Question 1

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?
A) Carefully document all assessments of the catheter site.
B) Use strict sterile procedure when performing dressing changes.
C) Label each new dressing with the date, time, and nurse's initials.
D) Ensure that the CVC is discontinued as soon as possible.

Accepted Answer

Strict sterile procedure is mandatory when changing CVC dressings because of the high risk of septicemia and/or sepsis.

Question 2

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 in order to correct the patient's fluid imbalance?
A) 0.33% normal saline
B) 0.45% normal saline
C) 0.9% normal saline
D) 3% normal saline

Accepted Answer

A hypertonic 3% saline solution will be used to correct the patient's hyponatremia and fluid overload that have developed as a result of 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 3

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 meeting with the patient?
A) The patient has generalized 3+ pitting edema.
B) The patient is confused and disoriented.
C) The patient's urine is dark and very concentrated.
D) The patient lung sounds are very diminished.

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.

Question 4

The nurse is caring for a patient who is to receive intermittent bolus doses of phenytoin (Dilantin) through the IV line. Which intervention has the highest priority when administering this medication?
A) Check for blood return and compatibility prior to administration.
B) Use a new IV tubing set each time the medication is administered.
C) Document the date, time, and nurse's initials after each dose is administered.
D) Use sterile gloves when drawing up and administering the medication.

Accepted Answer

Phenytoin (Dilantin) 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. Dilantin may not be given with IV fluids that contain dextrose as precipitation and crystallization, so the nurse must also check compatibility with the patient's prescribed IV fluids.

Question 5

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?
A) Perform regular neurologic checks and institute seizure precautions.
B) Encourage the patient to eat foods that are high in sodium.
C) Administer hypotonic IV solutions as ordered by the physician.
D) Assess for signs and symptoms of digoxin (Lanoxin) toxicity.

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. Lanoxin toxicity is seen with hypokalemia rather than hyponatremia.

Question 6

The nurse is caring for a patient who is at risk for fluid overload as a result of a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?
A) "Check to make sure that your urine is a bright yellow color."
B) "Weigh yourself every morning before breakfast."
C) "Count your heart rate every evening before you go to bed."
D) "Drink plain water rather than soda, coffee, or fruit juice."

Accepted Answer

Checking the weight every morning before breakfast is a sensitive indicator of the patient's fluid volume status. Weight gain of 2 to 3 lb over 1 to 2 days generally indicates fluid retention and should be reported to the physician.

Question 7

The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCOS1U1B12S1U1B0 32 mm Hg, HCOS1U1B13S1U1B0 42 mEq/L, PaOS1U1B12S1U1B0 90 mm Hg. Which condition will the nurse expect to see in the patient's chart as the underlying cause of these results?
A) Gastroenteritis with severe nausea, vomiting, and diarrhea
B) Widespread tissue ischemia caused by cardiogenic shock
C) Respiratory failure caused by pneumonia with pleural effusions
D) Hyperventilation after a panic attack

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 HCOS1U1B13S1U1B0 42 mEq/L and normal PaCOS1U1B12S1U1B0 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 PaCOS1U1B12S1U1B0 level. Hyperventilation leads to respiratory alkalosis with an elevated pH and elevated HCOS1U1B13S1U1B0 level.

Question 8

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. Which is the most likely cause of the patient's collapse?
A) Orthostatic hypotension
B) Circulatory overload
C) Hemolytic reaction
D) Catheter embolism

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.

Question 9

The nurse is caring for a patient who was brought to the ER 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?
A) pH 7.56, PaCOS1U1B12S1U1B0 32 mm Hg, HCOS1U1B13S1U1B0 32 mEq/L, PaOS1U1B12S1U1B0 90 mm Hg
B) pH 7.35, PaCOS1U1B12S1U1B0 45 mm Hg, HCOS1U1B13S1U1B0 26 mEq/L, PaOS1U1B12S1U1B0 70 mm Hg
C) pH 7.45, PaCOS1U1B12S1U1B0 38 mm Hg, HCOS1U1B13S1U1B0 28 mEq/L, PaOS1U1B12S1U1B0  80 mm Hg
D) pH 7.27, PaCOS1U1B12S1U1B0 58 mm Hg, HCOS1U1B13S1U1B0 24 mEq/L, PaOS1U1B12S1U1B0 60 mm Hg

Accepted Answer

The patient who overdosed on narcotic pain medication will be in respiratory acidosis as a result of respiratory suppression. Low pH of 7.27 and elevated PaCOS1U1B12S1U1B0 are consistent with respiratory acidosis as insufficient carbon dioxide is removed from the blood. The low 60 mm Hg PaOS1U1B12S1U1B0 is due to insufficient oxygen intake.

Question 10

The nurse is caring for a patient who is receiving a blood transfusion. One hour 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?
A) Check the patient's temperature and administer acetaminophen (Tylenol) if higher than 101° F.
B) Recheck the patient's blood pressure in 15 minutes after administering pain medication.
C) Stop the blood transfusion and administer 0.9% normal saline through new IV tubing.
D) Double-check that the transfusion blood type is an exact match to the patient.

Accepted Answer

A significant drop in blood pressure and a severe headache are signs that the patient may be experiencing a transfusion 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 11

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?
A) Identify the blood group, type, and expiration date with another nurse.
B) Insert an 18- or 20-gauge angiocatheter into the patient's other arm.
C) Program the IV infusion pump so that the transfusion will complete within 4 hours.
D) Obtain a new microdrip tubing and extension tubing from the clean utility room.

Accepted Answer

Blood products such as packed red blood cells and whole blood should be infused through an IV catheter than is no smaller than a 20 gauge. An 18- or 20-gauge IV should be started in the patient's other arm before picking up the packed red blood cells from the blood bank. Identification of the blood group and expiration date will be done once the blood is obtained from the blood bank. Microdrip tubing is never used for blood transfusions.

Question 12

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 as a result of this therapy?
A) Hypocalcemia
B) Hypernatremia
C) Hypokalemia
D) Hyperphosphatemia

Accepted Answer

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

Question 13

The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis fluid volume excess in the patient's care plan. Which goal statement has the highest priority for the patient and nurse?
A) The patient's lung sounds will remain clear.
B) The patient will have urine output of at least 30 mL/hr.
C) The patient will verbalize understanding of fluid restrictions.
D) The patient's pitting pedal edema will resolve within 72 hours.

Accepted Answer

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

Question 14

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?
A) Discontinue the IV and start another line in the other arm.
B) Aspirate to check for blood return and flush the IV with sterile saline.
C) Clean the IV site with chlorhexidine and apply a new sterile dressing.
D) Change the IV tubing and administer prescribed pain medication.

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.

Question 15

The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of her three meals and had another 150 mL with her medications. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume in order to stay within the prescribed fluid restriction?
A) 100 mL
B) 150 mL
C) 250 mL
D) 300 mL

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 16

The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus doses of furosemide (Lasix) for a few days to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert in order to administer the patient's medication?
A) Peripherally inserted central catheter
B) Midline inside-the-needle catheter
C) Central venous catheter
D) Over-the-needle catheter

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 17

The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) in order to prevent fluid overload and pulmonary edema. The patient tells the nurse that she has stopped taking the medication because she has to urinate frequently during the night. What is the nurse's best response?
A) "You should ask your doctor to decrease the dose."
B) "Take the diuretic early in the morning before breakfast."
C) "Eat foods high in potassium and limit your salt intake."
D) "Restrict your fluid intake after dinner and in the evening."

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 18

The nurse is caring for a patient who is very dehydrated. Which goal best indicates that the nursing diagnosis of Deficient fluid volume has been corrected and that the patient's fluid balance has been restored?
A) The patient had 1300 mL of light yellow urine in the last 24 hours.
B) The patient's lung sounds are clear bilaterally.
C) The patient has no jugular venous distention.
D) The patient verbalizes need for adequate daily fluid intake.

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 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?
A) The patient's respirations are very deep and rapid.
B) The patient's urine is dark and concentrated.
C) The patient's skin is pale, cool, and diaphoretic.
D) The patient is sleepy and difficult to arouse.

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 reviewing the patient's laboratory results. Which result must be communicated to the physician immediately?
A) Serum chloride level 85 mEq/L
B) Serum sodium level 134 mEq/L
C) Serum potassium level 6.8 mEq/L
D) Serum magnesium level 2.3 mEq/L

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.

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

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 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 in order to correct the patient's fluid imbalance?

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 meeting with the patient?

The nurse is caring for a patient who is to receive intermittent bolus doses of phenytoin (Dilantin) through the IV line. Which intervention has the highest priority when administering this medication?

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 who is at risk for fluid overload as a result of 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 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 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. Which is the most likely cause of the patient's collapse?

The nurse is caring for a patient who was brought to the ER 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 receiving a blood transfusion. One hour 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 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 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 as a result of this therapy?

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

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

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