriate? Select all that apply.

A) Apply sterile gloves and mask (and possibly gown).
B) Scrub the insertion site with antibacterial soap for 1 min.
C) Verify that informed consent has been obtained.
D) Place the patient in low Fowler's position.
E) Prepare an infusion bag with dextrose 10% and water.

Question 22

When performing a central venous catheter dressing change,which step is correct?

A) Wear sterile gloves while removing and discarding the soiled dressing.
B) Apply pressure on the catheter-hub junction when removing the soiled dressing.
C) Place a sterile transparent dressing over the site and the catheter-hub junction.
D) Have the patient wear a mask or turn his head away from the site.

Question 23

A patient has a continuous IV infusion at 60 mL/hr.The right hand IV has infiltrated and the nurse has started a new IV on the left forearm.Which intervention should the nurse also perform?

A) Elevate the patient's left forearm.
B) Schedule daily dressing changes to the new IV site.
C) Change the administration set.
D) Place the patient in Fowler's position.

Question 24

The nurse notes that a client has had significant diarrhea over the past several days.Which level in the client's arterial blood gas result will be most affected?

A) pH
B) PO₂
C) PCO2
D) HCO₃

Question 25

The nurse needs to relocate an intravenous site in a patient with an infiltrated IV in the right forearm.In which site is it appropriate for the nurse to insert the new IV line? Select all that apply.

A) Left hand
B) Right wrist
C) Right antecubital area
D) Right saphenous vein
E) Left jugular vein

Question 26

A patient with chronic renal failure will be dialyzed for the first time the following morning.Which is an appropriate nursing intervention for the patient? Select all that apply.

A) Encourage oral fluid intake as desired.
B) Place the patient on strict I&O.
C) Weigh the patient before and after dialysis.
D) Maintain a total fluid restriction of 1,000 mL as prescribed.
E) Monitor laboratory values.

Question 27

What is the mechanism that controls acid-base balance? Select all that apply.

A) Respiratory mechanisms
B) Active transport mechanisms
C) Renal mechanisms
D) Buffer systems
E) Peripheral vascular system

Question 28

In a healthy adult,which regulates body fluids? Select all that apply.

A) Hormone levels
B) Fluid intake
C) Oxygen saturation
D) Kidney function
E) Neurological function

Question 29

A patient has been diagnosed with hypovolemia.Which hydration prescription should the nurse question? Select all that apply

A) 0.9% (normal)saline at 100 mL/hr
B) Lactated Ringer's solution at 100 mL/hr
C) Total parenteral nutrition solution at 100 mL/hr
D) D₅W solution at 100 mL/hr
E) D₅ 0.9% NaCl at 100 mL/hr

Question 30

A patient's blood group is B.From which donor groups can this patient receive blood? Select all that apply.

A) A
B) B
C) O
D) AB

Question 31

Which is an appropriate intervention for a patient with hypovolemia? Select all that apply.

A) Teach deep-breathing techniques.
B) Monitor I&O daily.
C) Encourage fluid intake.
D) Monitor electrolyte balance.
E) Measure daily weights.

Question 32

The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37°C (98.6°F).What disorder should the nurse suspect?

A) Hypovolemia
B) Hypercalcemia
C) Hyperkalemia
D) Hypervolemia