Chapter 10 Fluid and Electrolytes
1. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic
hormone secretion (SIADH). Your patient's plan of care includes
assessment of specific gravity every 4 hours. The results of this test will allow the nurse to
assess what aspect of the patient's health?
A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status
Ans: D
Feedback:
A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess.
Nutrition, potassium, and calcium levels are not directly indicated.
2. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review
your patient's most recent laboratory reports, you note that the patient's magnesium levels
are high. You should prioritize assessment for which of the following health problems?
A) Diminished deep tendon reflexes
B) Tachycardia
C) Cool, clammy skin D) Acute flank pain Ans: A
Feedback:
To gauge a patient's magnesium status, the nurse should check deep tendon reflexes. If the
reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool,
clammy skin are not typically associated with hypermagnesemia.
,3. You are working on a burns unit and one of your acutely ill patients is exhibiting signs and
symptoms of third spacing. Based on this change in status, you should expect the patient to
exhibit signs and symptoms of what imbalance?
A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia
D) Hypovolemia
Ans: D
Feedback:
Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not
into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels
are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.
4. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the
emergency room. The triage nurse notes upon assessment that the patient is hyperventilating.
The triage nurse is aware that hyperventilation is the most common cause of which acidñbase
imbalance?
A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2
D) CNS disturbances
Ans: B
Feedback:
The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety
can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such
as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS
disturbances are found in extreme hyponatremia and fluid overload.
5. You are an emergency-room nurse caring for a trauma patient. Your patient has the following
arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret
these results?
A) Respiratory acidosis with no compensation
B) Metabolic alkalosis with a compensatory alkalosis
C) Metabolic acidosis with no compensation
D) Metabolic acidosis with a compensatory respiratory alkalosis
, Ans: D
Feedback:
A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes
alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely
corresponds with a decrease in pH, making the metabolic component the primary problem.
6. You are making initial shift assessments on your patients. While assessing one patient's
peripheral IV site, you note edema around the insertion site. How should you document this
complication related to IV therapy?
A) Air emboli
B) Phlebitis
C) Infiltration
D) Fluid overload
Ans: C
Feedback:
Infiltration is the administration of nonvesicant solution or medication into the
surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the
vein. Infiltration is characterized by edema around the insertion site, leakage of
IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a
significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not
indications of infiltration.
7. You are performing an admission assessment on an older adult patient newly admitted for
end-stage liver disease. What principle should guide your assessment of the patient's skin
turgor?
A) Overhydration is common among healthy older adults. B) Dehydration causes the
skin to appear spongy.
C) Inelastic skin turgor is a normal part of aging.
1. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic
hormone secretion (SIADH). Your patient's plan of care includes
assessment of specific gravity every 4 hours. The results of this test will allow the nurse to
assess what aspect of the patient's health?
A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status
Ans: D
Feedback:
A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess.
Nutrition, potassium, and calcium levels are not directly indicated.
2. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review
your patient's most recent laboratory reports, you note that the patient's magnesium levels
are high. You should prioritize assessment for which of the following health problems?
A) Diminished deep tendon reflexes
B) Tachycardia
C) Cool, clammy skin D) Acute flank pain Ans: A
Feedback:
To gauge a patient's magnesium status, the nurse should check deep tendon reflexes. If the
reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool,
clammy skin are not typically associated with hypermagnesemia.
,3. You are working on a burns unit and one of your acutely ill patients is exhibiting signs and
symptoms of third spacing. Based on this change in status, you should expect the patient to
exhibit signs and symptoms of what imbalance?
A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia
D) Hypovolemia
Ans: D
Feedback:
Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not
into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels
are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.
4. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the
emergency room. The triage nurse notes upon assessment that the patient is hyperventilating.
The triage nurse is aware that hyperventilation is the most common cause of which acidñbase
imbalance?
A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2
D) CNS disturbances
Ans: B
Feedback:
The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety
can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such
as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS
disturbances are found in extreme hyponatremia and fluid overload.
5. You are an emergency-room nurse caring for a trauma patient. Your patient has the following
arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret
these results?
A) Respiratory acidosis with no compensation
B) Metabolic alkalosis with a compensatory alkalosis
C) Metabolic acidosis with no compensation
D) Metabolic acidosis with a compensatory respiratory alkalosis
, Ans: D
Feedback:
A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes
alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely
corresponds with a decrease in pH, making the metabolic component the primary problem.
6. You are making initial shift assessments on your patients. While assessing one patient's
peripheral IV site, you note edema around the insertion site. How should you document this
complication related to IV therapy?
A) Air emboli
B) Phlebitis
C) Infiltration
D) Fluid overload
Ans: C
Feedback:
Infiltration is the administration of nonvesicant solution or medication into the
surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the
vein. Infiltration is characterized by edema around the insertion site, leakage of
IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a
significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not
indications of infiltration.
7. You are performing an admission assessment on an older adult patient newly admitted for
end-stage liver disease. What principle should guide your assessment of the patient's skin
turgor?
A) Overhydration is common among healthy older adults. B) Dehydration causes the
skin to appear spongy.
C) Inelastic skin turgor is a normal part of aging.
