Exam 3 Chapter 38 Fluid, Electrolyte, and Acid-Base Balance

The nurse is caring for a client diagnosed with chronic heart failure. The nurse understands that the client is at risk of developing extracellular fluid volume excess. Which clinical findings would the nurse observe in this client? Select all that apply.

A Ankle edema

B Postural hypotension

C Overnight weight loss

D Overnight weight gain

E Neck veins full when upright

A,D,E

Which food item does the nurse include in the diet plan of a patient with magnesium deficiency?

A Milk

B Broccoli

C Brazil nuts

D Dark-green leafy vegetables

D

A client with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first?

A Serum albumin

B Serum sodium

C Hematocrit

D Serum potassium

D

Which client being cared for by the nurse is at the highest risk of developing respiratory acidosis?

A A client with hypokalemia

B A client with pulmonary fibrosis

C A client with salicylate overdose

D A client with chronic obstructive pulmonary disease (COPD)

D

The nurse is caring for a client who has an accumulation of fluid in the pleural cavity. The nurse understands that this fluid is transcellular fluid secreted by epithelial cells. Which bodily fluids are examples of transcellular fluids? Select all that apply.

Serum

Plasma

Peritoneal fluid

Synovial fluid

Cerebrospinal fluid

C,D,E

As the nurse is assessing the caseload of clients for the day, which of the clients would she expect to be at the highest risk of developing dehydration?

A A 78-year-old client with dementia

B A 47-year-old client with hyperthyroidism

C A 53-year-old client with pulmonary embolism

D A 32-year-old client with a respiratory infection

A

A client with blood type A is in need of packed red cells on an emergency basis, but none of the donors of this type are available. How can the nurse provide better health care to the client?

A Arrange to provide red blood cells of group O

B Arrange to provide red cells of group AB

C Arrange for an autologous blood transfusion

D Wait until the donor of blood type A becomes available

A

The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate do you program into the infusion pump?

A 125 mL/hr

B 167 mL/hr

C 200 mL/hr

D 1000 mL/hr

B

A client with blood type O needs platelets. How should the nurse choose a donor for platelet transfusion?

Rh compatibility is excluded

Donor can be of any blood group

Donor should be of blood group O

Donor can be exempted from screening for infections

C

While performing a general examination of a client, the nurse finds that the client is positive for Chvostek's sign, Trousseau's sign, and has tetany. Which electrolyte disturbance is responsible for this clinical presentation?

A Hypokalemia

B Hyponatremia

C Hypocalcemia

D Hypermagnesemia

C

A client has extracellular volume deficit due to diarrhea. How does the nurse correct the volume deficit in the client?

A Provide caffeinated fluids.

B Provide low-sodium fluids.

C Provide fluids that contain lactose.

D Provide fluids that contain sodium

D

How much fluid is lost daily through feces in a healthy adult? Record your answer using a whole number. __________ mL

100

While receiving a blood transfusion, your client develops chills, tachycardia, and flushing. What is your priority action?

A Notify a health care provider.

B Insert an indwelling catheter.

C Alert the blood bank.

D Stop the transfusion

D

Which of the following defining characteristics is consistent with fluid volume deficit?

A A 1-lb (0.5 kg) weight loss in one week, pale yellow urine

B Engorged neck veins when upright, bradycardia

C Dry mucous membranes, thready pulse, tachycardia

D Bounding radial pulse, flat neck veins when supine

C

What could be a cause of extracellular fluid volume excess?

A Vomiting

B Diarrhea

C Hemorrhage

D Chronic heart failure

D

The nurse is teaching a group of nursing students about the acid-base regulation process. What should the nurse teach the students regarding the excretion of carbonic acid from the body?

A The liver excretes carbonic acid.

B The lungs excrete carbonic acid.

C The kidneys excrete carbonic acid.

D The intestines excrete carbonic acid.

B

A client develops a mild allergic reaction during blood transfusion. How should the nurse manage this allergic reaction?

A Administer sympathomimetics

B Administer corticosteroids

C Administer antihistamines

D Administer vasoconstrictors

C

The nurse finds fresh blood at a venipuncture site in a client and pooling of fluids under the extremity. What should be the immediate nursing action?

A Culture the blood at the venipuncture site.

B Assess for intactness of the IV.

C Start a new line even if the catheter is in place.

D Apply a pressure dressing if the catheter is dislodged.

B

The arterial pH of a client is 7.3. How should the nurse record this pH in the client case record?

A Alkalosis

B Acidosis

C Neutral pH

D Normal pH

B

The nurse is caring for a client who is undergoing intravenous fluid therapy to correct dehydration. What measures should the nurse take to prevent complications related to IV lines? Select all that apply.

Order a nursing assistant to regulate intravenous flow.

A Inspect intravenous site and check for client complaints.

B Review the type and amount of intravenous fluid ordered.

C Perform hand hygiene when handling intravenous devices.

D Plan for intravenous therapy at any preferred rate for all clients.

B,C,D

Which of the following activities can you delegate to nursing assistive personnel (NAP)? Select all that apply.

A Measuring oral intake and urine output

B Preparing intravenous (IV) tubing for routine change

C Reporting an IV container that is low in fluid

D Changing an IV fluid container

E Reporting an electronic infusion device alarm

A,C,E

When caring for a client undergoing intravenous therapy, the nurse observes redness and swelling around the IV catheter insertion site. A purulent drainage is also present. What immediate actions should the nurse perform? Select all that apply.

A Apply pressure to the dressing over the site.

B Raise the head of the bed and administer oxygen.

C Remove the catheter and preserve for culture.

D Start a new intravenous line in another extremity.

E Clean the site with alcohol and apply sterile dressing.

C,D,E

Your client had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record?

A 700 mL

B 900 mL

C 1000 mL

D 1100 mL

C

The nurse is reviewing the arterial blood gas report of a client. Which is correct regarding partial pressure of carbon dioxide (PaCO2)?

A PaCO2 is a measure of how well the lungs are excreting CO2.

B PaCO2 is a measure of how well the kidneys are excreting metabolic acids.

C PaCO2is a measure of how well gas exchange is occurring in the lungs.

D PaCO2 is the ability of hemoglobin to carry as much O2 as possible.

A

The nurse is assessing the risk factors for fluid and electrolyte imbalance in a client. Which factors causing extracellular volume deficit should the nurse evaluate? Select all that apply.

A Diarrhea

B Vomiting

C Heart failure

D Nasogastric suctioning

A,B,E

A client who has not been eating for more than a week presents with abdominal pain. On examination, the client is found to be confused and disoriented. Which metabolic event is most likely responsible for such presentation?

A Metabolic acidosis

B Metabolic alkalosis

C Respiratory acidosis

D Respiratory alkalosis

A

A client who has an intravenous line has pain at the access site associated with erythema, edema, red streaks, and a palpable vein. What grade does the nurse assign while entering the phlebitis grade in the client's record?

A Grade 1

B Grade 2

C Grade 3

D Grade 4

C

Why are older adults prone to dehydration?

A They sweat more in hot weather.

B Their lungs evaporate more water during respiration.

C The ability of their kidneys to concentrate urine decreases.

D Water absorption from their GI tract decreases.

C

A client who was started on intravenous (IV) fluids to correct dehydration develops shortness of breath. On auscultation, the nurse finds crackles in the dependent portion of the lungs and dependent edema. Which interventions are appropriate in correcting the fluid and electrolyte imbalance in the client? Select all that apply.

A Aspirate fluid from lungs

B Reduce the IV flow rate

C Elevate the foot end of bed

D Notify the primary health care provider

E Administer diuretics if prescribed

B,D,E

A nurse is advised to administer hyperosmolar solution to a client. How should the nurse administer the solution to the client?

A Use central IV catheter.

B Use peripheral IV catheter.

C Use gastrostomy tube.

D Use jejunostomy tube

A

The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid?

A Flat neck veins

B Tachycardia

C Hypotension

D Oliguria

D

The nurse works in an acute care facility. Which clients should the nurse monitor for development of hypokalemia? Select all that apply.

A Clients with adrenal insufficiency

B Clients with end-stage renal disease

C Clients with diarrhea

D Clients with vomiting

E Clients using potassium-wasting diuretics

C,D,E