Deck 38: Fluids, Electrolytes, Acidbase Balance

Question 1

The nurse is assessing a client who has been vomiting for 2 days and has not been able to eat or drink anything during this time. The client's mucous membranes are dry, there is decreased skin turgor, and the client complains of weakness. The client's vital signs are blood pressure (BP) 80/52; temperature (T) = 99.6°F (37.6°C) orally; pulse (P) = 110 beats/min, weak and thready. Her skin and mucous membranes are dry, and there is decreased skin turgor. The following are the laboratory results:
Sodium
138 mEq/L
Potassium
3)7 mEq/L
Calcium
9)2 mg/dL
Magnesium
1)8 mg/dL
Chloride
99 mEq/L
Blood urea nitrogen (BUN)
29 mg/dL
Which of the following is an appropriate nursing diagnosis for this client?
1)Impaired Gas Exchange related to ineffective breathing
2)Excess Fluid Volume related to limited fluid output
3)Deficient Fluid Volume related to abnormal fluid loss
4)Electrolyte Imbalance related to decreased oral intake

Answer 1

3

Question 2

Which of the following best describes the sodium-potassium pump that maintains the unique composition of extracellular and intracellular compartments?
1)Diffusion
2)Osmosis
3)Filtration
4)Active transport

Answer 2

4

Question 3

The nurse is providing care to the client with hypokalemia. Which of the following disease conditions may have contributed to the hypokalemia?
1)Congestive heart failure
2)Renal failure
3)Gastroenteritis
4)Major trauma

Answer 3

3

Question 4

The nurse assesses that her client's intravenous solution has infiltrated into the tissues. What action should she take first?
1)Aspirate, and then inject 0.5 mL normal saline.
2)Restart the IV line in a different vein.
3)Stop the infusion immediately.
4)Notify the primary care provider.

Question 5

A client is admitted to the emergency department in respiratory distress. The initial arterial blood gases (ABGs) results are pH = 7.30; partial pressure of carbon dioxide (PCO₂) = 40; bicarbonate (HCO₃) = 19 mEq/L; partial pressure of oxygen (PO₂) = 80. The nurse evaluates the client's treatment plan by examining repeat ABGs. The results are pH = 7.38; PCO₂ = 32; HCO₃ = 19 mEq/L. The nurse concludes which of the following?
1)Respiratory acidosis; the treatment plan is ineffective.
2)Metabolic alkalosis; the treatment plan is effective.
3)Partial compensation; the treatment plan is ineffective.
4)Full compensation; the treatment plan is effective.

Question 6

A client is admitted to the emergency department (ED) in respiratory distress. The results of the arterial blood gases are the following: pH = 7.30; partial pressure of carbon dioxide (PCO₂) = 40; bicarbonate (HCO₃) = 19 mEq/L; partial pressure of oxygen (PO₂) = 80. The nurse interprets the findings as which of the following?
1)Respiratory acidosis with normal oxygen levels
2)Respiratory alkalosis with hypoxia
3)Metabolic acidosis with normal oxygen levels
4)Metabolic alkalosis with hypoxia

Question 7

Which of the following is the most appropriate goal for a client with the nursing diagnosis of Deficient Fluid Volume?
1)Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive orientation
2)Electrolyte balance restored, as evidenced by sodium and potassium returning to normal range
3)Fluid balance restored, as evidenced by lowered blood pressure and absence of jugular venous distention
4)Fluid balance restored, as evidenced by moist mucous membranes and urinating every 4 hours

Question 8

A client's arterial blood gas results are as follows: pH = 7.30; partial pressure of carbon dioxide (PCO₂) = 40; bicarbonate (HCO₃) = 19 mEq/L; partial pressure of oxygen (PO₂) = 80. An appropriate nursing diagnosis for the client is which of the following?
1)Impaired Gas Exchange
2)Metabolic Acidosis
3)Risk for Impaired Gas Exchange
4)Risk for Acid-Base Imbalance

Question 9

The nurse recognizes that a balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or deficits can lead to severe disorders. Which of the following is the principal site for regulation of fluid and electrolyte balance?
1)Cardiac system
2)Vascular system
3)Pulmonary system
4)Renal system

Question 10

Which laboratory result on a client's health record should alert the nurse to a potential problem?
1)Sodium (Na⁺) = 137 mEq/L
2)Potassium (K⁺) = 5.2 mEq/L
3)Calcium (Ca²⁺) = 9.2 mg/dL
4)Magnesium (Mg²⁺) = 1.8 mg/dL

Question 11

A client's vital signs prior to a blood transfusion were: temperature (T) = 97.6°F (36.4°C); pulse (P) = 72 beats/min; respirations (R) = 22 breaths/min; blood pressure (BP) = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the client began complaining of feeling "itchy and hot." The nurse discovered a rash on the client's trunk. Vital signs were 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 most appropriate initial intervention?
1)Administer an antihistamine medication.
2)Flush the blood tubing with D₅W immediately.
3)Prepare for emergency resuscitation.
4)Stop the blood transfusion immediately.

Question 12

The nurse is assessing a client in the acute care unit. The client's blood pressure is 80/40 mm Hg, pulse 120 beats/min and thready, has poor skin turgor, and has dry mucus membranes. Which of the following IV fluids would the nurse expect the healthcare provider to prescribe for this client's condition?
1)0.9% normal saline
2)Serum albumin 3.0.45% normal saline
4)D₅W with normal saline

Question 13

The nurse records a client's hourly urine output from an indwelling catheter as follows:
0700: 36 mL
0800: 45 mL
0900: 85 mL
1000: 62 mL
1100: 50 mL
1200: 48 mL
1300: 94 mL
1400: 78 mL
1500: 60 mL
The nurse can conclude that the client's urine output should be described as which of the following?
1)Low
2)Within normal limits
3)High
4)Inconclusive

Question 14

The nurse is caring for a client who has the following lab results: sodium (Na) 147; potassium (K) 3.6; calcium (Ca) 8.8; magnesium (Mg) 1.9. The following prescriptions are written in the client's electronic health record. Which one should the nurse question?
1)Administer intravenous (IV) D₅W at 125 mL/hr.
2)Perform strict intake and output (I&O) monitoring.
3)Restrict oral intake to 900 mL per 24 hours.
4)Monitor serum electrolytes every 4 hours.

Question 15

After morning care, the nurse lowered the height of the IV container infusing via gravity flow, at the client's request. What is the nurse's next best action?
1)Calculate the new infusion rate.
2)Readjust the infusion rate, as needed.
3)Change the IV site and move it to the other arm.
4)Instruct the client to call when the IV bag is empty.

Question 16

The nurse has started to infuse the first of two units of packed red blood cells (PRBCs) on her client. What is the nurse's next best action?
1)Delegate to the UAP to take vital signs every 15 minutes for 1 hour.
2)Infuse the blood at a rate of 100 mL/hr. so it will infuse in 4 hours.
3)Infuse an IV solution of lactated Ringer's with the blood.
4)Remain with the client for the first 15 minutes of the infusion.

Question 17

An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: temperature (T) = 99.6°F (37.6°C) orally; pulse (P) = 110 beats/min, weak and thready; blood pressure (BP) = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The client states that she feels very weak. The following are her laboratory results:
Sodium
138 mEq/L
Potassium
3)7 mEq/L
Calcium
9)2 mg/dL
Magnesium
1)8 mg/dL
Chloride
99 mEq/L
Blood urea nitrogen (BUN)
29 mg/dL
The nurse recognizes that the client is displaying symptoms associated with which of the following?
1)Hypovolemia
2)Hypervolemia
3)Hypernatremia
4)Hyponatremia

Question 18

When a client has metabolic acidosis; which body system influences the acid-base imbalance to produce the compensatory changes in the arterial blood gases?
1)Respiratory system
2)Renal system
3)Vascular system
4)Neurological system

Question 19

Which electrolyte is the primary regulator of fluid volume?
1)Potassium
2)Calcium
3)Sodium
4)Magnesium

Question 20

A client is receiving an IV infusion of lactated Ringer's solution and 40 mEq of potassium chloride (KCl) at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The client is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following?
1)Infiltration
2)Extravasation
3)Hematoma
4)Phlebitis

Question 21

At a first aid station on a marathon route, a client complains of headache, muscle cramps, weakness, nausea, and confusion after the race. Which statement made by the client might explain these symptoms?
1)"I was really thirsty after the race. I drank several large bottles of water."
2)"I perspired quite a bit during the race, so I drank sports drinks when I finished."
3)"I take steroids regularly and did not stop taking them for the race."
4)"I am diabetic and checked my blood sugar after the race. It was normal."

Question 22

A client has a continuous IV infusion at 60 mL/hr. The right-hand IV has infiltrated, and the nurse has started a new IV line on the left forearm. Which of the following interventions should the nurse also perform?
1)Elevate the client's left forearm.
2)Schedule daily IV dressing changes.
3)Change the administration set.
4)Place the client in Fowler's position.

Question 23

The nurse is caring for a client with gastroenteritis who has been vomiting for 48 hours. A family member of the client asks the nurse, "Why is he breathing that way?" What is the nurse's most accurate response after explaining the meaning of pH?
1)"He is breathing fast and deep to help reduce carbon dioxide to increase his pH."
2)"He is breathing slow and shallow to try to retain carbon dioxide to decrease his pH."
3)"He is breathing fast and deep to help reduce carbon dioxide to decrease his pH."
4)"He is breathing slow and shallow to try to retain carbon dioxide to increase his pH."

Question 24

The client presents to the emergency department with a bicarbonate (HCO_3-) level of 14 mEq/L. What may be the explanation for this laboratory result?
1)The client's kidneys are not able to conserve HCO_3-.
2)The client has not included enough HCO_3-in the diet.
3)The client's kidneys are retaining too much HCO_3-.
4)The client's diet includes too much carbonic acid.

Question 25

The nurse is aware that a balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. In a healthy adult, which of the following regulate body fluids? Select all that apply.
1)Hormone levels
2)Kidney function
3)Oxygen saturation
4)Thirst mechanism
5)Integumentary function

Question 26

A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A micro-drip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor?
1)60
2)75
3)125
4)250

Question 27

A new father begins to hyperventilate as his baby is about to be born; he becomes light headed. The nurse instructs him to breathe into the paper bag until his breathing slows down. When he feels better he asks the nurse why using the paper bag helped him. What is the nurse's best response? "Breathing into the paper bag allowed you to
1)Rebreathe carbon dioxide to correct respiratory alkalosis"
2)Reduce carbon dioxide to correct respiratory acidosis"
3)Rebreathe carbon dioxide to correct metabolic alkalosis"
4)Reduce carbon dioxide to correct metabolic acidosis"

Question 28

The nurse is caring for a client with no spontaneous respiratory effort who requires mechanical ventilation. The first blood gas after initiating the ventilator shows a pH of 7.52 and partial pressure of carbon dioxide (PCO₂) of 20. What intervention is required to correct this pH imbalance?
1)Increase fluid infusion.
2)Increase oxygen percentage.
3)Reduce number of breaths/min.
4)Increase number of breaths/min.

Question 29

The nurse is providing care to the adult client in the acute care center. When the nurse began to assess the client's blood pressure, the client's hand began to "cramp" and involuntarily flex. What is the possible answer to this phenomenon?
1)The client is displaying signs of hyponatremia.
2)The client is displaying signs of hypocalcemia.
3)The client is displaying signs of hypokalemia.
4)The client is displaying signs of hypophosphatemia.

Question 30

The nurse is providing care for the adult male client with a hematocrit of 30. Which condition would accurately explain this finding?
1)Elevated blood cell count
2)Excess transcellular fluid
3)Extracellular fluid deficit
4)Intravascular fluid excess

Question 31

A 60-year-old woman complains of muscle weakness, constipation, nausea, and frequent urination and is displaying bizarre behavior. The woman takes prescribed thiazide diuretics and steroids for asthma. What statement made by the client might indicate an additional cause of her symptoms?
1)"I have been working hard to drink plenty of water to prevent dehydration."
2)"I should probably tell you I take steroids regularly because of my asthma."
3)"I take calcium supplements to prevent osteoporosis and eat lots of dairy foods."
4)"I recently quit drinking alcohol. I quit cold turkey and did it all by myself."

Question 32

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

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

Question 33

A client had gastric surgery 10 days ago and continues to require gastric suction because of a paralytic ileus. The client reports tingling in the fingers, has hypertonic reflexes, and has a respiratory rate of 8 breaths per minute that are deep in nature. The nurse recognizes that these symptoms are consistent with which diagnosis?
1)Respiratory alkalosis
2)Metabolic acidosis
3)Respiratory acidosis
4)Metabolic alkalosis

Question 34

The nurse examines the electrocardiography (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect?
1)Hypokalemia
2)Hypophosphatemia
3)Hyperkalemia
4)Hyperphosphatemia

Question 35

The nurse is assessing the client in the long-term care facility and notes that client has bilateral pedal pitting edema. The nurse knows that this signifies excess volume in which fluid compartment?
1)Intracellular
2)Interstitial
3)Intravascular
4)Transcellular

Question 36

The nurse is caring for a client with heart failure. The client has chronic fluid volume excess secondary to ineffective pumping action of the heart. When teaching this client about fluid and electrolyte balance, which diet is most important for the nurse to explain?
1)High-calcium
2)Low-sodium
3)Low-potassium
4)High-magnesium

Question 37

When performing a central venous catheter dressing change, which of the following steps is correct?
1)Wear sterile gloves while removing and discarding the soiled dressing.
2)Apply pressure on the catheter-hub junction when removing the soiled dressing.
3)Place a sterile transparent dressing over the site and the catheter-hub junction.
4)Have the client wear a mask or turn his head away from the site.

Question 38

The nurse is assessing the client with renal failure and notes that the client's respirations are depressed, the client is lethargic with depressed respirations. His blood pressure (BP) is 80/40 mm Hg; pulse (P) is 58 beats/min; respiration rate (RR) is 12 breaths/min; and hypoactive reflexes are present. Which of the following may be the cause of these symptoms?
1)The client took frequent doses of magnesium-based laxative.
2)The client continued use of potassium-sparing diuretics after the renal failure diagnosis.
3)The client took calcium supplements and increased diary intake due to osteoporosis.
4)The client did not adhere to the prescribed fluid restriction and now has fluid overload.

Question 39

The nurse is to administer an intravenous (IV) solution to a client with diffuse edema. Which of the following prescriptions for this client would the nurse question?
1)5% Dextrose in water (D₅W)
2)10% Dextrose in water (D₁₀W)
3)5% Dextrose in normal saline (D₅ 0.9% sodium chloride [NaCl])
4)5% Dextrose lactated Ringer's solution (D₅LR)

Question 40

Which of the following older clients' needs to increase the daily fluid intake? One who typically drinks (assume three meals per day):
1)200 mL at each meal, plus 1,000 mL throughout the day
2)250 mL at each meal, plus 600 mL throughout the day
3)300 mL at each meal, plus 1,000 mL throughout the day
4)400 mL at each meal, plus 500 mL throughout the day

Question 41

Identify the appropriate interventions for a client with hypovolemia. Select all that apply.
1)Teach deep-breathing techniques.
2)Monitor intake and output (I&O) daily.
3)Encourage fluid intake.
4)Monitor electrolyte balance.
5)Monitor daily weights.

Question 42

A client has been diagnosed with hypovolemia. Which prescriptions for hydration should the nurse question? Select all that apply.
1)0.9% (normal) saline at 100 mL/hr
2)Lactated Ringer's solution at 100 mL/hr
3)D₅₀W at 100 mL/hr
4)D₅W solution at 100 mL/hr
5)D₅W with 20 mEq potassium chloride (KCl)

Question 43

A nurse is caring for a client with a peripheral IV line located in the right forearm. The client informs the nurse that the IV site is burning. Upon assessment the nurse determines that the IV solution has infiltrated. What site(s) is/are appropriate to consider when restarting the IV line? Select all that apply.
1)Left hand
2)Right wrist
3)Right antecubital area
4)Right saphenous vein
5)Left antecubital area

Question 44

Identify the mechanisms involved in acid-base balance. Select all that apply.
1)Respiratory mechanisms
2)Active transport mechanisms
3)Renal mechanisms
4)Buffer systems
5)Osmotic pressure systems

Question 45

A client has been admitted to the nursing unit with a diagnosis of chronic renal failure. The client is scheduled for the first dialysis session in the morning. Which of the following are appropriate nursing interventions for the client? Select all that apply.
1)Encourage oral fluid intake, as desired.
2)Place the client on strict intake and output (I&O) monitoring.
3)Weigh the client before and after dialysis.
4)Maintain a total fluid restriction of 1,000 mL, as prescribed.
5)Provide a dinner rich in magnesium and potassium.

Question 46

A client's blood group is B. The nurse knows the client can receive blood only from donors with what group of blood? Select all that apply.
1)A
2)B
3)O
4)AB
5)AO

Question 47

The nurse is caring for a client who is normally healthy but is experiencing dehydration secondary to acute diarrhea and vomiting. What assessment findings would indicate a return to fluid homeostasis? Select all that apply.
1)Urine output of 35 mL/hour
2)Elevated antidiuretic hormone levels
3)Reduced renin production
4)Reduced aldosterone release
5)Formed stools

Question 48

When assisting with bedside central venous catheter (CVC) placement, which nursing intervention is appropriate? Select all that apply.
1)Don sterile gloves and mask (and possibly gown).
2)Verify that informed consent has been obtained.
3)Scrub the insertion site with antibacterial soap for 1 min.
4)Place the client in low-Fowler's position.
5)Have the client wear a mask or turn their head.

Question 49

The nurse is caring for a client with metabolic acidosis secondary to renal failure caused by poor glucose regulation. The client reports a headache, weakness, and nausea. The nurse assesses an elevated blood sugar, Kussmaul's breathing, and peripheral vasodilation. What collaborative interventions will the nurse anticipate to restore pH balance? Select all that apply.
1)Insulin to lower blood sugar
2)Tylenol for headache
3)Mechanical ventilation to correct breathing
4)Dialysis to remove toxins
5)Bicarbonate administration