Question 1

Which patient would the nurse expect to have the least amount of body fluid?

Accepted Answer

The amount of body fluid is inversely related to the amount of body fat. An obese individual has a higher proportion of body fat, which means they have a lower proportion of body fluid compared to individuals with less body fat. Therefore, a 75-year-old woman with a BMI in the obese range would have the least amount of body fluid.

Question 2

A patient with hypoxia is at risk for disruption of the sodium potassium pump.Which would the nurse expect if this occurs?

Accepted Answer

Disruption of the sodium potassium pump can lead to cell death as it is critical for maintaining the cell's membrane potential and normal function. The other options are not directly related to disruption of the pump.

Question 3

Laboratory testing reveals a patient's serum osmolality to be 240 mOsm/kg.The nurse would assess for which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

A) Excessive infusion of D5W (5% dextrose in water) can lead to hyponatremia, which would decrease serum osmolality. D) Syndrome of inappropriate ADH (SIADH) secretion leads to water retention and hyponatremia, also decreasing serum osmolality.

Question 4

A patient's temperature has been elevated for the past 24 hours.The nurse should monitor which electrolyte?

Accepted Answer

An elevated temperature can lead to dehydration and electrolyte imbalance. Sodium is an important electrolyte that is lost in sweat and urine when the body is dehydrated, so monitoring sodium levels is important in this case. Phosphorous, potassium, and magnesium levels may also need to be monitored, but sodium is the best choice for this specific scenario.

Question 5

The nurse is planning the care of a patient in the intensive care unit.With regard to maintaining adequate fluid volume for this patient,the nurse realizes that interventions should be planned to reduce the risk of which condition?

Accepted Answer

Maintaining adequate fluid volume can increase the risk of retaining sodium, which can lead to fluid overload and increased blood pressure. Therefore, interventions should be planned to prevent excessive sodium intake and promote sodium excretion through appropriate diuretic therapy.

Question 6

A patient's laboratory report indicates critically low serum calcium levels.The nurse would conduct further assessment for which conditions? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Critically low serum calcium levels can indicate disrupted parathyroid gland function, decreased supply of vitamin D, insufficient levels of calcitriol, and insufficient levels of calcidiol. Low levels of calcitonin are not typically associated with critically low serum calcium levels.

Question 7

A urine electrolyte test is ordered to evaluate aldosterone disorder in a patient just admitted to the intensive care unit.How would the nurse collect this specimen?

Accepted Answer

A 24-hour urine collection system is used for urine electrolyte testing as it provides a more accurate assessment of aldosterone levels over a longer period of time. The other options do not guarantee an accurate representation of the patient's electrolyte levels.

Question 8

A patient's potassium and calcium levels are below the normal range.The nurse should check for a decreased level of which other electrolyte?

Accepted Answer

Hypocalcemia and hypokalemia are often seen in patients with hypomagnesemia. Therefore, the nurse should check for a decreased level of magnesium. Options A, B, and D are not typically related to hypocalcemia and hypokalemia.

Question 9

After reviewing a patient's laboratory values,the nurse determines the patient is experiencing fluid volume deficit.Which laboratory value would the nurse cite as supporting this determination?

Accepted Answer

Urine osmolality of 330 mOsm/kg indicates a higher concentration of solutes in the urine, which can occur with fluid volume deficit as the body tries to conserve water, leading to more concentrated urine.

Question 10

A patient admitted to the intensive care unit has been taking high levels of magnesium supplements.The nurse would add which information to this patient's plan of care?

Accepted Answer

High levels of magnesium can cause cardiac dysrhythmias, so monitoring for them is essential. Chvostek's sign is associated with low levels of calcium, not magnesium. Sudden decrease in respiratory rate and hyperthermia are not associated with high levels of magnesium.

Question 11

The nurse is reviewing laboratory results for a patient just admitted to the intensive care unit.The nurse would anticipate interventions to be necessary for which values? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Calcium and potassium are both electrolytes that are important for maintaining normal heart function. Calcium is necessary for muscle contraction, while potassium is necessary for maintaining the electrical gradient across the cell membrane. When calcium or potassium levels are abnormal, it can lead to arrhythmias and other cardiac problems.

Question 12

Which laboratory value would require that the nurse closely monitor a patient's cardiac rhythm?

Accepted Answer

A potassium level of 3.3 mEq/L is significantly low and can lead to cardiac arrhythmias. Therefore, the nurse would closely monitor the patient's cardiac rhythm to ensure that any arrhythmias are promptly identified and managed.

Question 13

A patient is admitted with bleeding from the gastrointestinal tract.The nurse plans interventions to support the balance of which fluid volume compartment?

Accepted Answer

Bleeding from the gastrointestinal tract causes a loss of intravascular volume, as blood is lost from the blood vessels. The nurse would plan interventions to support the balance of intravascular volume by monitoring vital signs, administering fluid and blood products as ordered, and assessing for signs of hypovolemia. The other fluid compartments, transcellular, interstitial, and intracellular, are less likely to be affected by bleeding from the gastrointestinal tract.

Question 14

While assessing a high-acuity patient,the nurse learns the patient has a history of arthritis.Which question would provide the most information regarding potential impact on the patient's fluid and electrolyte balance?

Accepted Answer

Nonsteroidal anti-inflammatory medications (NSAIDs) are known to cause fluid and electrolyte imbalances, particularly in patients with pre-existing conditions such as arthritis. Therefore, asking about the frequency of NSAID use may provide the most information regarding potential impact on the patient's fluid and electrolyte balance.

Question 15

Which findings would the nurse evaluate as indication that a pregnant female is hypovolemic? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Hypovolemia is the condition of having a decreased blood volume, and it can be indicated by flat hand veins when dependent, sunken eyes, and tenting of the skin. Flat neck veins and bilateral adventitious lung sounds are not necessarily indicative of hypovolemia.

Question 16

The nurse notes that a patient's serum albumin level is elevated.Which other lab result should the nurse review?

Accepted Answer

Elevated serum albumin levels can affect calcium levels because albumin binds to calcium. A significant portion of the body's calcium is bound to albumin, so changes in albumin levels can lead to changes in measured calcium levels, necessitating a review of calcium levels for a comprehensive assessment.

Question 17

When assessing the patient's edema of the lower extremities,the nurse notes that it takes 3 minutes before the 8-mm indentation created by applying pressure above the ankles disappears.This information should be documented as being which type of pitting edema?

Accepted Answer

Pitting edema is graded on a scale from +1 to +4, with +4 being the most severe. An 8-mm indentation that takes 3 minutes to disappear is classified as +4 pitting edema.

Question 18

The nurse is assessing for the presence of Trousseau sign.Which findings would the nurse evaluate as indicating this sign is present? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

The answer of The nurse is assessing for the presence...

Question 19

A patient's BUN/creatinine ratio is 13:1.How would the nurse interpret this finding?

Accepted Answer

A BUN/creatinine ratio of 13:1 is considered within normal limits, indicating that the patient is normovolemic. It does not necessarily indicate any renal dysfunction or changes in glomerular filtration rate.

Question 20

A patient in the intensive care unit has low blood pressure.If the patient's baroreceptors are functioning appropriately,what will the nurse assess in this patient?

Accepted Answer

Baroreceptors are specialized pressure-sensitive nerve endings that sense changes in blood pressure and signal the cardiovascular center in the brain to regulate blood pressure. If the patient's baroreceptors are functioning appropriately, reduced urine output would be assessed as the kidney's response to low blood pressure is to conserve fluids, leading to decreased urine output. Weak hand grasps, decreased level of consciousness, and peripheral edema are not directly related to baroreceptor function.

Quiz 25: Determinants and Assessment of Fluid and Electrolyte Balance