Question 1

Which of the following is an example of a hypertonic solution?

Accepted Answer

A hypertonic solution has a higher concentration of solutes compared to the inside of a cell. Dextrose 10% in water is hypertonic because it has a higher concentration of solutes than the other options listed.

Question 2

A patient complains of a headache and chills during a blood transfusion.Which one of the following actions should the nurse take immediately?

Accepted Answer

Headache and chills are symptoms of transfusion reactions, which requires an immediate cessation of the transfusion to prevent further harm to the patient. Checking vital signs, slowing the rate of blood flow, and notifying the physician and blood bank personnel can be done after stopping the transfusion.

Question 3

An IV of 125 mL is to be infused over a one-hour period.A microdrip infusion set will be used.Which of the following is the nurse's calculation of the infusion rate?

Accepted Answer

A microdrip infusion set delivers 60 drops per mL. To infuse 125 mL over one hour, the rate is 125 mL/hour, which equals 125 gtt/minute.

Question 4

Which of the following is of great importance for the nurse to check before administering an IV solution with potassium that is prescribed for the patient?

Accepted Answer

Checking renal function is important before administering IV solution with potassium because impaired renal function can lead to the accumulation of potassium, which can cause hyperkalemia and potentially life-threatening cardiac dysrhythmias.

Question 5

Among the following four patients,the nurse recognizes that which one is most at risk for a fluid volume deficit?

Accepted Answer

Severe diarrhea can lead to excessive fluid loss and puts the patient at a high risk for fluid volume deficit. The 6-month-old may still be breastfeeding or receiving formula and would likely have close monitoring for hydration status. The 12-year-old may be active, but the temperature is not extreme and they are likely to have access to fluids. The 90-year-old with frequent headaches may need further assessment for underlying causes, but the information provided does not indicate a higher risk for fluid volume deficit.

Question 6

The nurse is looking after a patient who has abdominal cramps,dizziness,and a rapid and thready pulse.The patient's laboratory results indicate hyponatremia.Which of the following additional signs can the nurse expect?

Accepted Answer

Hyponatremia can cause fluid shifts in the body leading to a decrease in blood volume and blood pressure, which can result in postural hypotension. Tetany is associated with hypocalcemia, not hyponatremia. Dry skin and mucous membranes are associated with dehydration but not specifically with hyponatremia. Elevated temperature and flushed skin are not commonly associated with hyponatremia.

Question 7

Which of the following is the most common electrolyte imbalance?

Accepted Answer

The answer of Which of the following is the most...

Question 8

When a deficit of body fluid exists in the intravascular compartment,which of the following signs can be expected?

Accepted Answer

An elevated hematocrit (the percentage of red blood cells in the blood) can occur in dehydration, as the volume of fluid decreases but the number of red blood cells remains the same, causing their percentage in the blood to increase. The other options are not typically associated with dehydration in the intravascular compartment.

Question 9

A homeless person is brought into the emergency department with indications of extremely poor nutrition.Arterial blood gases are assessed,and the nurse anticipates that this patient will demonstrate which of the following results?

Accepted Answer

The indicated arterial blood gas results suggest metabolic acidosis with respiratory compensation. The pH is low, indicating acidosis, and the HCO₃- (bicarbonate) level is low, indicating the presence of a metabolic acidosis. The respiratory compensation is demonstrated by the decreasing PaCO₂ (partial pressure of carbon dioxide) level. This pattern can be seen in severe malnutrition, as the body relies on protein catabolism for fuel, resulting in the production of acidic metabolites.

Question 10

The nurse knows that older adults are more prone to fluid volume alterations for which of the following reasons?

Accepted Answer

Older adults have a decreased thirst sensation, which can lead to inadequate fluid intake and an increased risk of dehydration. This is due to changes in the hypothalamus, which regulates thirst sensation. Additionally, aging can lead to a decrease in total body water, making older adults more susceptible to fluid volume alterations.

Question 11

A child having an asthma attack has presented to the emergency department.He is breathing rapidly and has a blood pH of 7.47,signs and symptoms that the nurse suspects are consistent with which of the following conditions?

Accepted Answer

The child's rapid breathing is indicative of hyperventilation, which can cause respiratory alkalosis. Additionally, the elevated blood pH of 7.47 also supports this diagnosis. Asthma attacks often cause hyperventilation, leading to a reduction in carbon dioxide levels in the blood and subsequent respiratory alkalosis.

Question 12

The single best indicator of a patient's fluid status is the nurse's assessment of which one of the following?

Accepted Answer

The patient's daily body weight is the single best indicator of their fluid status as weight gain or loss can indicate fluid retention or loss respectively. Skin turgor, intake and output, and serum electrolyte levels can also provide important information about fluid status, but they are not as reliable as daily body weight measurements.

Question 13

A rapid infusion of blood has been given to the patient.The nurse assesses the patient for which one of the following?

Accepted Answer

A rapid infusion of blood can cause fluid overload, leading to hypertension and tachycardia as the heart tries to pump a larger volume of blood through the system. Diaphoresis, anxiety, nausea, and vomiting are not typical adverse reactions to a blood transfusion.

Question 14

Arterial blood gases are obtained for the patient.The patient's results (pH 7.48,PaCO₂ 42 mm Hg,HCO₃⁻ 32 mmol/L)indicate which one of the following acid-base imbalances?

Accepted Answer

The pH is elevated, indicating alkalosis. The PaCO₂ is normal, ruling out a respiratory cause. The HCO₃⁻ is elevated, indicating a metabolic cause. Therefore, the patient has metabolic alkalosis.

Question 15

The nurse will be starting a new IV infusion and needs to select the site for the insertion.In selecting a site,the nurse should do which of the following?

Accepted Answer

Starting with the most distal site (furthest from the heart) is recommended as it allows for easier access and reduces the risk of damage or infiltration to other IV sites. Looking for hard, cordlike veins is not recommended as it may indicate thrombosis or sclerosis, which can lead to complications. The nurse should also avoid using the dominant arm if possible to prevent interference with daily activities and reduce the risk of infiltration due to movement. Vigorous rubbing and tapping of the chosen vein can cause discomfort and may increase the risk of complications.

Question 16

On the infiltration scale for assessing a peripheral intravenous (IV)site,what grade would the nurse document when the assessment indicates the skin is blanched with 4.5 cm of edema,and the area is cool to touch?

Accepted Answer

The answer of On the infiltration scale for assessing a...

Question 17

An 8-year-old is admitted to the pediatric unit with pneumonia.On assessment,the nurse notes that the child is warm and flushed,is lethargic,has difficulty breathing,and has moist crackles.The nurse determines that the child has which one of the following?

Accepted Answer

The child's symptoms of difficulty breathing and moist crackles suggest respiratory involvement, while the warmth and flushing may indicate a fever. These are all indicative of respiratory acidosis, which occurs when there is an accumulation of carbon dioxide in the bloodstream due to inadequate breathing.

Question 18

The physician orders 1000 mL of D5RL with 20 mmol KCl to run for eight hours.With an infusion set with a drop factor of 15 gtt/mL,which of the following flow rates will the nurse calculate?

Accepted Answer

To calculate the flow rate using the formula:
flow rate (gtt/minute) = (volume to be infused in mL × drop factor) ÷ infusion time in minutes

Substituting the given values in the formula, we get:
flow rate (gtt/minute) = (1000 mL × 15 gtt/mL) ÷ 480 minutes
flow rate (gtt/minute) = 31250 ÷ 480
flow rate (gtt/minute) ≈ 31 gtt/minute

Therefore, the correct choice is C) 31 gtt/minute.

Question 19

A patient has IV therapy for the administration of antibiotics and is stating that the IV site "hurts and is swollen." Which one of the following items of information assessed on the patient indicates the presence of phlebitis,as opposed to infiltration?

Accepted Answer

Phlebitis is inflammation of the vein, which often causes warmth and redness in the surrounding tissue. Infiltration is the leakage of fluid out of the vein and into the surrounding tissue, which causes swelling and often coolness in the surrounding tissue. Therefore, the warmth of the integument surrounding the IV site is a sign of phlebitis rather than infiltration. The intensity of pain, amount of subcutaneous edema, and skin discoloration do not necessarily differentiate between phlebitis and infiltration.

Question 20

For a patient with a nursing diagnosis of "Fluid volume excess," the nurse is alert to which one of the following signs and symptoms?

Accepted Answer

Hypertension is a common sign of fluid volume excess, as it can cause an increase in blood pressure due to the excess fluid in the bloodstream. Tachycardia may be present in some cases, but it is not a definitive sign of fluid volume excess. Dry mucous membranes and fever are not typically associated with this nursing diagnosis.

Quiz 39: Fluid, electrolyte, and Acid-base Balances