Question 1

The nurse is planning care for a patient with severe burns. What condition should the nurse realize that this patient could develop?

Accepted Answer

A

Question 2

A patient is diagnosed with hypokalemia. After reviewing the patient's current medications, which drug should the nurse consider that might have contributed to the patient's health problem?

Accepted Answer

A

Question 3

The nurse is planning care for a patient with fluid volume overload and hyponatremia. What should be included in this patient's plan of care?

Accepted Answer

Restricting fluids is important in managing fluid volume overload and hyponatremia to prevent further dilution of sodium levels in the body.

Question 4

The nurse is caring for a patient diagnosed with hypocalcemia. What additional assessments should the nurse include when caring for this patient?

Accepted Answer

Hypocalcemia is often associated with other electrolyte disturbances such as hypomagnesemia or hypokalemia. It is important for the nurse to assess for and monitor for these imbalances in order to effectively manage the patient's condition. Hypertension, visual disturbances, and drug toxicity are not typically associated with hypocalcemia.

Question 5

The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?

Accepted Answer

Patients with bulimia may induce vomiting, causing loss of stomach acid and leading to metabolic alkalosis. Patients on dialysis, with venous stasis ulcer, and COPD are not specifically at increased risk for metabolic alkalosis.

Question 6

The nurse is analyzing an arterial blood gas report of a patient with COPD and respiratory acidosis. Through which mechanism should the nurse expect compensation to occur?

Accepted Answer

Compensation for respiratory acidosis usually occurs through the kidneys retaining bicarbonate. This occurs in order to neutralize the excess acid in the blood that is caused by the accumulation of carbon dioxide in the lungs. Retention of bicarbonate by the kidneys increases the pH of the blood, which helps to offset the effects of respiratory acidosis. The other options (B, C, and D) are not mechanisms of compensation in respiratory acidosis.

Question 7

The nurse assesses a patient's weight loss as being 22 lbs. How many liters of fluid did this patient lose?

Accepted Answer

The answer of The nurse assesses a patient's weight loss...

Question 8

A patient is receiving intravenous fluids postoperatively following cardiac surgery. On which potential postoperative complication should the nurse focus the assessment of this patient?

Accepted Answer

The administration of intravenous fluids can potentially cause fluid volume excess, which can lead to complications such as pulmonary edema, congestive heart failure, and electrolyte imbalances. For this reason, the nurse should focus on assessing the patient for signs and symptoms of fluid overload, such as edema, shortness of breath, and decreased urine output. Seizure activity and liver failure are not commonly associated with postoperative fluid administration.

Question 9

A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which electrolyte imbalance?

Accepted Answer

Spironolactone is a potassium-sparing diuretic that can often lead to hyperkalemia, which can cause ECG changes and muscle weakness.

Question 10

A patient is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the patient is receiving this replacement is

Accepted Answer

Potassium plays a critical role in regulating acid‒base balance in the body.

Question 11

An elderly patient does not complain of thirst. What should the nurse do to assess that this patient is not dehydrated?

Accepted Answer

Monitoring the patient's serum osmolality level can help assess for dehydration, as changes in this level can indicate shifts in fluid balance. Simply asking for an order for intravenous fluid replacement or diagnostic tests like a chest x-ray or brain scan is not appropriate without first assessing the patient's hydration status. The patient's lack of thirst may not necessarily indicate dehydration, as elderly patients may become less sensitive to thirst signals.

Question 12

The nurse is caring for a patient diagnosed with renal failure. What should the nurse recognize as compensation for the acid‒base disturbance found in patients with renal failure?

Accepted Answer

In renal failure, the kidneys cannot excrete acid effectively, leading to metabolic acidosis. The body compensates by increasing respiratory rate to expel more CO2, reducing acidity.

Question 13

A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volumes should the nurse notify the patient's healthcare provider?

Accepted Answer

Normal urine output for an adult is approximately 0.5 to 1 mL/kg/hr, which translates to about 1200 to 1500 mL per 24 hours for most adults. An output of 600 mL in 24 hours is significantly below normal and could indicate inadequate kidney function or fluid retention, warranting notification of the healthcare provider.

Question 14

The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO₂ 110, PaCO₂ 25, and HCO₃ 2

Accepted Answer

The arterial blood gas (ABG) findings indicate a state of respiratory alkalosis (pH 7.48, PaCO2 25, indicating hyperventilation leading to decreased carbon dioxide levels). Encouraging the patient to breathe in and out slowly into a paper bag can help rebreathe CO2, correcting the alkalosis.

Question 15

A pregnant patient is admitted with excessive thirst and increased urination. For which problem should the nurse focus the care of this patient?

Accepted Answer

Excessive thirst and increased urination are symptoms of hyperglycemia, which is associated with gestational diabetes. The nurse should focus on addressing imbalanced fluid levels in the patient to prevent further complications such as dehydration and electrolyte imbalances.

Question 16

A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. What intervention should the nurse include in this patient's plan of care?

Accepted Answer

Hypophosphatemia is a condition characterized by low levels of phosphorus in the blood. Phosphorus is an essential mineral that plays an important role in bone health and many other physiological processes in the body. Some common causes of hypophosphatemia include malnutrition, alcoholism, and certain medications, such as antacids. In this case, the patient has a history of stomach ulcers, which likely indicates that they have been taking antacids. Aluminum hydroxide antacids can interfere with the absorption of phosphorus, leading to hypophosphatemia. Therefore, the nurse should provide a dietitian consult for selecting foods high in phosphorus to help the patient increase their levels of this essential mineral. Foods high in phosphorus include meats, dairy products, fish, nuts, and seeds.

Question 17

A patient experiencing multisystem fluid volume deficit has tachycardia; pale, cool skin; and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

Accepted Answer

The patient's multisystem fluid volume deficit is likely causing the body's natural compensatory mechanisms to activate, resulting in tachycardia and decreased urine output. Pale, cool skin may also be a result of decreased blood flow due to hypovolemia. The other options are not likely to be the direct cause of these symptoms.

Question 18

The nurse is caring for an older patient who is occasionally confused. What should be the nurse's primary concern regarding fluid and electrolytes when caring for this patient?

Accepted Answer

Confusion in an older patient may increase the risk of dehydration as they may forget to drink fluids or may not be able to communicate their thirst effectively. Therefore, the nurse's primary concern should be to maintain the patient's hydration levels and monitor their fluid and electrolyte balance.

Question 19

An elderly patient who is being medicated for pain had an episode of incontinence. The nurse realizes that this patient is at risk for developing

Accepted Answer

Dehydration can occur in elderly patients who are medicated for pain, especially if they are taking medications that may lead to decreased fluid intake or increased fluid loss, and if the episode of incontinence is not properly managed, leading to further fluid loss.

Question 20

A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need precautions implemented for what event?

Accepted Answer

Severe hyponatremia, or low sodium levels in the blood, can lead to neurological complications such as seizures. Precautions to prevent seizures, such as padding the bed and providing continuous monitoring, may be necessary for this patient. Precautions for infection, neutropenia, or high-risk fall may also be needed depending on the individual patient's situation, but seizures are the most likely immediate concern with severe hyponatremia.

Quiz 10: Nursing Care of Patients With Altered Fluid, Electrolyte, and Acidbase Balance