Question 1

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient to correct the patient's fluid imbalance?

Accepted Answer

A hypertonic 3% saline solution will be used to correct the patient's hyponatremia and fluid overload that have developed due to SIADH. A 0.9% normal saline solution can be used once the serum sodium level has been raised nearer to normal range. A 0.45% or 0.33% normal saline solution is hypotonic and will only worsen the patient's fluid overload and hyponatremia.

Question 2

The nurse is caring for a patient who is to receive dopamine (Intropin) through the IV line. Which intervention has the highest priority when administering this medication?

Accepted Answer

Dopamine is a vesicant and can cause significant irritation to blood vessels and tissues when administered via IV. For this reason, the nurse must ensure that the IV catheter is located correctly in the vein by checking for a blood return prior to administration.

Question 3

The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of the three meals and had another 150 mL with medication administration. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume to stay within the prescribed fluid restriction?

Accepted Answer

The patient has had an oral fluid intake of 900 mL and an IV fluid intake of 150 mL, giving a total of 1050 mL. This leaves 150 mL that the patient may consume for the rest of the evening to stay within the prescribed fluid restriction.

Question 4

The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus doses of furosemide (Lasix) to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert to administer the patient's medication?

Accepted Answer

Intermittent doses of IV diuretics are best administered via an over-the-needle angiocatheter that is connected to a saline lock. The other IV catheter options are used when the patient requires a vesicant drug that could cause significant damage to tissues or when the patient requires weeks of IV therapy.

Question 5

The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) to prevent fluid overload and pulmonary edema. The patient admits to stopping the medication due to nocturia. What is the nurse's best response?

Accepted Answer

The patient should be instructed to take the diuretic early in the morning so that the effects will wear off before the patient goes to bed at night. Decreasing the dose could lead to fluid overload and pulmonary edema.

Question 6

The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is the nurse's best action?

Accepted Answer

An IV site that is puffy and painful should be discontinued promptly because the fluid has infiltrated outside the vein and is causing localized irritation. The IV should be restarted in the other arm if possible. The other actions are inappropriate.

Question 7

The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank?

Accepted Answer

Before obtaining the blood from the blood bank, the nurse ensures the patient's IV is patent. Research confirms blood can be safely infused in as small as a 24 gauge IV. Then the nurse obtains the blood and double checks the blood group, type, expiration date, and patient ID with a second nurse. Next the nurse sets up the IV and IV pump. Blood is not run through a microdrip tubing set.

Question 8

The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient's albumin level is critically low. What assessment finding will the nurse expect to note when assessing the patient?

Accepted Answer

The patient's low albumin level will lead to generalized pitting edema because there isn't enough protein in the blood to keep water within the bloodstream. Lack of oncotic pressure from low serum albumin leads to edema. The other findings are not related to malnutrition.

Question 9

The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis hypervolemia in the patient's care plan. Which goal statement has the highest priority for the patient and nurse?

Accepted Answer

Oxygenation is the highest priority for the patient with congestive heart failure and hypervolemia. Keeping the patient's lungs clear is the most important goal for the nurse to consider when caring for this patient.

Question 10

The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur due to this therapy?

Accepted Answer

Furosemide is a loop diuretic that causes loss of potassium through the urine. Patients taking this medication are at risk for hypokalemia, so the nurse should check the patient's electrolyte values closely, particularly the serum potassium level.

Question 11

The nurse is caring for a patient who has a central venous catheter (CVC). Which nursing intervention is the most important for the nurse to include in the patient's plan of care?

Accepted Answer

Strict sterile procedure is mandatory when changing CVC dressings because of the high risk of septicemia and/or sepsis. The other actions are appropriate, but not of the highest priority.

Question 12

The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. The nurse knows which condition to be the most likely cause of the patient's collapse?

Accepted Answer

The patient with dehydration is at risk for orthostatic hypotension or falling of the blood pressure when the patient rises to a standing position. When the blood pressure falls sufficiently, fainting may occur. The patient should be assisted to rise slowly from a supine to a sitting position first before slowly getting to his feet. Circulatory overload, hemolytic anemia, and catheter embolism are unlikely to be causative factors.

Question 13

The nurse is caring for a patient who is receiving a blood transfusion. Fifteen minutes into the transfusion, the patient's blood pressure decreases significantly, and the patient complains of a severe headache. What is the priority action of the nurse?

Accepted Answer

A significant drop in blood pressure and a severe headache are signs that the patient may be experiencing a transfusion reaction. Also, most reactions to a transfusion occur within the first 15 minutes of initiation. Therefore the nurse should remain with the patient at the bedside during this time to observe for signs of a reaction. The transfusion should be stopped and 0.9% normal saline should be administered through new IV tubing to prevent infusion of additional blood through the tubing used for the transfusion. The physician should be notified immediately to evaluate the patient. Ensuring that the transfusion blood type is an exact match to the patient is done before the transfusion is begun.

Question 14

The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO₂ 32 mm Hg, HCO₃ 42 mEq/L, PaO₂ 90 mm Hg. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results?

Accepted Answer

Gastroenteritis with nausea, vomiting, and diarrhea will lead to a metabolic alkalosis resulting from loss of electrolytes and acids through emesis and loose stools. Metabolic alkalosis features the elevated pH of 7.56, elevated HCO₃ 42 mEq/L, and normal PaCO₂ of 32 mm Hg. Widespread tissue ischemia would lead to metabolic acidosis with low pH resulting from release of lactic acid from the tissues. Respiratory failure leads to a respiratory acidosis with a low pH and elevated PaCO₂ level. Hyperventilation leads to respiratory alkalosis with an elevated pH and elevated HCO₃level.

Question 15

The nurse is caring for a patient who was brought to the ED after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect to see?

Accepted Answer

The patient who overdosed on narcotic pain medication will be in respiratory acidosis due to respiratory suppression. Low pH of 7.27 and elevated PaCO₂ are consistent with respiratory acidosis as insufficient carbon dioxide is removed from the blood. The low 60 mm Hg PaO₂ is due to insufficient oxygen intake.

Question 16

The nurse is caring for a patient who is very dehydrated. Which goal best indicates that dehydration has been corrected and that the patient's fluid balance has been restored?

Accepted Answer

The goal that best indicates that the patient's dehydration has been corrected is output of 1300 mL of clear yellow urine in the last 24 hours. Dark concentrated urine is a symptom of dehydration. Jugular venous distention and presence of crackles in the lungs are both indicative of fluid volume overload.

Question 17

The nurse is caring for a patient who is at risk for fluid overload due to a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?

Accepted Answer

Checking the weight every morning before breakfast is a sensitive indicator of the patient's fluid volume status. Weight gain of 2 kg in 3 days generally indicates fluid retention and should be reported to the physician.

Question 18

The nurse is reviewing the patient's laboratory results. Which result must be communicated to the physician immediately?

Accepted Answer

Normal serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 6.8 mEq/L is very high and puts the patient at risk for cardiac arrhythmias. The potassium level should be reported to the physician immediately. The chlorine and sodium levels are slightly low and the magnesium level is slightly elevated.

Question 19

The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient's body to correct the pH?

Accepted Answer

The patient with diabetic ketoacidosis is in a state of metabolic acidosis. The body will attempt to compensate for the acidosis by blowing off extra amounts of carbon dioxide through deep, rapid respirations. Since carbon dioxide is converted to carbonic acid, removal of carbon dioxide will help shift the body's pH to a less acidotic state.

Question 20

The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform?

Accepted Answer

A serum sodium level of 124 mEq/L is dangerously low and may cause neurologic problems including seizures, confusion, and weakness. Regular neurologic checks should be performed and the patient should be placed on seizure precautions until the sodium level is corrected. Encouraging the patient to eat high-sodium foods is fine, but it is not as important as the patient's safety. A hypotonic saline solution will further lower the patient's sodium level. Digoxin toxicity is seen with hypokalemia rather than hyponatremia.

Quiz 39: Fluid, Electrolytes, and Acid-Base Balance

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient to correct the patient's fluid imbalance?

The nurse is caring for a patient who is to receive dopamine (Intropin) through the IV line. Which intervention has the highest priority when administering this medication?

The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus doses of furosemide (Lasix) to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert to administer the patient's medication?

The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) to prevent fluid overload and pulmonary edema. The patient admits to stopping the medication due to nocturia. What is the nurse's best response?

The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is the nurse's best action?

The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank?

The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient's albumin level is critically low. What assessment finding will the nurse expect to note when assessing the patient?

The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis hypervolemia in the patient's care plan. Which goal statement has the highest priority for the patient and nurse?

The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur due to this therapy?

The nurse is caring for a patient who has a central venous catheter (CVC) . Which nursing intervention is the most important for the nurse to include in the patient's plan of care?

The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. The nurse knows which condition to be the most likely cause of the patient's collapse?

The nurse is caring for a patient who is receiving a blood transfusion. Fifteen minutes into the transfusion, the patient's blood pressure decreases significantly, and the patient complains of a severe headache. What is the priority action of the nurse?

The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO₂ 32 mm Hg, HCO₃ 42 mEq/L, PaO₂ 90 mm Hg. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results?

The nurse is caring for a patient who was brought to the ED after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect to see?

The nurse is caring for a patient who is very dehydrated. Which goal best indicates that dehydration has been corrected and that the patient's fluid balance has been restored?

The nurse is caring for a patient who is at risk for fluid overload due to a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?

The nurse is reviewing the patient's laboratory results. Which result must be communicated to the physician immediately?

The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient's body to correct the pH?

The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform?

Quiz 39: Fluid, Electrolytes, and Acid-Base Balance

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient to correct the patient's fluid imbalance?

The nurse is caring for a patient who is to receive dopamine (Intropin) through the IV line. Which intervention has the highest priority when administering this medication?

The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus doses of furosemide (Lasix) to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert to administer the patient's medication?

The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) to prevent fluid overload and pulmonary edema. The patient admits to stopping the medication due to nocturia. What is the nurse's best response?

The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is the nurse's best action?

The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank?

The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient's albumin level is critically low. What assessment finding will the nurse expect to note when assessing the patient?

The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis hypervolemia in the patient's care plan. Which goal statement has the highest priority for the patient and nurse?

The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur due to this therapy?

The nurse is caring for a patient who has a central venous catheter (CVC) . Which nursing intervention is the most important for the nurse to include in the patient's plan of care?

The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. The nurse knows which condition to be the most likely cause of the patient's collapse?

The nurse is caring for a patient who is receiving a blood transfusion. Fifteen minutes into the transfusion, the patient's blood pressure decreases significantly, and the patient complains of a severe headache. What is the priority action of the nurse?

The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 32 mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results?

The nurse is caring for a patient who was brought to the ED after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect to see?

The nurse is caring for a patient who is very dehydrated. Which goal best indicates that dehydration has been corrected and that the patient's fluid balance has been restored?

The nurse is caring for a patient who is at risk for fluid overload due to a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?

The nurse is reviewing the patient's laboratory results. Which result must be communicated to the physician immediately?

The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient's body to correct the pH?

The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform?

The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO₂ 32 mm Hg, HCO₃ 42 mEq/L, PaO₂ 90 mm Hg. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results?