Chapter 25: Fluid, Electrolyte, and AcidBase Balance My Nursing Test Banks

Chapter 25: Fluid, Electrolyte, and AcidBase Balance

Test Bank

MULTIPLE CHOICE

1. A 10-month-old infant has had watery green stool for 2 days and refuses the bottle. The nurse is aware that the primary concern for this baby is:

a.

metabolic acidosis.

b.

metabolic alkalosis.

c.

weight loss.

d.

diaper rash.

ANS: A

Loss of bowel contents leads to metabolic acidosis. The child will lose weight and will probably have diaper rash, but the primary concern is the electrolyte imbalance.

DIF: Cognitive Level: Analysis REF: pp. 436-437 OBJ: Clinical Practice #1

TOP: Dehydration KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

2. The patient who was admitted after vomiting for 3 days would show an abnormally low blood pressure because of a fluid shift from:

a.

intracellular to the extracellular.

b.

interstitial to intravascular.

c.

intravascular to the interstitial.

d.

interstitial to the intracellular.

ANS: C

If intravascular fluid, a type of extracellular fluid within the blood vessels, shifts from the plasma in the vascular space out to the interstitial space, a drop in blood volume occurs.

DIF: Cognitive Level: Comprehension REF: p. 432 OBJ: Theory #3

TOP: Distribution of Body Fluids KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

3. An isotonic state exists within a patients body fluids when the solute concentration of:

a.

interstitial fluid is less than the transcellular.

b.

intracellular and extracellular fluid is equal.

c.

intracellular fluid is greater than extracellular fluid.

d.

extracellular fluid is lesser than intracellular fluid.

ANS: B

When the intracellular and extracellular fluid has the same concentration of particles, the solution is called isotonic (equal solute concentration).

DIF: Cognitive Level: Comprehension REF: p. 433 OBJ: Theory #3

TOP: Movement of Fluid KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: physiological adaptation

4. The nurse is aware that an infant is more at risk for dehydration because the infant:

a.

has kidneys that reabsorb water from the intravascular space.

b.

has a larger body surface compared with body weight.

c.

urinates more frequently.

d.

has fat that absorbs water.

ANS: B

Infants are more at risk for dehydration because they have a larger body surface compared with body weight. Their immature kidneys cannot reabsorb water as well as an adult, and fat does not absorb water.

DIF: Cognitive Level: Comprehension REF: p. 431 OBJ: Clinical Practice #1

TOP: Dehydration KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

5. The nurse points out that non-electrolyte products of metabolism are as important to health as electrolytes. Non-electrolytes include:

a.

magnesium.

b.

amino acids.

c.

calcium.

d.

phosphates.

ANS: B

The non-electrolytes that are products of metabolism and serve to promote health in the body are amino acids, glucose, and fatty acids.

DIF: Cognitive Level: Knowledge REF: p. 432 OBJ: Theory #2

TOP: Non-electrolytes KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

6. The nurse assesses that the patient has developed abdominal pain, urinary retention, and confusion. The nurse concludes these signs are the result of an inadequate supply of:

a.

calcium (Ca2+).

b.

sodium (NA+).

c.

phosphates (PO43).

d.

potassium (K+).

ANS: D

The symptoms of a potassium level below 3.5 mEq/L are abdominal pain, urinary retention, confusion, decreased reflexes, and ECG changes.

DIF: Cognitive Level: Analysis REF: p. 438, Table 25-4

OBJ: Theory #4 TOP: Hypokalemia

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

7. A nurse gets a positive Chvosteks sign on a young woman with bulimia who has been giving herself frequent enemas containing phosphate. The nurse anticipates a laboratory finding of _____ mEq/L.

a.

sodium 140

b.

potassium 4.5

c.

magnesium 1.6

d.

calcium 6.5

ANS: D

The low level of calcium is responsible for the sign. The positive Chvosteks sign is an indicator of a reduced calcium level.

DIF: Cognitive Level: Analysis REF: p. 438, Table 25-4

OBJ: Clinical Practice #2 TOP: Hypocalcemia

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

8. A patient has been identified as having a dietary deficiency of vitamin D. The nurse understands that this patient is also at risk for having a deficiency of:

a.

calcium.

b.

magnesium.

c.

sodium.

d.

potassium.

ANS: A

Nutritional deficiency of vitamin D can result in hypocalcemia because of the patients inability to absorb calcium.

DIF: Cognitive Level: Comprehension REF: p. 440 OBJ: Clinical Practice #1

TOP: Hypocalcemia KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

9. The nurse explains that the dehydrated patients urine is concentrated because:

a.

renal tubules reabsorb more water and reduce urine output.

b.

kidneys cease to function.

c.

blood pressure drops.

d.

the colon retains more fluid from the fecal waste.

ANS: A

When dehydration occurs, the renal tubules of the kidney reabsorb more water to be returned to the circulating volume, making the urine concentrated.

DIF: Cognitive Level: Comprehension REF: p. 433 OBJ: Theory #3

TOP: Dehydration KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

10. The nurse is aware that small ions such as glucose, oxygen, and carbon dioxide redistribute themselves through semi-permeable membranes by a process called:

a.

diffusion.

b.

osmosis.

c.

blood pressure.

d.

rehydration.

ANS: A

Glucose, oxygen, carbon dioxide, and other small ions diffuse through membranes until they are evenly distributed.

DIF: Cognitive Level: Knowledge REF: p. 433 OBJ: Clinical Practice #5

TOP: Diffusion KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

11. A patient with healthy kidneys experiences metabolic alkalosis resulting from episodes of vomiting. The nurse takes into consideration that the kidneys can clear the alkaline substances and fully stabilize the patients pH in approximately:

a.

3 to 5 minutes.

b.

12 to 24 hours.

c.

3 days.

d.

1 week.

ANS: C

The compensatory ability of the kidneys takes more time to work than does the compensatory action of the lungs; 3 days are needed for the kidneys to stabilize pH within normal range.

DIF: Cognitive Level: Knowledge REF: p. 441, Clinical Cues

OBJ: Clinical Practice #5 TOP: AcidBase Balance

KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: physiological adaptation

12. A patient with a history of severe chronic obstructive pulmonary disease (COPD) is most likely to have:

a.

respiratory alkalosis.

b.

respiratory acidosis.

c.

metabolic alkalosis.

d.

metabolic acidosis.

ANS: B

People with COPD are prone to chronic respiratory acidosis because of the retained CO2.

DIF: Cognitive Level: Comprehension REF: p. 441 OBJ: Clinical Practice #5

TOP: AcidBase Balance KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

13. A patient who is experiencing severe diarrhea is losing excessive bicarbonate ions. This patient is at risk for developing:

a.

respiratory alkalosis.

b.

respiratory acidosis.

c.

metabolic alkalosis.

d.

metabolic acidosis.

ANS: D

Metabolic acidosis can be caused by either an excessive loss of bicarbonate ions or an excessive retention of hydrogen ions.

DIF: Cognitive Level: Comprehension REF: p. 442, Table 25-5

OBJ: Theory #5 TOP: AcidBase Balance

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

14. An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to:

a.

sit up.

b.

lie down.

c.

breathe through a re-breather mask.

d.

pant with mouth open.

ANS: C

Anxiety can lead to hyperventilation, causing respiratory alkalosis; the treatment is to have the patient breathe through a re-breather mask. In the home setting, the patient can be asked to breathe into a paper bag.

DIF: Cognitive Level: Application REF: p. 442 OBJ: Theory #5

TOP: AcidBase Balance KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

15. The nurse is aware that a more dynamic process that moves molecules into cells regardless of their electrical charge or concentration in the cell is:

a.

filtration.

b.

osmosis.

c.

active transport.

d.

hydrostatic pressures.

ANS: C

Active transport can move molecules into cells regardless of their electrical charge or concentration already in the cell.

DIF: Cognitive Level: Knowledge REF: p. 434 OBJ: Theory #3

TOP: Active Transport KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: pharmacological and parenteral therapies

16. For the accurate measurement to detect fluid retention, the nurse instructs the nursing assistants to measure the weight with the same scale:

a.

each morning before breakfast after the patient has voided.

b.

each day at noon before lunch, dressed in light clothing

c.

in between meals, dressed in light clothing after voiding.

d.

just before bedtime, while the patient is in a hospital gown or pajamas.

ANS: A

Weight is measured at the same time every morning on the same scale, after the patient has voided and before eating.

DIF: Cognitive Level: Application REF: p. 444, Assignment

OBJ: Clinical Practice #1 TOP: Assessment: Fluid and Electrolytes

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

17. A patient with congestive heart failure has gained 1.1 pounds over the last 24 hours. The nurse is aware that this weight gain represents a fluid retention of _____ L.

a.

0.25

b.

0.5

c.

1.0

d.

2.0

ANS: B

Each 2.2 pounds of weight equals 1 kg, which in turn equals 1.0 L of fluid. Therefore, 1.1 pounds equals 0.5 kg and is equal to 0.5 L of fluid.

DIF: Cognitive Level: Analysis REF: p. 444, Clinical Cues

OBJ: Theory #4 TOP: Calculation KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

18. The nurse is comparing sitting and standing vital signs for a patient who has been diagnosed with dehydration. The pulse rate has increased by 10 beats/min at 1 minute. The nurse then anticipates the blood pressure to show a(n) _____ mm Hg.

a.

increase of 5

b.

drop of 40

c.

drop of 20

d.

increase of 10

ANS: C

A drop in systolic blood pressure by at least 20 mm Hg accompanied by a pulse rate increase of at least 10 beats/min at 1 minute following position change is suggestive of fluid-volume deficit.

DIF: Cognitive Level: Analysis REF: p. 444, Clinical cues

OBJ: Clinical Practice #1 TOP: Assessment: Fluid and Electrolytes

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

19. A patient drank a cup of coffee, a half glass of orange juice, and half a carton of milk with breakfast. Using common equivalents of food containers as a guide, the nurse notes on the intake column of the intake and output sheet that the patient consumed _____ mL.

a.

360

b.

400

c.

420

d.

600

ANS: C

A coffee cup is generally equivalent to 240 mL, a half glass of juice is 60 mL, and half a carton of milk is 120 mL.

DIF: Cognitive Level: Analysis REF: p. 446, Table 25-8

OBJ: Clinical Practice #1 TOP: Intake and Output

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

20. At the beginning of the shift, a patients IV bag has 960 mL remaining. The IV fluid is running at 75 mL/hr. In 8 hours, there should be how many milliliters remaining in the IV bag?

a.

150

b.

360

c.

450

d.

600

ANS: B

75 mL/hr 8 hours = 600; 960 600 = 360.

DIF: Cognitive Level: Analysis REF: p. 446 OBJ: Clinical Practice #1

TOP: Intake and Output KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: pharmacological and parenteral therapies

21. The physician orders fluid restriction for a patient with severe fluid-volume excess. When a patient is placed on a fluid restriction, the allowance of fluids should be:

a.

greatest during the day shift.

b.

greatest during the evening shift.

c.

greatest during the night shift.

d.

spaced in equal increments for all shifts.

ANS: A

The greatest amount of fluid is given during the day shift, followed by the evening shift. The least amount of fluid is given at night, when the patient should be sleeping.

DIF: Cognitive Level: Comprehension REF: p. 447 OBJ: Clinical Practice #1

TOP: Intake and Output KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

22. The nurse is aware that the patient who suffered a brain injury with cerebral edema will most likely receive a fluid that is:

a.

isotonic.

b.

hypertonic.

c.

hypotonic.

d.

enhanced with vitamin B.

ANS: B

Hypertonic fluids draw fluid from the intracellular space and reduce edema.

DIF: Cognitive Level: Comprehension REF: p. 446, Table 25-6

OBJ: Clinical Practice #4 TOP: Hypertonic Solutions

KEY: Nursing Process Step: N/A

MSC: NCLEX: Physiological Integrity: basic care and comfort

23. The patient who is prescribed a diuretic for fluid-volume excess is discharged home. The patient verbalizes understanding of his disease process when he says:

a.

I can put catsup on my scrambled eggs.

b.

I can snack on salted popcorn.

c.

I will snack on raisins.

d.

I will avoid apricots.

ANS: C

The patient will lose electrolytes, especially potassium, because he is on a diuretic; snacks such as raisins and apricots are rich in potassium.

DIF: Cognitive Level: Analysis REF: p. 437, Patient Teaching

OBJ: Clinical Practice #3 TOP: Teaching Plan for Sodium Restriction

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

24. The nurse is caring for a patient for whom a dose of IV potassium has been ordered. Prior to hanging the potassium, the nurse should:

a.

check urine output to be above 60 mL/hr.

b.

check the dose with another licensed person.

c.

confirm the IV fluid running is compatible with potassium.

d.

start potassium with another venipuncture.

ANS: C

The nurse must confirm that the IV fluid that is running is compatible with potassium. A urine output of at least 30 ml/hr is essential prior to giving IV potassium.

DIF: Cognitive Level: Application REF: p. 449, Safety Alert

OBJ: Clinical Practice #4 TOP: Intake and Output

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

25. The nurse caring for a frail 92-year-old dehydrated patient should add to the plan of care the potential for

a.

over-hydration related to excessive thirst.

b.

diarrhea related to dehydration.

c.

pulmonary congestion related to excessive fluid intake.

d.

fall related to confusion.

ANS: D

The dehydrated patient may become confused because of fluid and electrolyte losses.

DIF: Cognitive Level: Analysis REF: p. 435, Elder Care

OBJ: Clinical Practice #4 TOP: Elder Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk potential

COMPLETION

26. A patient with a serum potassium value of less than 3.5 mEq/L is _________.

ANS:

hypokalemic

The normal range for potassium is 3.5 to 5.0 mEq/L.

DIF: Cognitive Level: Analysis REF: p. 432, Table 25-2

OBJ: Theory #2 TOP: Electrolytes KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

27. The nurse clarifies that when electrolytes are in solution, they break up and become ______.

ANS:

ions

Ions are charged particles of electrolytes in solutions. They become either a cation with a positive charge or an anion with a negative charge.

DIF: Cognitive Level: Knowledge REF: p. 432 OBJ: Theory #3

TOP: Ions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

MULTIPLE RESPONSE

28. The nurse clarifies that the electrolytes include: (Select all that apply.)

a.

sodium.

b.

fatty acids.

c.

potassium.

d.

magnesium.

e.

amino acids.

f.

glucose.

ANS: A, C, D

The intermediate products of metabolismamino acids (proteins), glucose, and fatty acidsare non-electrolytes. Sodium, potassium, and magnesium are all electrolytes.

DIF: Cognitive Level: Comprehension REF: p. 432, Table 25-2

OBJ: Theory #2 TOP: Electrolytes KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

29. Based on the information provided, which of these measurements should be recorded on the output sheet? (Select all that apply.)

a.

250 mL nasogastric secretions

b.

200 mL diarrhea stool

c.

900 mL IV therapy

d.

650 mL urine from Foley catheter

e.

50 mL chest tube drainage

f.

240 mL milk

ANS: A, B, D, E

The nurse should calculate fluid intake, both orally and intravenously, and mark and record the amount of gastric suction contents, chest tube drainage, Foley catheter drainage, and feces.

DIF: Cognitive Level: Application REF: p. 448, Skill 25-1

OBJ: Clinical Practice #1 TOP: Intake and Output

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

30. The nurse assessing a newly admitted patient with marked edema from severe congestive failure would anticipate that the patient would exhibit: (Select all that apply.)

a.

a thready pulse.

b.

concentrated urine.

c.

hypertension.

d.

weight gain.

e.

crackles heard on auscultation.

ANS: C, D, E

Persons with excess fluid volume as with a patient in congestive failure would exhibit a bounding hypertension and weight gain. These persons would also have a bounding pulse and copious diluted urine as the kidneys try to excrete the excess fluid. Because of fluid accumulation in the pleural space, crackles can be heard on auscultation when assessing a person with congestive failure.

DIF: Cognitive Level: Comprehension REF: p. 436 OBJ: Theory #4

TOP: Overhydration KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

31. The nurse explains that water as a constituent of the body has the functions of: (Select all that apply.)

a.

transportation of nutrients.

b.

blood pressure regulation.

c.

heat regulation.

d.

removing waste from the cells.

e.

assists with digestion of protein.

ANS: A, C, D

Water has four functions: (1) vehicle of transportation to and from the cells, (2) heat regulation, (3) assists with hydrogen balance, and (4) acts as medium for enzymatic action of digestion. Although the amount of water in the circulating volume has an effect on blood pressure, water does not control blood pressure. Water does not digest protein.

DIF: Cognitive Level: Comprehension REF: p. 431 OBJ: Theory #1

TOP: Function of Water KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

Leave a Reply