Deck 52: Fluid, Electrolyte, and Acid-Base Balance

Question 1

The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days.What instruction should the nurse give this infant's mother?

A)Have the infant be seen by a physician
B)Give the infant at least 2 ounces of juice every 2 hours.
C)Measure the infant's urine output for 24 hours.
D)Provide the infant with 50 mL of glucose water.

Answer 1

Have the infant be seen by a physician

Question 2

The nurse is collecting equipment to administer a unit of packed red blood cells.Which IV fluid should be used to initiate the IV for this transfusion?

A)1,000 mL of lactated Ringer's solution
B)250 mL of normal saline
C)500 mL of 5% dextrose and water
D)100 mL of 5% dextrose and 1/2 normal saline

Answer 2

250 mL of normal saline

Question 3

A client has experienced a narcotic overdose.What acid-base imbalance should the nurse expect to observe in this client?

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

Answer 3

Respiratory acidosis

Question 4

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 milliliter of fluid the tubing delivers.Where should the nurse look for this information?

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

Question 5

A client has had a subclavian central venous catheter inserted.What should the nurse assess as a priority for this client's care?

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

Question 6

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

Question 7

A client tells the nurse about passing out after following a fasting diet for 5 days.Which acid-base imbalance should the nurse expect to assess in this client?

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

Question 8

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)Slow the IV infusion and reassess the area in 15 minutes.
B)Apply ice over the IV site and vein.
C)Discontinue the IV and place a warm pack on the area.
D)Call the physician for direction.

Question 9

After obtaining a unit of packed red blood cells for a client,the nurse learns the client needed to leave the care area for an emergency x-ray.What action should the nurse take?

A)Set up the blood with the IV fluid and y-tubing and place it on the IV stand in the client's room to initiate immediately after the client returns.
B)Place the blood in the unit refrigerator until the client returns.
C)Return the blood to the laboratory blood bank 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 10

The nurse is reviewing orders for parenteral potassium.Which order is safe for the nurse to implement?

A)Add 20 mEq of KCL to 1,000 mL of IV fluid
B)10 mEq KCL IV over 1-2 minutes
C)Dilute 20 mEq KCL in 3 mL of NS and give IV push
D)10 mEq KCL SQ

Question 11

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

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

Question 12

A 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 UAP is preparing to bathe the client.What should the nurse do?

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

Question 13

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

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

Question 14

The nurse is preparing to start an IV in the hand of a client who has very small veins.Which actions would be useful in dilating the veins?

A)Position the hand at heart level.
B)Stroke the vein.
C)Have the client clench and unclench the fist.
D)Slap the back of the client's hand.
E)Massage the vein.

Question 15

The nurse suspects that a client's body is attempting to correct an acid-base imbalance.How will this imbalance be corrected?

A)Slow but efficient respiratory regulation will occur.
B)Primary regulation is through GI system losses.
C)Kidney regulation is powerfully effective.
D)The cardiovascular system is the major buffer.

Question 16

The nurse is caring for a client who is recovering from surgery.Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia?

A)Measure vital signs every 4 hours.
B)Assist the client to turn,cough,and deep breathe every 2 hours.
C)Assist the client to ambulate around the room at least three times daily.
D)Irrigate the client's nasogastric tube every 2 hours.

Question 17

The 154-pound adult client has had vomiting and diarrhea for 4 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)35 mL per hour
B)80 mL per hour
C)50 mL per hour
D)30 mL per hour

Question 18

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

Question 19

The nurse initiates a blood transfusion for a client.What action should the nurse take next?

A)Stay with the client and closely observe him for the first 5 to 10 minutes of the transfusion.
B)Assign the UAP to sit with the client for 15 minutes.
C)Advise the client to notify the nurse if he experiences any chilling,nausea,flushing,or rapid heart rate.
D)Return to the room and take a set of vital signs in 15 minutes.

Question 20

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

Question 21

A client tells the nurse about rarely feeling thirsty.The nurse realizes that further assessment is needed to evaluate
Standard Text: Select all that apply.

A)status of osmotic pressure.
B)vascular volume.
C)presence of angiotensin.
D)urine output.
E)body weight.

Question 22

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

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

Question 23

A client is receiving a continuous intravenous infusion.What should the nurse document in the medical record about this infusion?
Standard Text: Select all that apply.

A)Latest body temperature
B)Type of solution and flow rate
C)Total intravenous intake for the shift
D)Status of the intravenous catheter site
E)Results of blood pressure measurement

Question 24

The nurse wants to assess a client for orthostatic hypotension.What action should the nurse take?

A)Assess the client for dependent edema and then raise the legs to the level of the heart and reassess for edema.
B)Measure the client's heart rate and blood pressure in both the sitting and standing position.
C)Measure the client's blood pressure before,during,and after administration of a normal saline fluid challenge.
D)Raise the client's legs above heart level and measure the blood pressure.

Question 25

An older client receiving intravenous fluids at 175 ml/hr is demonstrating crackles,shortness of breath,and distended neck veins.The nurse recognizes these findings as being which complication of intravenous fluid therapy?

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

Question 26

A client sustained a significant loss of blood after a motor vehicle accident.The nurse notes that the client's urine output has decreased and suspects that which hormones have influenced this client's fluid balance?
Standard Text: Select all that apply.

A)Aldosterone
B)Angiotensin
C)Antidiuretic hormone
D)Estrogen
E)Progesterone

Question 27

The nurse is preparing to discontinue a client's intravenous infusion.Which actions should the nurse take when removing the catheter from the vein?
Standard Text: Select all that apply.

A)Pull the catheter out in line with the vein
B)Apply pressure to the site while removing the catheter.
C)Pull the catheter out at an angle perpendicular to the vein.
D)Bend the client's elbow if bleeding at the site persists after removal.
E)Apply pressure to the site after the catheter is removed for 2 to 3 minutes.