Question 1

An older adult is at home after being diagnosed with a fluid volume excess. Which of the following should the community nurse instruct this person to do?

Accepted Answer

Wearing support hose can help reduce fluid accumulation in the legs by promoting venous return and reducing edema, which is beneficial for someone with fluid volume excess.

Question 2

A 28-year-old male is admitted with diabetic ketoacidosis. The nurse realises that this person may have a need for which of the following electrolytes?

Accepted Answer

D

Question 3

A person is admitted with an elevated serum sodium level caused by being stranded in rugged bushland for 5 days without a fresh water source. Which of the following is this person at risk of developing?

Accepted Answer

Elevated serum sodium levels can lead to dehydration and neurological symptoms such as confusion, seizures, and cerebral bleeding.

Question 4

A person with fluid retention related to renal problems is admitted to the hospital. The nurse realises that this person could possibly have which of the following electrolyte imbalances?

Accepted Answer

Renal problems can lead to fluid retention, which may manifest as an increase in serum sodium levels, causing hypernatraemia. The other electrolyte imbalances listed are not typically associated with renal problems.

Question 5

A person is prescribed 40 mEq of potassium as a replacement. How should this be administered?

Accepted Answer

Potassium replacement should be mixed in the prescribed intravenous fluid and infused slowly to avoid the risk of hyperkalemia and irritation of blood vessels. Rapid administration or bolus dosing can cause cardiac arrest. Intramuscular injection is not an appropriate route for potassium replacement.

Question 6

A postoperative person is diagnosed with a fluid volume excess. Which of the following should the nurse expect to observe in this person?

Accepted Answer

A fluid volume excess will result in increased fluid in the body, including in the vascular system. This excess fluid will increase venous pressure, leading to distention of neck veins. A person with fluid volume excess may also experience edema, weight gain, and shortness of breath. Increased hemoglobin and hematocrit levels would suggest a fluid volume deficit, while orthostatic hypotension and oliguria are also not typically associated with fluid volume excess.

Question 7

A 35-year-old postoperative woman comes into the clinic after a parathyroidectomy. Which of the following should the nurse teach this person?

Accepted Answer

After a parathyroidectomy, the patient may experience hypocalcemia due to a decrease in parathyroid hormone. Milk and milk-based products are a good source of calcium and can help prevent hypocalcemia. Salty foods should also be limited to prevent fluid retention, but this is not the most important teaching point in this situation. Lean red meat is a good source of protein, but it is not directly related to post-parathyroidectomy care. Minimising direct exposure to sunlight is important for patients with certain skin conditions or taking certain medications, but is not specifically related to post-parathyroidectomy care.

Question 8

A person is admitted for treatment of hypercalcaemia. What will this person's intravenous fluid most likely be?

Accepted Answer

0.9% sodium chloride is often used to treat hypercalcemia because it helps to increase renal calcium excretion by improving hydration and increasing urine output.

Question 9

The nurse is admitting a person who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder?

Accepted Answer

Acute renal failure can cause hyperkalemia (high potassium levels) because the kidneys are not able to excrete potassium properly. Other electrolyte imbalances may also occur, but potassium is the most commonly affected.

Question 10

A person is diagnosed with an elevated serum phosphate level. The nurse realises that this person might also have an imbalance of which of the following electrolytes?

Accepted Answer

An elevated serum phosphate level is often accompanied by a decrease in serum calcium, as the two electrolytes are inversely related. Therefore, the nurse should consider that the person may have an imbalance of calcium.

Question 11

The nurse is reviewing a person's blood pH level. Which body system helps regulate blood pH?

Accepted Answer

The renal (or urinary) system helps regulate blood pH through the excretion of excess acids or bases. The musculoskeletal system is responsible for movement and support. The neurological system is responsible for communication and control of bodily functions. The gastrointestinal system is responsible for digestion and absorption of nutrients.

Question 12

An older adult does not complain of thirst. What should the nurse do to assess whether this person is dehydrated?

Accepted Answer

Assessing urine-specific gravity is a good indicator of hydration status. If the specific gravity is high, it could indicate dehydration. However, other factors such as medication use can also impact urine-specific gravity, so it is important to consider other signs and symptoms as well. Checking pupillary reactions, deep tendon reflexes, and compensatory changes in respirations may not necessarily be good indicators of dehydration.

Question 13

An older adult with peripheral neuropathy has been self-medicating with magnesium supplements. The nurse realises that which of the following symptoms can indicate hypermagnesaemia?

Accepted Answer

Hypermagnesaemia can cause hypotension, warmth and sweating as magnesium causes vasodilation and decreased cardiac output. Increased deep tendon reflexes and paraesthesias are symptoms of hypomagnesaemia. Tachycardia is not a common symptom in hypermagnesaemia.

Question 14

An older adult comes into the clinic complaining of watery diarrhoea for several days with abdominal and muscle cramping. The nurse realises that this person could be experiencing: which condition?

Accepted Answer

The combination of watery diarrhoea, abdominal and muscle cramping suggests a loss of fluids and electrolytes, especially sodium. Hyponatraemia is a condition where there is a low concentration of sodium in the blood, which can lead to symptoms such as diarrhoea, cramps, and weakness. Therefore, hyponatraemia is the best choice for this scenario.

Question 15

A postoperative person with a fluid volume deficit is prescribed progressive ambulation, yet is weak from the inadequate fluid status. What can the nurse do to help this person?

Accepted Answer

Assisting the person to move into different positions in stages is the best choice to help this person. The nurse can gradually progress the person from lying down to sitting up, and then to standing, while monitoring their tolerance and vital signs closely. This approach will help the person to gradually increase their physical activity without overwhelming their weakened state. The other options are not appropriate because a walker may not be necessary, maintaining a standing position may be too strenuous, and bed rest may not be appropriate for a postoperative person who needs to mobilize.

Question 16

A person who is taking digoxin (Lanoxin)is admitted with a low serum potassium level. Which of the following does the nurse realise might occur with this person?

Accepted Answer

Hypokalemia (low serum potassium) can potentiate the effects of digoxin, increasing the risk of digoxin toxicity. It is important to monitor serum potassium levels in patients taking digoxin and adjust the dosage as necessary to avoid toxicity. Choices B and C may be possible consequences of hypokalemia but are not directly related to digoxin use. Choice D is not recommended as increasing the dosage of digoxin in the presence of hypokalemia can further increase the risk of toxicity.

Question 17

An older adult with a history of sodium retention arrives at the clinic complaining of 'missed heartbeats' and leg tremors. Which of the following should the nurse ask this person regarding these symptoms?

Accepted Answer

The older adult has a history of sodium retention, and using a salt substitute can increase sodium intake and worsen the retention. Missed heartbeats and leg tremors are potential signs of hypernatremia (high sodium levels).

Question 18

A person is admitted with burns over 50% of his body. The nurse realises that this person is at risk of which of the following electrolyte imbalances?

Accepted Answer

Burn injuries cause an increase in phosphate loss due to damaged cells and tissues, leading to hypophosphataemia. The other options are not typically associated with burn injuries.

Question 19

An elderly person who is being medicated for pain had an episode of incontinence. What is this person at risk of developing?

Accepted Answer

Dehydration can occur in elderly individuals who experience incontinence, as they may limit their fluid intake to avoid further episodes, leading to inadequate hydration.

Question 20

The nurse assesses a person's recent weight loss as being 10 kilograms. How many litres of fluid did this person lose? ____________

Accepted Answer

The answer of The nurse assesses a person's recent weight...

Quiz 9: Nursing Care of People With Altered Fluid, Electrolyte, Acid-Based Balance