Chapter 12Fluid, Electrolyte, and Acid-Base Imbalances My Nursing Test Banks

Chapter 12Fluid, Electrolyte, and Acid-Base Imbalances

MULTIPLE CHOICE

1.The nurse is concerned that a client can become dehydrated when which of the following is assessed?

1.

History of arthritis

2.

Appendicitis diagnosis 3 years ago

3.

Age 30

4.

Obese female

ANS: 4

An adult female has 50% of body weight that is fluid. Adipose cells contain less fluid than other cells. Females have more fat cells than males. Overweight people have less body fluid than thin people. A history of arthritis and appendicitis does not predispose the client to dehydration.

PTS:1DIF:AnalyzeREF:Fluid Balance

2.A client has lost a significant amount of blood. The nurse realizes that the fluid compartment most effected with the blood loss will be:

1.

intracellular.

2.

interstitial.

3.

intravascular.

4.

transcellular.

ANS: 3

Intravascular fluid is the fluid in the bloodstream. Intracellular fluid is the fluid inside each cell. Interstitial fluid is the fluid between cells. Transcellular fluid is the fluid outside all of the other fluid compartments, and it includes cerebrospinal fluid, joint fluid, and fluid within the gastrointestinal tract.

PTS:1DIF:AnalyzeREF:Fluid Balance

3.A client is diagnosed with chronic renal failure. Which of the following electrolytes should the nurse monitor for this client?

1.

Hydrogen

2.

Phosphorus

3.

Calcium

4.

Vitamin D

ANS: 1

The kidneys contribute to the regulation of electrolyte levels. Two electrolytes regulated by the kidneys are hydrogen and bicarbonate. The kidneys do not directly influence a clients phosphorus level. The kidneys affect calcium by activation of vitamin D; however, the kidneys do not regulate calcium levels. Vitamin D is not an electrolyte.

PTS: 1 DIF: Analyze REF: Control of Fluid and Electrolyte Balance

4.A client had a 2 kg weight loss in one day. The nurse realizes this change in weight is due to:

1.

fluid loss.

2.

poor appetite.

3.

medications.

4.

bed rest.

ANS: 1

A weight loss of more than 0.5 kg over 24 hours generally is the result of fluid loss and not of body mass. The client would not lose 2 kgs of body weight because of poor appetite, medications, or bed rest.

PTS:1DIF:Analyze

REF:Fluid Imbalances: Assessment with Clinical Manifestations

5.A client has a serum sodium level of 129 mEq/L. The nurse should prepare to administer which of the following intravenous solutions?

1.

Dextrose 5% and Lactated Ringer

2.

Dextrose 5% and 0.45% Normal Saline

3.

0.9% Normal Saline

4.

Dextrose 5% and 0.9% Normal Saline

ANS: 3

Normal saline (0.9%) is commonly provided to restore extracellular fluid volume and increase sodium levels. Dextrose 5% and Lactated Ringers, Dextrose 5% and 0.45% Normal Saline, and Dextrose 5% and 0.9% Normal Saline are hypertonic solutions, and they will move water from the cells into the bloodstream.

PTS:1DIF:Apply

REF: Table 12-3 Isotonic IV Solutions; Table 12-4 Hypertonic IV Solutions

6.A client is diagnosed with fluid volume excess. Which of the following will the nurse most likely assess in this client?

1.

Poor skin turgor

2.

Jugular vein distention

3.

Dry mouth

4.

Increased heart rate

ANS: 2

Excess fluid in the intravascular space causes an elevation in blood pressure, and increased jugular venous pressure may be visible in distended neck veins. Poor skin turgor, dry mouth, and increased heart rate are findings consistent with fluid volume deficit.

PTS:1DIF:Apply

REF:Fluid Volume Excess: Assessment with Clinical Manifestations

7.A client is demonstrating dizziness and lightheadedness upon standing. The nurse is concerned the client is experiencing postural hypotension when which of the following is assessed?

1.

Lying BP 120/70 mmHg, P 70; standing BP 116/78 mmHg, P 78

2.

Lying BP 116/64 mmHg, P 62; standing BP 94/58 mmHg, P 78

3.

Lying BP 130/80 mmHg, P 84; standing BP 118/72 mmHg, P 90

4.

Lying BP 126/74 mmHg, P 74; standing BP 108/62 mmHg, P 84

ANS: 2

A decrease in systolic blood pressure of more than 20 mmHg when going from lying to standing, along with an increase in heart rate of 10 beats per minute or a decrease in diastolic blood pressure of more than 10 mmHg, along with a 10 beats per minute increase in heart rate, is considered postural hypotension. The other vital sign measurements do not support the criteria for postural hypotension.

PTS:1DIF:Analyze

REF:Fluid Imbalances: Assessment with Clinical Manifestations

8.The nurse assesses a client to have mild pitting edema of the lower extremities. The nurse would document this finding as being:

1.

0+.

2.

1+.

3.

2+.

4.

3+.

ANS: 2

Mild pitting edema is documented as being +1. No pitting edema would be documented as 0+. Moderate pitting edema would be documented as 2+. Moderately severe pitting edema would be documented as 3+.

PTS: 1 DIF: Apply REF: Figure 12-4 Pitting Edema Grading Scale

9.An elderly client is demonstrating new signs of confusion. Which of the following should the nurse consider when caring for this client?

1.

Assess for signs of elevated sodium level.

2.

Restrict fluids.

3.

Administer prescribed diuretic medication.

4.

Monitor daily weights.

ANS: 1

Elderly clients who develop a new onset of confusion should have their serum sodium levels checked for an elevated serum sodium level. Restricting fluids, administering diuretics, and monitoring daily weights are all interventions appropriate for a client with a low-serum sodium level.

PTS:1DIF:Apply

REF:Excess Sodium Ion: Assessment with Clinical Manifestations

10.A client diagnosed with hypokalemia should have which of the following electrolytes also assessed?

1.

Sodium

2.

Calcium

3.

Bicarbonate

4.

Magnesium

ANS: 4

Clients with hypokalemia often have concurrent hypomagnesemia. Hypokalemia is resistant to treatment unless the hypomagnesemia is corrected. Sodium, calcium, and bicarbonate changes are not associated with hypokalemia.

PTS:1DIF:Apply

REF: Deficient Potassium Ion: Planning and Implementation

11.A client is diagnosed with hypophosphatemia. The nurse realizes that this electrolyte imbalance is most likely associated with:

1.

diabetes mellitus.

2.

congestive heart failure.

3.

arthritis.

4.

chronic alcoholism.

ANS: 4

A diet deficient in phosphorous may cause hypophosphatemia and reduced absorption of phosphorous occurs with chronic alcoholism. Hypophosphatemia is not associated with diabetes mellitus, congestive heart failure, or arthritis.

PTS: 1 DIF: Analyze REF: Deficient Phosphorus Ion: Etiology

12.A client diagnosed with chronic renal failure is experiencing muscle weakness, paresthesias, and depression. Which of the following do these assessment findings suggest to the nurse?

1.

Hyperkalemia

2.

Hyponatremia

3.

Hypocalcemia

4.

Hypermagnesemia

ANS: 4

Signs and symptoms of hypermagnesemia are similar to those seen with hypercalcemia and include paresthesias, muscle weakness, anorexia, nausea, diminished bowel sounds, and constipation. Confusion, depression, lethargy, and coma can also occur. Muscle weakness, paresthesias, and depression are not seen in hyperkalemia, hyponatremia, or hypocalcemia.

PTS:1DIF:Analyze

REF:Excess Magnesium Ion: Assessment with Clinical Manifestations

13.A client begins rapid breathing and demonstrates anxiety after learning of a diagnosis of breast cancer. After a short while, the client complains of tingling lips and fingers. Which of the following should the nurse do to assist this client?

1.

Provide oxygen.

2.

Coach the client in the use of an incentive spirometer.

3.

Help the client slow the respiratory rate or breathe into a paper bag.

4.

Administer intravenous fluids.

ANS: 3

With the clients rapid respirations, too much carbon dioxide is being excreted. This leads to alkalosis. Symptoms of respiratory alkalosis include tingling of the lips and fingers. If the client is unable to control the respiratory rate, the nurse may have the client breathe into a paper bag, which forces the rebreathing of carbon dioxide. Providing oxygen, using an incentive spirometer, and intravenous fluids is not going to help correct the clients rapid respiratory rate and respiratory alkalosis.

PTS:1DIF:ApplyREF:Respiratory Alkalosis

MULTIPLE RESPONSE

1.A client is diagnosed with hyponatremia. Which of the following assessment findings would cause the nurse to become concerned? (Select all that apply.)

1.

Confusion

2.

Poor appetite

3.

Restlessness

4.

Lethargy

5.

Seizures

6.

Coma

ANS: 1, 3, 4, 5, 6

The change in osmolality that occurs with hyponatremia causes fluid to shift into the intracellular space. Signs and symptoms associated with an expanded intracellular compartment include confusion, restlessness, lethargy, seizures, and coma. Poor appetite is not an assessment finding of hyponatremia.

PTS:1DIF:Analyze

REFeficient Sodium Ion: Assessment with Clinical Manifestations

2.After reviewing a clients most recent electrocardiogram, the nurse suspects the client is experiencing hyperkalemia. Which of the following did the nurse assess on the clients rhythm strip? (Select all that apply.)

1.

Tall peaked T-waves

2.

Short QRS complex

3.

Dysrhythmias

4.

Wide QRS complex

5.

Bradycardia

6.

Tachycardia

ANS: 1, 3

Tall peaked T-waves and dysrhythmias are seen on the electrocardiogram of a client experiencing hyperkalemia. The other choices are not seen with hyperkalemia.

PTS: 1 DIF: Analyze REF: Excess Potassium Ion: Diagnostic Tests

3.A client has a serum potassium level of 2.9 mEq/L. Which of the following should be done to assist this client? (Select all that apply.)

1.

Implement continuous cardiac monitoring.

2.

Check for an elevated ST segment.

3.

Assess muscle strength, tone, and reflexes.

4.

Monitor digoxin levels.

5.

Monitor for seizure activity.

ANS: 1, 3, 4

Interventions for a patient with hypokalemia are continuous cardiac monitoring; assessing for flattening T-waves; monitoring for digoxin toxicity, which may cause dysrhythmias; and assessing muscle strength, tone, and reflexes. Seizure activity is a sign of a sodium imbalance.

PTS:1DIF:Apply

REF: Deficient Potassium Ion: Assessment with Clinical Manifestations

4.Which of the following assessment techniques can the nurse use to determine if a client is experiencing hypocalcemia? (Select all that apply.)

1.

Allen test

2.

Chvosteks sign

3.

Percussion of the abdomen

4.

Auscultation of the lungs

5.

Trousseaus sign

6.

Palpation of the neck

ANS: 2, 5

Trousseaus sign is assessed by inflating a blood pressure cuff for up to 4 minutes and assessing for hand spasms as a sign of hypocalcemia. Chvosteks sign is done by tapping on the facial nerve and assessing for a spasm of the facial muscle on the same side as evidence of hypocalcemia. The Allens test, percussion of the abdomen, auscultation of the lungs, and palpation of the neck are not performed specifically for hypocalcemia.

PTS:1DIF:Apply

REFeficient Calcium Ion: Assessment with Clinical Manifestations

5.A client is diagnosed with a serum calcium level of 11.2 mEq/L. Which of the following interventions would be appropriate for this client? (Select all that apply.)

1.

Administer diuretics as prescribed.

2.

Restrict fluids.

3.

Administer intravenous fluids as prescribed.

4.

Continuous cardiac monitoring.

5.

Administer intravenous sodium as prescribed.

6.

Change to a low fat diet.

ANS: 1, 3, 4, 5

Management of hypercalcemia is focused on removing calcium, which is accomplished by administering diuretics, administering intravenous fluids, and administering intravenous sodium. Continuous cardiac monitoring is needed for clients at risk for developing dysrhythmias. Restricting fluids and changing to a low-fat diet are not used to treat hypercalcemia.

PTS: 1 DIF: Apply REF: Excess Calcium Ion: Planning and Implementation

6.Which of the following components of the arterial blood gas will the nurse focus when on determining a clients acid-base status? (Select all that apply.)

1.

pH

2.

PO2

3.

PCO2

4.

HCO3

5.

O2 Sat

6.

Hgb

ANS: 1, 3, 4

Interpretation of the clients acid-base status involves the evaluation of three components of the arterial blood gas: pH, PCO2 and HCO3-.. PO2 and O2 Sat are not used to evaluate the clients acid-base status. Hgb level is not a component of the arterial blood gas.

PTS:1DIF:ApplyREF:Arterial Blood Gases

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