Deck 54: Fluid, Electrolyte and Acidbase Balance

Question 1

The nurse is caring for a client who is three days postoperative. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcaemia?

A) Assist the client to ambulate around the room at least three times daily.
B) Assist the client to turn, cough, and deep breathe every two hours.
C) Irrigate the client's nasogastric tube every two hours.
D) Measure vital signs every four hours.

Answer 1

Assist the client to ambulate around the room at least three times daily.

Question 2

The nurse has admitted a client who was brought to the hospital after a narcotic overdose. What acid-base imbalance does the nurse expect to observe in this client?

A) Metabolic alkalosis.
B) Respiratory acidosis.
C) Respiratory alkalosis.
D) Metabolic acidosis.

Answer 2

Respiratory acidosis.

Question 3

Match the following terms and statements.
1. Osmosis
2. Diffusion
3. Filtration
4. Active transport
A. Requires energy for the process
B. Moving from an area of higher pressure to lower
C. Water and concentrations
D. Solutes and concentration

Answer 3

1C, 2D, 3B, 4A

Question 4

The nurse is caring for a client who is being mechanically ventilated. Arterial blood gas analysis reveals respiratory acidosis. Which change in ventilator settings would the nurse anticipate?

A) Decreased tidal volume of each breath.
B) Decrease in oxygen delivery.
C) Increased respiratory rate.
D) Increase in humidification of inspired air.

Answer 4

Increased respiratory rate.

Question 5

Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority?

A) Prepare to resuscitate the client.
B) Slow the rate of the transfusion.
C) Discontinue the transfusion.
D) Notify the client's medical practitioner.

Question 6

A client is admitted to the hospital after vomiting for three days. Which arterial blood gas results would the nurse expect to find in this client?

A) pH 7.43; PaCO₂ 50; HCO₃ 28.
B) pH 7.47; PaCO₂ 30; HCO₃ 23.
C) pH 7.47; PaCO₂ 43; HCO₃ 28.
D) pH 7.30; PaCO₂ 50; HCO₃ 27.

Question 7

Sodium and potassium are the two dominant electrolytes in the body. Which of these electrolytes maintains intracellular osmolality?

Question 8

The mother of a 1-month-old infant calls the nurse who works in the local primary health care clinic. The mother is concerned because the infant has had vomiting and diarrhoea for two days. What instruction should the nurse give this infant's mother?

A) Measure the infant's urine output for 24 hours.
B) Provide the infant with 50 mL of glucose water.
C) Give the infant at least two ounces of juice every two hours.
D) Bring the infant to the clinic for evaluation.

Question 9

Which statement correctly reflects the body's attempt to restore acid-base balance?

A) The cardiovascular system is the major buffer.
B) Respiratory regulation is slow, but very efficient.
C) Kidneys are the ultimate long-term regulator.
D) Primary regulation is through GI system losses.

Question 10

A client is brought to the emergency department after passing out in a local supermarket. The client reports dieting by fasting for the last five days. Which acid-base imbalance would the nurse expect to assess in this client?

A) Metabolic acidosis.
B) Respiratory alkalosis.
C) Metabolic alkalosis.
D) Respiratory acidosis.

Question 11

The client's arterial blood gas report reveals a pH of 6.58. How does the nurse evaluate this value?

A) This value is extremely elevated.
B) This is a low normal value.
C) This value is incompatible with life.
D) There is a slight elevation.

Question 12

The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500 mL IV bottle was hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What nursing action should be taken?

A) Discontinue the IV site and restart an IV in the opposite hand.
B) Infuse the remaining IV fluid before hanging a new bag.
C) Discard the remaining IV fluid and hang a new bag.
D) Refigure the rate of the IV.

Question 13

The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention would support this client's homeostasis?

A) Encourage consumption of a high-kilojoule carbohydrate diet.
B) Strain all urine.
C) Enforce strict isolation protocols.
D) Encourage consumption of milk and yoghurt.

Question 14

The nurse is providing discharge instructions to a client who has been started on frusemide (Lasix) once daily. What information is essential to include in this information?

A) Avoid high-potassium foods.
B) Do not take this medication on the days you take digitalis (Digoxin).
C) Stand up slowly from a sitting position.
D) Take the medication at bedtime.

Question 15

The client who has been taking a diuretic has a serum potassium of 3.4. Which food would the nurse encourage this client to choose from the dinner menu?

A) Green beans.
B) Baked chicken.
C) Bananas.
D) Iced tea.

Question 16

The regulation of fluids by the renin-angiotensin-aldosterone system has its origins from receptors in the:

A) heart.
B) lungs.
C) kidneys.
D) liver.

Question 17

The client has orders for the administration of IV fluid at a "keep vein open" rate in preparation for administration of IV antibiotics starting at noon. When the nurse goes to the room to start the IV, the Assistant in Nursing (AIN) is preparing to bathe the client. What should the nurse do?

A) Give the AIN permission to skip the client's bath for today.
B) Ask the AIN to notify the nurse as soon as the bath is completed.
C) Let the AIN start the bath on the opposite side of where the nurse will be starting the IV.
D) Instruct the AIN to wait until the IV is started then bathe the client.

Question 18

The primary regulator of fluid intake is:

A) kidneys.
B) thirst.
C) liver.
D) heat.

Question 19

The client has just returned to the nursing unit after placement of a subclavian central venous catheter. Because of the dangers associated with this procedure, which assessment finding is the most important in planning care for this client?

A) Presence of bibasilar crackles.
B) Headache.
C) Decreased pedal pulses.
D) Tachycardia.

Question 20

The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per millilitre of fluid the tubing delivers. Where should the nurse look for this information?

A) In the drug reference book.
B) On the roller clamp of the tubing.
C) In the charting from the nurse who started the infusion.
D) On the packaging of the tubing.

Question 21

The most accurate assessment of a client's fluid status is gained by:

A) fluid intake and output chart.
B) daily weight.
C) skin turgor.
D) eyes.

Question 22

The client has been placed on a 1,200 mL oral fluid restriction. How should the nurse plan for this restriction?

A) Instruct the client that the 1,200 mL of fluid placed in the bedside water jug must last until tomorrow.
B) Schedule a specified amount every one or two hours between meals.
C) Offer the client softer, cold foods such as sorbet and custard.
D) Remove fluids from diet trays and offer them only between meals.

Question 23

The client who has an IV with an intermittent infusion lock in place wishes to shower. What action should be taken by the nurse?

A) Discontinue the lock.
B) Cover the lock with an occlusive dressing.
C) Tell the client that a bed bath is necessary until the IV is discontinued.
D) Place a piece of cloth tape under the lock, wrapping the top in a U shape.

Question 24

The nurse is caring for an 80-year-old client with the medical diagnosis of heart failure. The client has oedema, orthopnoea, and confusion. Which nursing diagnosis is most appropriate for this client?

A) Excess Fluid Volume related to congestive heart failure as evidenced by oedema and confusion.
B) Fluid Volume Deficit related to loss of fluids as evidenced by oedema.
C) Excess Fluid Volume related to retention of fluids as evidenced by oedema and orthopnoea.
D) Heart Failure related to oedema, as evidenced by confusion.

Question 25

The nurse has obtained a unit of packed red blood cells from the laboratory blood bank to administer to a postoperative client. Upon returning to the client's room, the nurse discovers that the client has been taken for an emergency CT scan and is expected to be gone from the unit for approximately 45 minutes. What action should the nurse take?

A) Set up the blood with the IV fluid and y-tubing and place it on the IV standard in the client's room to initiate immediately after the client returns.
B) Return the blood to the laboratory blood bank until the client returns.
C) Place the blood in the unit refrigerator until the client returns.
D) Set up the blood with the IV fluid and y-tubing and place it in the unit medication room to initiate immediately after the client returns.

Question 26

The nurse has initiated a blood transfusion. Which action is now priority?

A) Return to the room and take a set of vital signs in 15 minutes.
B) Assign the Assistant in Nursing (AIN) to sit with the client for 15 minutes.
C) Stay with the client and closely observe him for the first five to 10 minutes of the transfusion.
D) Advise the client to notify the nurse if he experiences any chilling, nausea, flushing, or rapid heart rate.

Question 28

The nurse is caring for an older adult client who has been receiving intravenous fluids at 175 mL/hr. The nurse assesses that the client has crackles, shortness of breath, and distended neck veins. The nurse would recognise these findings as indicating which complication of IV fluid therapy?

A) Speed shock.
B) Fluid volume excess.
C) An allergic reaction to the antibiotics in the fluid.
D) Pulmonary embolism.

Question 29

The medical practitioner has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately infuse this solution, the electronic controller should be set to deliver how many mL/hr?

Question 30

A 70 kg adult client has had vomiting and diarrhoea for four days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have not yet been successful and should continue?

A) 50 mL per hour.
B) 30 mL per hour.
C) 80 mL per hour.
D) 35 mL per hour.

Question 31

An intravenous infusion is to be commenced. Select which health care professional/s is/are able to start the intravenous infusion.

A) A medical practitioner.
B) A registered nurse.
C) An assistant in nursing who has undertaken specific training for this task.
D) A registered nurse who has successfully completed an IV cannulation competency.

Question 32

The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse?

A) Place a cool pack over the IV site and vein.
B) Slow the IV infusion and reassess the area in 15 minutes.
C) Discontinue the IV and place a warm pack on the area.
D) Call the medical practitioner for direction.

Question 33

The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop factor of 20. How many drops per minute should the nurse set the controller to deliver?