Question 1

A patient with severe diarrhea develops an imbalance of potassium. The nurse expects the client to exhibit which of the following symptoms?

Accepted Answer

Severe diarrhea can lead to hypokalemia (low potassium levels), which may cause symptoms such as shallow respirations, lethargy, and nausea due to the role of potassium in muscle function and nerve transmission.

Question 2

The nurse tests a patient for Trousseau's sign by inflating a blood pressure cuff around the upper arm for 2 minutes. Which patient response indicates a positive result?

Accepted Answer

A positive Trousseau's sign is indicated by spasticity of the arm and fingers in response to the inflation of the blood pressure cuff, due to hypocalcemia. Weakness (A) and pain (D) may occur with other conditions, while redness (B) may occur as a result of the pressure from the cuff.

Question 3

An older adult patient has an intravenous infusion of 0.45% normal saline infusing at 150 mL/hr. The nurse is most concerned by which of the following assessment findings?

Accepted Answer

The newly noted crackles in the lungs suggest fluid overload and potential pulmonary edema, which could be a serious complication of too much fluid being infused too quickly. The other assessment findings are within normal limits or expected with IV therapy.

Question 4

What is a serious respiratory complication of fluid volume excess?

Accepted Answer

Pulmonary edema is a serious respiratory complication of fluid volume excess, as it is characterized by the accumulation of excess fluid in the lungs, which can lead to difficulty breathing and potentially life-threatening respiratory failure. Pulmonary infarct, pulmonary fibrosis, and pulmonary embolism are not necessarily directly related to fluid volume excess.

Question 5

While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which of the following actions should the nurse take first?

Accepted Answer

Placing the patient in a high Fowler's position is the first action the nurse should take to help improve breathing and oxygenation, especially given the presence of bilateral crackles indicating fluid in the lungs.

Question 6

Which definition best describes an electrolyte?

Accepted Answer

An electrolyte is a chemical that can conduct electricity when dissolved in water. This is because when it dissolves, it separates into ions and can carry a charge. Examples of electrolytes include sodium, potassium, and chloride.

Question 7

A patient with hypertension is placed on a low-sodium diet. The nurse recognizes that further teaching is necessary if the patient chooses which of the following menus?

Accepted Answer

Tomato soup and grilled cheese sandwich are both high in sodium, and the chocolate chip cookie will likely have additional sodium as well. The other options listed have lower sodium options included. A better option for a low-sodium diet would be grilled chicken, boiled potatoes, frozen green beans, and gelatin dessert.

Question 8

Which of the following foods should be encouraged in a postmenopausal woman who is 5 feet, 1 inch tall and weighs 100 lb?

Accepted Answer

Dairy products are encouraged for postmenopausal women as they are a good source of calcium and vitamin D, which are important for bone health.

Question 9

A nurse is providing care for an 82-year-old patient who has a colostomy and was admitted 3 days ago with weakness, nausea, vomiting, and loose stools. To determine the effectiveness of care, which of the following actions should the nurse take first?

Accepted Answer

Weighing the patient is the priority action in this situation as the patient is experiencing weakness, nausea, vomiting, and loose stools. These symptoms can indicate dehydration, which is important to monitor in a patient with a colostomy. Measuring the patient's weight is the most effective way to assess their hydration status, as weight loss can be an early sign of dehydration. Checking a pulse oximetry reading, determining creatinine clearance, and measuring urine specific gravity may be important assessments as well, but they are not the priority in this situation.

Question 10

Which term describes a solution that has a lower osmolarity than blood?

Accepted Answer

A hypotonic solution has a lower osmolarity than blood. This means that the concentration of solutes is lower in the hypotonic solution compared to the blood. As a result, water tends to diffuse into the cells, causing them to swell and potentially burst.

Question 11

A 22-year-old patient is admitted with a diagnosis of inflammatory bowel disease. The patient has been having 16 or more stools per day. Which of the following symptoms would the nurse expect to find during the admission assessment?

Accepted Answer

The patient with inflammatory bowel disease and frequent stools is likely to be dehydrated, leading to symptoms such as furrows of the tongue and sticky mucous membranes.

Question 12

Which type of fluid loss is an example of insensible loss?

Accepted Answer

Insensible loss refers to fluid loss that is not noticeable, such as through breathing or evaporation from the skin. Perspiration is a form of fluid loss, but it is considered sensible because it is noticeable. Urination, vomiting, and diarrhea are also forms of sensible fluid loss.

Question 13

A patient with a history of renal failure is admitted to the hospital because of decreasing urine output and a potassium level of 5.9 mEq/L. Which of the following foods should the nurse teach the patient to avoid?

Accepted Answer

Potatoes are high in potassium and should be avoided by a patient with renal failure and high potassium levels. Gelatin, white bread, and zucchini are all low in potassium and can be safely consumed in moderation.

Question 14

An older adult has approximately six loose stools a day and is admitted to the hospital with a diagnosis of gastroenteritis. In addition to being disoriented and weak, the patient has the following laboratory test results: Hct 56% (normal 40% to 51%)
BUN 32 mg/dL (normal 6 mg/dL to 20 mg/dL)
Which nursing diagnosis would be most appropriate for this patient?

Accepted Answer

The patient's loose stools could lead to dehydration and consequently, fluid loss, resulting in deficient fluid volume. The elevated hematocrit (Hct) and blood urea nitrogen (BUN) levels also suggest dehydration. Excess fluid volume is not likely since the patient is experiencing diarrhea. There is no evidence of impaired skin integrity or risk for injury mentioned in the scenario.

Question 15

A patient develops an irregular heart rate, abdominal cramping, and diarrhea after a thyroidectomy. Which emergency medication should the nurse anticipate being prescribed?

Accepted Answer

The symptoms described suggest the patient is experiencing hypoparathyroidism, which can occur following thyroidectomy. Hypoparathyroidism results in low levels of calcium in the blood, and calcium gluconate is given as an emergency medication to quickly increase calcium levels and resolve symptoms. Furosemide is a loop diuretic used to manage fluid overload, potassium chloride is given to manage low potassium levels, and diazepam is a benzodiazepine used to manage anxiety or seizures. However, none of these medications would be appropriate for the symptoms described.

Question 16

Which definition best describes the process of diffusion?

Accepted Answer

The process of diffusion is the movement of solute (molecules or ions) from an area of higher concentration to an area of lesser concentration, which occurs due to the random motion of particles. This movement continues until the solute becomes evenly distributed throughout the solvent. Option B is incorrect as it describes osmosis, which is the movement of water from an area of lesser concentration to an area of higher concentration. Option C is incorrect as it describes active transport, which requires energy input to transport a solute against the concentration gradient. Option D is incorrect as it describes filtration, which is the movement of solute and water caused by hydrostatic pressure differences.

Question 17

Which electrolyte should the nurse monitor carefully when administering furosemide (Lasix)?

Accepted Answer

Furosemide (Lasix) is a loop diuretic that can cause potassium loss through increased urine output. It is important for the nurse to monitor potassium levels to prevent hypokalemia.

Question 18

Which complication is associated with an abnormal potassium level?

Accepted Answer

An abnormal potassium level, especially a very high level (hyperkalemia), can lead to cardiac arrest due to changes in the electrical activity of the heart. Low potassium levels (hypokalemia) can also have cardiovascular complications but are less likely to result in cardiac arrest. Tetany with laryngospasm (A) is associated with low calcium levels, fluid overload (B) can result from a variety of conditions but is not directly related to potassium levels, and internal bleeding (C) can have multiple causes but is not commonly associated with potassium disturbances.

Question 19

A patient is admitted to a surgical unit with acute abdominal pain. The laboratory calls to report a serum potassium level of 2 mEq/L. What should the nurse do first?

Accepted Answer

A serum potassium level of 2 mEq/L is critically low and requires immediate intervention. The nurse should call the physician STAT to alert them of the situation and initiate treatment. Administering Kayexalate or documenting the result can wait until after the patient is stabilized.

Question 20

The nurse should recognize that an 82-year-old patient is at risk for dehydration because of a reduction in which of the following functions?

Accepted Answer

As people age, the sensation of thirst diminishes, which can lead to a decreased intake of fluids and an increased risk of dehydration.

Quiz 6: Nursing Care of Patients With Fluid, Electrolyte, and Acid-Base Imbalances