Basic Geriatric Nursing, 5th Edition Chapter 06: Maintaining Fluid Balance and Meeting Nutrition Needs Test Bank

Basic Geriatric Nursing, 5th Edition Chapter 06: Maintaining Fluid Balance and Meeting Nutrition Needs Test BankChapter 06: Maintaining Fluid Balance and Meeting Nutrition Needs My Nursing Test Banks Wold: Basic Geriatric Nursing, 5th Edition Chapter 06: Maintaining Fluid Balance and Meeting Nutrition Needs Test Bank MULTIPLE CHOICE 1. The nurse explains that the lowest recommended daily caloric intake to meet nutritional needs of the older adult safely is calories. a. 1000 b. 1200 c. 1400 d. ANS: B 1800 The minimal caloric intake for the older adult that will meet nutritional needs of the older adult is 1200 calories. 2. The 65-year-old woman brags that by using the MyPyramid guidelines for nutrition, she has lost 15 lb. The nurse reminds her that in order to maintain the weight loss, she must be physically active for minutes a day. a. 15 to 20 b. 20 to 30c. 30 to 40 d. 40 to 60 ANS: D According to the guidelines of MyPyramid, an activity period of 40 to 60 minutes a day is necessary to maintain weight loss. 3. The nurse recommends that the older man eat chicken and fish because these are complete proteins, which have: a. some molecules of carbohydrate. b. all the essential amino acids. c. high fat content. d. soluble fiber. ANS: B Fish and lean chicken have all the essential amino acids and very little fat content, unlike red meat. 4. The nurse explains that high-density lipoproteins (HDLs), the so-called healthy fats, are made up of: a. mainly proteins. b. mostly triglycerides. c. mainly cholesterol. d. a variety of minerals.ANS: A HDLs are made up primarily of proteins, as opposed to lipids such as triglycerides, which are found in very-low-density lipoproteins (VLDLs) and cholesterol, which is found in low-density lipoproteins (LDLs). 5. The nurse points out that the nonhealing pressure ulcers and decreasing visual acuity in a patient on a fat-restricted diet may be related to the patients impaired ability to metabolize vitamin: a. A. b. B6. c. B12. d. C. ANS: A Vitamin A is a fat-soluble vitamin and helps with wound healing and night vision acuity. Persons on low-fat diets may not be able to metabolize vitamin A from food sources because of the decreased fat in their diet. 6. The home health nurse does an ongoing assessment of the patient who has had a subtotal gastrectomy for evidence of a deficiency in vitamin: a. A. b. B6. c. B12. d. C. ANS: CVitamin B12 is generated from the digestion of protein in the stomach. If part of the stomach is gone (gastrectomy), there is less digestive potential for vitamin B12. 7. The nurse giving an iron preparation in capsule form will improve its absorption by giving the patient extra: a. orange juice. b. milk products. c. water. d. caffeine drinks. ANS: A Vitamin C improves the absorption of iron. 8. The nurse caring for the older adult patient who is taking a diuretic for control of hypertension should monitor the patient closely for signs of: a. hypokalemia. b. hypocalcemia. c. hyponatremia. d. hyperkalemia. ANS: A Diuretics deplete the body of potassium, a necessary mineral.9. The older adult patient in an extended-care facility has a pressure ulcer. The nurse would encourage wound healing by increasing the patients intake of zinc from food sources such as: a. meat. b. citrus fruit. c. green leafy vegetables. d. complex carbohydrates. ANS: A Meat, nuts, and shellfish are dietary sources of zinc. 10. The nurse is aware that older adults need a minimum daily fluid intake of mL. a. 1000 b. 2000 c. 3000 d. ANS: B 4000 The minimum daily fluid requirement is 2000 mL/day. 11. Older adults who consume excessive amounts of alcohol put themselves at risk for nutritional deficits because alcohol: a. decreases blood glucose levels.b. alters the function of some minerals. c. interferes with the absorption of nutrients. d. increases the metabolism. ANS: C Excessive intake of alcohol interferes with the absorption of nutrients because of changes in the stomach lining. 12. The nurse in a retirement center who is selecting a main dish from the residents menu for an Orthodox Jewish man would select: a. crab cakes with white sauce. b. lamb chops with mint jelly. c. ham steak with red gravy. d. pork chops with cranberries. ANS: B Shellfish and pork are not permitted in the diet of Orthodox Jewish persons. 13. The nurse takes into consideration that the patient who would need higher caloric intake would be the patient with a condition such as: a. bacterial pneumonia. b. osteoporosis. c. arthritis. d. stroke.ANS: A Persons with infections require a higher caloric intake. 14. The nurse explains that most older adults need only about 50 g of protein daily, which is equivalent to approximately lb. a.1 b. c. d. ANS: D There are approximately 450 g in a pound, so 50 g is roughly equivalent to lb, essentially the weight of one thin hamburger patty. 15. The nurse instructing the older man in the use of MyPyramid points out that he should eat cup(s) of fruit a day. a. b. 1 c. d. 2 ANS: D The MyPyramid guidelines recommend eating 2 cups of fruit daily.16. While instructing the patient who is to take oral iron supplements, the nurse indicates that: a. supplements should be taken between meals on an empty stomach. b. medication should be drunk from a nonmetal glass. c. the color of the stool will change to dark green or black. d. constipation is likely to occur. ANS: C Iron supplements can color the stool a dark green or black. Iron should be taken with a meal to reduce gastrointestinal irritation. The preparation should be taken through a straw. The supplement might cause diarrhea. 17. When the nurse weighs an edematous patient with congestive heart failure, the weight increase from yesterday is 2.2 lb. The nurse assesses that this patient has retained of fluid. a. 500 mL b. 1 L c. 1500 mL d. 2 L ANS: B The weight gain of 2.2 lb (1 kg) is equal to 1 L of fluid retention.18. The nurse encourages a group of extended care residents to sit out on the sunny patio for an hour a day during the afternoon in order to help them with the synthesis of vitamin: a. A. b. B12. c. D. d. K. ANS: C Exposure to the sun allows the skin to synthesize vitamin D, which is required for calcium absorption. 19. What is the caloric value (in calories per gram [cal/g]) of protein? a. 9 cal/g b. 4 cal/g c. 0 cal/g d. 7 cal/g ANS: B Proteins yield 4 cal/g. 20. What is the caloric value of alcohol? a. 9 cal/g b. 4 cal/gc. 0 cal/g d. 7 cal/g ANS: D Alcohol yields 7 cal/g. 21. What is the caloric value of vitamins? a. 9 cal/g b. 4 cal/g c. 0 cal/g d. 7 cal/g ANS: C Vitamins yield no calories. 22. What is the caloric value of fat? a. 9 cal/g b. 4 cal/g c. 0 cal/g d. 7 cal/g ANS: A Fats, which can come from either plant sources or animal sources, yield 9 cal/g. MULTIPLE RESPONSE1. The nurse takes into consideration the factors that influence nutritional needs, which include . (Select all that apply.) a. bone density b. gender c. climate d. presence of illness e. body temperature ANS: B, C, D, E Bone density is not a factor, but all other options are factors that have a significant effect on nutritional needs. 2. The nurse uses a chart to show the vital nutrients required by all persons, which are . (Select all that apply.) a. carbohydrates b. proteins c. vitamins and minerals d. fats e. electrolytes ANS: A, B, C, D Electrolytes are not nutrients, but all other listed options are considered essential nutrients.3. The nurse encourages older adults to include complex carbohydrates such as vegetables and fruits in their diet because complex carbohydrates contain . (Select all that apply.) a. minerals b. fats c. vitamins d. soluble fiber e. polysaccharides ANS: A, C, D, E No fat is contained in complex carbohydrates. 4. The nurse is aware that older adults who do not take in adequate fluids are at risk for . (Select all that apply.) a. altered absorption of drugs b. digestive disorders c. constipation d. bleeding disorders e. reduced appetite ANS: A, B, C, E Bleeding disorders are not associated with inadequate intake. All other options are problems associated with a fluid deficit.5. Older adults plagued with chronic health problems may become undernourished because they . (Select all that apply.) a. are too fatigued to prepare meals b. become frustrated when attempting to open packaging c. may be unable to carry groceries any distance d. have no interest in eating out due to health issues e. lack stamina to shop for groceries ANS: A, B, C, E Having no interest in eating out is not going to cause the older adult to be malnourished. Lack of interest in eating or socialization due to a chronic health problem can cause the older adult to be malnourished. All the other options listed can result in the older adult being malnourished. 6. The home health nurse is painfully aware that older adults living independently have many barriers to providing themselves with adequate nutrition, which include . (Select all that apply.) a. difficulty chewing b. lack of transportation to shop c. use of quick frozen meals d. lack of motivation to cook e. sensory changes ANS: A, B, D, EThe availability of quick frozen foods, which are easy to prepare, offer a source of better nutrition to the older adult. 7. An older adult who is a resident in an extended-care facility is at risk for nutritional deficits related to . (Select all that apply.) a. repetitive nature of meals b. lack of culturally significant food c. environmental odors d. reaction to being fed by others e. non-nutritious food choices ANS: A, B, C, D Although the food is nutritious, the repetitive nature of the menu, the lack of culturally significant food, and environmental concerns alter the motivation to have adequate intake. 8. The nurse suggests to the older adult that sources of protein that are less expensive than meat include . (Select all that apply.) a. corn b. beans c. whole-grain foods d. cheese e. nuts ANS: B, C, D, ECorn is not a source of protein. 9. The nurse cautions the older adult against taking excess vitamin supplements because some vitamins can be retained in fatty tissue and cause liver damage, including vitamin(s) . (Select all that apply.) a. A b. B6 c. C d. D e. E ANS: A, D, E Excess fat-soluble vitamins A, D, and E can be retained in fatty tissue and result in hepatic damage. Chapter 39. Fluids, Electrolytes, & Acid-Base Balance My Nursing Test Banks Chapter 39. Fluids, Electrolytes, & Acid-Base Balance Multiple ChoiceIdentify the choice that best completes the statement or answers the question. 1. Which body fluid lies in the spaces between the body cells? 1) Interstitial 2) Intracellular 3) Intravascular 4) Transcellular ANS: 1 Extracellular fluid lies outside the cells. It is composed of three types of fluid: interstitial, intravascular, and transcellular. Interstitial fluid lies in the spaces between the body cells. Intracellular fluid is contained within the cells. Intravascular fluid is the plasma within the blood. Transcellular fluid includes specialized fluids, such as cerebrospinal, pleural, peritoneal, and synovial; and digestive juices. 2. Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles and why? 1) Cations, because they carry a positive charge3. A patient is brought to the emergency department (ED) by paramedics 2) Cations, because they carry a negative charge 3) Anions, because they carry a positive charge 4) Anions, because they carry a negative charge ANS: 4 Anions are electrolytes that carry a negative charge; they include chloride, bicarbonate, phosphate, and sulfate. Electrolytes that carry a positive charge are called cations. Cations include sodium, potassium, calcium, and magnesium. after a person standing on the sidewalk saw him fall on a crowded street. He has a history of alcoholism and is frequently brought to the ED. The nurse finds the patient to be disoriented; he has periods of being calm mixed with episodes of being disruptive and loud. His vital signs are the following: BP 138/84 mm Hg; pulse 135 beats/min, regular and strong; respiratory rate 22 breaths/min; temperature 37.1C (98.1F). What electrolyte imbalance might the nurse suspect? 1) Hypomagnesemia 2) Hypocalcemia 3) Hyperkalemia4) Hypernatremia ANS: 1 Hypomagnesemia is a frequent consequence of alcoholism. Signs and symptoms include disorientation, mood changes, and tachycardia. Hypocalcemia, a low calcium level, is associated with muscle spasms and tetany. Hyperkalemia, a high potassium level, manifests as weakness, fatigue, and cardiac dysrhythmias. Hypernatremia, a high sodium level, produces extreme thirst and agitation. PTS:1DIFifficultREF:p. 1392 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis 4. The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following? 1) Osmosis 2) Filtration 3) Hydrostatic pressure 4) Diffusion ANS: 4 Diffusion is a passive process by which molecules move from an area of higher concentration to an area of lower concentration. Osmosis is the movement of water across a membrane from an area of a less-concentrated solution to an area of more-concentrated solution. Filtration is the movement of water andsmaller particles from an area of high pressure to low pressure. Hydrostatic pressure is the force created by fluid within a closed system. 5. A client is admitted to the emergency department (ED) in respiratory distress. The results of his arterial blood gases are the following: pH = 7.30; PCO2= 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse interprets the findings as which of the following? 1) Respiratory acidosis with normal oxygen levels 2) Respiratory alkalosis with hypoxia 3) Metabolic acidosis with normal oxygen levels 4) Metabolic alkalosis with hypoxia ANS: 3 The pH is acidotic. The HCO3 of 19 mEq/L is low and has moved in the same direction as the pH, indicating a metabolic disorder. The PCO2 is within normal range with no signs of compensation. The PO2 level is normal. 6. A patient is admitted to the emergency department (ED) in respiratory distress. The results of his first arterial blood gases were: pH = 7.30; PCO2= 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse evaluates the patients treatment plan by examining repeat arterial blood gases (ABGs). The results are: pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/L. The nurse concludes which of the following? 1) Respiratory acidosis; the treatment plan is ineffective. 2)Metabolic alkalosis; the treatment plan is effective. 3) Partial compensation; the treatment plan is ineffective. 4) Full compensation; the treatment plan is effective. ANS: 4 Full compensation has occurred as the PCO2 has returned the pH to the normal range. This change indicates that the treatment plan is effective. Partial compensation would be indicated by changes in the PCO2, but the pH would still be outside the normal range. The ABG is now complete compensation metabolic acidosis. 7. When a patient has metabolic acidosis, which body system influences the acidbase imbalance to produce the compensatory changes in the arterial blood gases? 1) Respiratory system 2) Renal system 3) Vascular system 4) Neurological system ANS: 1 In a metabolic problem, the respiratory system compensates. In a respiratory problem, the renal system must compensate. The respiratory systemcompensates early in the disorder, but it may take up to 3 days for the renal system to compensate fully. PTS:1DIF:ModerateREF:p. 1394 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 8. A patients arterial blood gas results are as follows: pH = 7.30; PCO2= 40; HCO3 = 19 mEq/L; PO2 = 80. An appropriate nursing diagnosis for the patient is which of the following? 1) Impaired Gas Exchange 2) Metabolic Acidosis 3) Risk for Impaired Gas Exchange 4) Risk for Acid-Base Imbalance ANS: 1 An appropriate diagnosis is Impaired Gas Exchange. The arterial blood gas (ABG) results provide the defining characteristics for Impaired Gas Exchange. The ABG results demonstrate metabolic acidosis; however, this is not a nursing diagnosis. The patient has an actual problem; therefore, the risk for nursing diagnoses are incorrect. Additionally, there is no nursing diagnosis of AcidBase Imbalance or Risk for AcidBase Imbalance. PTS:1DIF:ModerateREF:p. 1401 KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: AnalysisRestricting the oral intake of a patient with hypernatremia (Na+ greater than 145 mEq/L) would lead to further elevation in the serum sodium level. Infusing D5W 9. The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the clients electronic health record. Which one should the nurse question? 1) Administer an IV of D5W at 125 mL/hr. 2) Strict I&O monitoring. 3) Restrict oral intake to 900 mL every 24 hr. 4) Monitor serum electrolytes every 4 hr. ANS: 3 IV fluid is appropriate, as this solution does not contain sodium. Hydrating the patient with D5W would reduce the serum sodium level. Strict I&O monitoringand laboratory evaluation of electrolytes every 4 hr would ensure that the patient is safely rehydrated. 10. Which process requires energy to maintain the unique composition of extracellular and intracellular compartments? 1) Diffusion 2) Osmosis 3) Filtration 4) Active transport ANS: 4 Active transport occurs when molecules move across cell membranes from an area of low concentration to an area of high concentration. Active transport requires energy expenditure for the movement to occur against a concentration gradient. In the presence of ATP, the sodiumpotassium pump actively moves sodium from the cell into the extracellular fluid. Active transport is vital formaintaining the unique composition of both the extracellular and intracellular compartments. Diffusion, osmosis, and filtration are passive processes. 11. The nurse records a patients hourly urine output from an indwelling catheter as follows: 0700: 36 mL 0800: 45 mL 0900: 85 mL 1000: 62 mL 1100: 50 mL 1200: 48 mL 1300: 94 mL 1400: 78 mL 1500: 60 mL The nurse can conclude that the patients urine output should be described as which of the following? 1) Low 2) Within normal limits 3)High 4) Inconclusive ANS: 2 Urine accounts for the greatest amount of fluid loss. Normal urine output for an average-sized adult is approximately 1,500 mL in 24 hr. Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour. The patients urine output is within the normal range. This patient has an indwelling catheter, which will result in continual flow of urine. PTS:1DIF:ModerateREF:p. 1385 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis 12. Which of the following is the principal site for regulation of fluid and electrolyte balance? 1) Cardiac system 2) Vascular system 3) Pulmonary system 4) Renal system ANS: 4 A balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or deficits can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluidoutput. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the bodys fluid and electrolyte balance. The heart and vascular system are involved in fluid balance but not in electrolyte balance and not as dramatically in fluid balance as are the kidneysthat is, they do not actually regulate electrolytes. The pulmonary system plays a major role in regulation of acidbase balance. 13. Which electrolyte is the primary regulator of fluid volume? 1) Potassium 2) Calcium 3) Sodium 4) Magnesium ANS: 3 Sodium is the major cation in the extracellular fluid (ECF). Its primary function is to regulate fluid volume. When sodium is reabsorbed in the kidney, water and potassium are also reabsorbed, thereby maintaining ECF volume. Potassium is a key electrolyte in cellular metabolism. Calcium is responsible for bone health and neuromuscular and cardiac functions. It is also an essential factor in bloodclotting. Magnesium is a mineral used in more than 300 biochemical reactions in the body. 14. An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6F (37.6C) orally; P = 110 beats/min weak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/LBUN 29 mg/dL The nurse recognizes that the patient is displaying symptoms associated with which of the following? 1) Hypovolemia 2) Hypervolemia 3) Hypernatremia 4) Hyponatremia ANS: 1 Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss through urine, skin, or the gastrointestinal tract; insensible losses; or loss of fluid into a third space. The first symptom of hypovolemia is thirst. Other symptoms are a rapid weak pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and mucous membranes, decreased skin turgor, and decreased urine output. Temperature increases because the body is less able to cool itself through perspiration. The person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and hematocrit levels. Hypervolemia involves excessive retention of sodium and water in the extracellular fluid, and the vital sign changes are opposite those of a patient with hypovolemia. Hypernatremia and hyponatremia are not applicable because the patients sodium level is within normal range. 15. A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6F (37.6C) orally; P = 110 beats/minweak and thready; BP = 80/52 mm Hg. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results: Sodium 138 mEq/L Potassium 3.7 mEq/L Calcium 9.2 mg/dL Magnesium 1.8 mg/dL Chloride 99 mEq/L BUN 29 mg/dL Which of the following is an appropriate nursing diagnosis for this patient? 1) Impaired Gas Exchange related to ineffective breathing 2) Excess Fluid Volume related to limited fluid output 3) Deficient Fluid Volume related to abnormal fluid loss 4) Electrolyte Imbalance related to decreased oral intake ANS: 3Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume. There is no information to indicate that she has respiratory problems or Impaired Gas Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte Imbalance is not a nursing diagnosis. 16. Which of the following is the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume? 1) Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive orientation 2) Electrolyte balance restored, as evidenced by sodium returning to normal range 3) Patient demonstrates effective coughing and deep breathing techniques. 4) Maintains fluid balance, as evidenced by moist mucous membranes and urinating every 4 hours ANS: 4 Moist mucous membranes and urinating every 4 hours would demonstrate restoration of fluid balance. Electrolyte imbalance does not necessarily occur with Deficient Fluid Volume; if electrolyte imbalance were present, the nursing diagnosis would be different. There is no evidence that this patient has a respiratory problem, so coughing and deep breathing are irrelevant. 17. Which laboratory results on a clients health record should alert the nurse to a potential problem? 1) Na+ = 137 mEq/L2) K+ = 5.2 mEq/L 3) Ca2+ = 9.2 mg/dL 4) Mg2+ = 1.8 mg/dL ANS: 2 A potassium level of 5.2 mEq/L indicates hyperkalemia. The other results are all within normal ranges. 18. A patients vital signs prior to a blood transfusion were: T = 97.6F (36.4C); P = 72 beats/min; R = 22 breaths/min; and BP = 132/76 mm Hg. Twenty minutes after the transfusion was begun, the patient began complaining of feeling itchy and hot. The nurse discovered a rash on the patients trunk. Vital signs were: T = 100.8F (38.2C); P = 82 beats/min; R = 24 breaths/min; BP = 146/88 mm Hg. Based on these findings, what is the priority intervention? 1) Administer an antihistamine (anti-allergenic) medication. 2) Flush the blood tubing with D5W immediately. 3) Prepare for emergency resuscitation. 4) Stop the blood transfusion immediately. ANS: 4The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected, the infusion should be stopped immediately. The blood bag and tubing must be sent to the laboratory for analysis. A new IV line of normal saline should be hung. Diphenhydramine (an antihistamine) may be ordered once the physician has been notified of the patients condition. There is no information indicating that the patient is in danger of cardiovascular collapse or requires resuscitation. PTS: 1 DIF: Moderate REF: p. 1417 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application 19. A patient is receiving an IV infusion of lactated Ringers solution and 40 mEq of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following? 1) Infiltration 2) Extravasation 3) Hematoma 4) Phlebitis ANS: 4 Phlebitis is an inflammation of the vein. It may be caused by the infusion of solutions that are irritating to the vein. Patients receiving IV solutions with potassium chloride are at a higher risk for phlebitis, as it is irritating to the vein.The symptom of a palpable cord along the vein distinguishes this as phlebitis. Infiltration presents as erythema, pain, and swelling. However, there is no palpable cord with inflammation. Extravasation is infiltration of a vesicant substance into the tissues. Differentiating symptoms include blanching and coolness of the surrounding skin; the formation of blisters and subsequent tissue sloughing and necrosis are later signs. A hematoma is a localized mass of blood outside the blood vessel. This is generally seen when a vein is nicked during an unsuccessful insertion of an IV line or when an IV line is discontinued without pressure applied over the site. 20. The nurse assesses that her patients intravenous solution has infiltrated into the tissues. What action should she take first? 1) Aspirate, then inject 0.5 mL normal saline. 2) Restart the IV line in a different vein. 3) Stop the infusion immediately. 4) Notify the primary care provider. ANS: 3 The nurse should first stop the infusion to avoid further tissue trauma. Because the IV has infiltrated, you must assume that the nurse has already checked the patency of the line by aspirating. There is no point in injecting saline because doing so puts even more fluid in the tissues. Injecting fluid to try to clear a clot from the catheter is not recommended because of the possibility of causing an embolism. Once the infusion is stopped, the nurse must assess whether the patient needs additional IV therapy. If so, a new IV line must be restarted above the site of infiltration or in the opposite arm. The nurse may need to inform theprimary care provider if she is unable to find a new IV site or if she believes the patient no longer needs an IV. 21. The physician has ordered a complete blood count for a 6-year-old child. When the nurse enters the room, she finds the child sobbing uncontrollably. His mother tells him to shut up and act your age. How should the nurse proceed? 1) Request that the mother leave the room immediately. 2) Request the help of a coworker to hold the child down. 3) Inform the child that this wont hurt a bit. 4) Calmly approach the child and tell him what is going to happen. ANS: 4 Having blood drawn may be uncomfortable and frightening for a 6-year-old child. A calm approach can alleviate some of the fear. Explain to the childs mother that the boys behavior is normal. Informing the child that the blood draw will not hurt is wrong and will make him distrustful of future interventions. The nurse may need the help of a coworker, but she should first try a calm approach. 22. A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A microdrip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor? 1) 60 2) 753) 125 4) 250 ANS: 3 Calculate the drip rate by multiplying the number of milliliters to be infused per hour (hourly rate) by the drop factor in drops/mL, divided by 60 minutes. An infusion of 250 mL in 2 hours results in an hourly rate of 125 mL/hr. 125 (mL/hr) 60 (drops/mL) = 125 drops/min 60 min 23. The nurse examines the electrocardiogram (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect? 1) Hypokalemia 2) Hypophosphatemia 3) Hyperkalemia 4) Hypercalcemia ANS: 3 Potassium levels affect the heart. A tall, peaked T wave on an ECG is associated with hyperkalemia. A flat T wave is associated with hypokalemia. Phosphorous levels do not trigger ECG changes.24. The nurse gathers the following data: BP = 150/94 mm Hg; neck veins distended; P = 104 beats/min; pulse bounding; respiratory rate = 20 breaths/min; T = 37C (98.6F). What disorder should the nurse suspect? 1) Hypovolemia 2) Hypercalcemia 3) Hyperkalemia 4) Hypervolemia ANS: 4 Hypervolemia results from retention of sodium and water. Blood pressure rises, the pulse is bounding, and neck veins become distended due to increased intravascular volume. 25. A patient has a continuous IV infusion at 60 mL/hr. The right hand IV has infiltrated and the nurse has started a new IV on the left forearm. Which of the following interventions should the nurse also perform? 1) Elevate the patients left forearm. 2) Schedule daily dressing changes to the new IV site. 3) Change the administration set. 4)Place the patient in Fowlers position. ANS: 3 Reusing an IV set from a previous site increases the risk of contamination. IV dressings are usually changed every 72 to 96 hours when the IV site is rotated. There is no reason to elevate the patients left forearm or to place him in Fowlers position. 26. When performing a central venous catheter dressing change, which of the following steps is/are correct? 1) Wear sterile gloves while removing and discarding the soiled dressing. 2) Apply pressure on the catheter-hub junction when removing the soiled dressing. 3) Place a sterile transparent dressing over the site and the catheter-hub junction. 4) Have the patient wear a mask or turn his head away from the site. ANS: 4 Aseptic technique should be used with approaching the insertion site. Therefore, both nurse and patient should wear a mask. If the patient cannot wear a mask, have him turn his head away from the insertion site during the procedure. Sterile gloves should be worn when placing the new sterile dressing; however, procedure gloves are used to remove the soiled dressing. The nurse should stabilize the catheter while removing the soiled dressing but not apply pressure to the catheter-hub junction. The transparent dressing should cover the hub of the catheter, but not the catheter-hub junction; this makes it too difficult to remove without disturbing the integrity of the IV line or the site. Multiple ResponseIdentify one or more choices that best complete the statement or answer the question. 1. In a healthy adult, which of the following regulate(s) body fluids? Choose all that apply. 1) Hormone levels 2) Fluid intake 3) Oxygen saturation 4) Kidney function ANS: 1, 2, 4 A balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. The kidneys are the principal regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the bodys fluid and electrolyte balance. Oxygen saturation does not regulate fluids. It measures the saturation of oxygen on hemoglobin and is influenced by the partial pressure of oxygen, alveolararterial gradient lung disease, and the amount and type of hemoglobin (such as sickle cell anemia). 2. A patient has been admitted to the nursing unit with a diagnosis of chronic renal failure. She will be dialyzed for the first time the following morning. Which of the following are appropriate nursing interventions for the patient? Choose all that apply. 1) Encourage oral fluid intake as desired.2) Place the patient on strict I&O. 3) Weigh the patient before and after dialysis. 4) Maintain a total fluid restriction of 1,000 mL as prescribed. ANS: 2, 3, 4 Fluids are restricted in patients with chronic renal failure because of decreased renal function. Therefore, encouraging oral fluids would not be appropriate. Appropriate nursing interventions for this patient include monitoring the intake and output, weighing the patient before and after dialysis, following a strict renal diet, and monitoring laboratory values. 3. Identify the mechanism(s) involved in acidbase balance. Choose all that apply. 1) Respiratory mechanisms 2) Active transport mechanisms 3) Renal mechanisms 4) Buffer systems ANS: 1, 3, 4 Acidbase balance is regulated by respiratory mechanisms, renal mechanisms, and buffer systems. Acidbase regulation can be monitored by examining arterialblood gases, especially blood pH. Buffer systems prevent wide swings in pH by absorbing or releasing free hydrogen ions. The lungs (respiratory mechanisms) control the carbonic acid supply via carbon dioxide. Conditions that cause retention of carbon dioxide, such as chronic obstruction pulmonary disease, lower the pH, whereas tachypneic conditions, such as hyperventilation syndrome, blow off carbon dioxide and increase the pH. The kidneys (renal mechanisms) regulate the concentration of plasma bicarbonate. By reabsorbing or excreting bicarbonate, the kidneys affect acidbase balance. Active transport involves the movement of fluids and electrolytes in the body. 4. Identify the appropriate intervention(s) for a patient with hypovolemia. Choose all that apply. 1) Teach deep-breathing techniques. 2) Monitor I&O daily. 3) Encourage fluid intake. 4) Monitor electrolyte balance. ANS: 2, 3, 4 Hypovolemia occurs when more fluid is lost than is taken into the body. Monitoring I&O provides information to evaluate the status of the problem. Encouraging fluid intake helps to correct the problem. It is good to monitor electrolytes because electrolyte imbalance can occur with hypovolemia (although it may not occur at first). Deep-breathing techniques do not address fluid balance; there is no evidence that the patient has a respiratory disorder. 5. A patients blood group is B. The nurse knows the patient can receive blood only from donors with what group(s) of blood? Choose all that apply.1) A 2) B 3) O 4) AB ANS: 2, 3 Persons with blood group B can receive blood only from the blood groups B and O. Those with blood group AB may receive AB, A, B, and O blood. Blood group A persons may receive blood from A and O donors. Persons with blood group O may receive blood only from O donors. Blood group AB persons are considered universal recipients, and blood group O persons are considered universal donors. PTS:1DIF:ModerateREF:p. 1416 KEY: Nursing process: Analysis/Diagnosis | Client need: SECE | Cognitive level: Analysis 6. A nurse is caring for a patient with a peripheral IV line located in the right forearm. The patient informs the nurse that the IV site is burning. Upon assessment the nurse determines that the IV solution has infiltrated. What site(s) is/are appropriate to consider when restarting the IV line? Choose all that apply. 1) Left hand 2) Right wrist3) Right antecubital area 4) Right saphenous vein ANS: 1, 3 When restarting an IV line after an infiltration, you must restart above the site of infiltration. As a result, the right antecubital area is correct. The opposite extremity (e.g., left hand) may also be used. The right saphenous vein is incorrect because that vein is located in the leg. The leg should be used as a last resort for an IV site. The primary care provider should be notified if a leg is being considered as an IV site. 7. A patient has been diagnosed with hypovolemia. Which order(s) for hydration should the nurse question? Choose all prescriptions that should be questioned. 1) 0.9% (normal) saline at 100 mL/hr 2) Lactated Ringers solution at 100 mL/hr 3) Total parenteral nutrition solution at 100 mL/hr 4) D5W solution at 100 mL/hr ANS: 3, 4 Hypovolemia occurs when there is a proportional loss of water and electrolytes from the ECF. Lactated Ringers and 0.9% (normal) saline are isotonic fluids that remain inside the intravascular space, thus increasing volume. The D5W is ahypotonic solution that would pull body water from the intravascular compartment into the interstitial fluid compartment. Total parenteral nutrition is a hypertonic fluid used to provide nutrition for the patient who cannot meet caloric needs by eating or enteral nutrition. 8. When assisting with bedside central venous catheter (CVC) placement, which nursing intervention is appropriate? Choose all that apply. 1) Don sterile gloves and mask (and possibly gown). 2) Scrub the insertion site with antibacterial soap for 1 min. 3) Verify that informed consent has been obtained. 4) Place the patient in low Fowlers position. ANS: 1, 3 Maximum barrier sterile technique is used for CVC insertion (sterile gloves, mask, and gown), although some agency policies do not include sterile gown for the nurse. This is an invasive procedure, so informed consent is required. The nurse should confirm that this has been obtained. The scrub is not done with antibacterial soap. The scrub is done with chlorhexidinealcohol solution or, alternatively, first with 70% alcohol and then with povidone detergent. The patient is placed in Trendelenburg position with a rolled towel between the shoulders for best site access. Completion Complete each statement. 1. are substances that develop an electrical charge when dissolved in water.2.A(n) is any compound that contains hydrogen ions that can be released. ANS: acid PTS:1DIF:EasyREF:p. 1389 KEY:Nursing process: N/A | Client need: PHSI | Cognitive level: Recall 3.A(n) is a compound that combines with (accepts) hydrogen ions in a solution. ANS:base alkali Chapter 38. Circulation and Perfusion My Nursing Test Banks Chapter 38. Circulation and Perfusion Multiple Choice Identify the choice that best completes the statement or answers the question. 1. A patient diagnosed with hypertension is taking an angiotensinconverting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the patient? 1) BP will be lower than 135/85 mm Hg on all occasions. 2) BP will be normal after 2 to 3 weeks on medication. 3) Patient will not experience dizziness on rising.4) Urine output will increase to at least 50 mL/hr ANS: 1 Goals must be clearly stated so that it is easy to evaluate if they have been met. BP . . . lower than 135/85 mm Hg . . . is clearly stated and easily evaluated. In contrast, BP will be normal . . . does not clearly state the desired endpoint. Freedom from dizziness on rising is probably not achievable because ACE inhibitors are vasodilating agents, which may cause vessel dilation and hypotension, especially when the patient arises from a seated or lying position. Patients should be warned of this effect. The expected/desired effect of the ACE inhibitor is to lower the blood pressure; the urine output is minimally relevant in determining that outcome, if at all. 2. You are preparing the nursing care plan for a middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate? 1) Decreased Cardiac Output 2) Impaired Tissue Perfusion 3) Impaired Cardiac Contractility 4) Impaired Activity Tolerance ANS: 1The patients symptoms reflect altered cardiac preload, a component of cardiac output. Acute myocardial infarction is often associated with decreased cardiac output as a result of altered cardiac pumping ability. Although the other nursing diagnoses might be associated with Decreased Cardiac Output, these diagnoses cannot be determined from the symptoms presented. Additionally, Impaired Cardiac Contractility is not a NANDA-I nursing diagnosis. 3. You are to connect a patient to a cardiac monitor. Which of the following actions should you take to ensure an accurate electrocardiogram tracing? 1) Select electrode placement sites over bony prominences. 2) Apply the electrodes immediately after cleansing the skin, before the alcohol evaporates. 3) Before applying the electrodes, rub the placement sites with gauze until the skin reddens. 4) Ensure that the gel on the back of the electrodes is dry. ANS: 3 Electrodes should be placed over soft tissues or close to bone in order to obtain accurate waveforms. Sites over bony prominences, thick muscles, and skinfolds can produce artifact; therefore, they should not be used. Alcohol removes skin oils that may prevent the electrodes from adhering. However, the alcohol should be allowed to dry before the electrodes are placed. Rubbing the skin with gauze or a washcloth removes dead skin cells and promotes better electrical contact. A dry electrode will not conduct electrical activity; gel should not be dry. 4. Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?1) Histamine 2) Catecholamines 3) Cortisol 4) Protease ANS: 2 The stress response stimulates release of catecholamines from the sympathetic nervous system. This results in increased heart rate and contractility, vasoconstriction, and increased tendency of blood to clot. Cortisol is also released in the stress response, but it is more indirectly related to development of cardiovascular disease through altered glucose, fat, and protein metabolism. 5. The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the patient comprehends the teaching when she makes the following statement: 1) I may need to drink more fluids in order to make more oxygen. 2) I may need to take an iron supplement so that I am not anemic. 3) I will need a multivitamin supplement for several months. 4) I will need to eat more fruits and vegetables.ANS: 2 During pregnancy, oxygen demand increases dramatically. To compensate, the mothers blood volume increases by 30%. The woman requires additional iron to produce this blood as well as to meet fetal requirements. Failure to meet these iron demands can result in maternal anemia, reducing tissue oxygenation of the mother. 6. Which part of the ECG tracing represents ventricular repolarization? 1) P wave 2) QRS complex 3) T wave 4) U wave ANS: 2 The QRS complex represents ventricular depolarization and leads to ventricular contraction. The P wave represents the firing of the SA node and conduction of the impulse through the atria. In the healthy heart, this leads to atrial contraction. The T wave represents the return of the ventricles to an electrical resting state so they can be stimulated again (ventricular repolarization). The atria also repolarize, but they do so during the time of ventricular depolarization; thus, they are obscured by the QRS complex and cannot be seen on the ECG complex. The U wave is not always seen on the ECG but may be detected with electrolyte imbalance, such as hypokalemia or hypercalcemia. U waves sometimes occur in response to certain medication (e.g., digitalis, epinephrine). Inverted U wave may occur with ischemia to the cardiac muscle. 1. 1)7. Three days ago a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication? 1) Deep vein thrombosis 2) Dehiscence of the wound 3) Internal bleeding 4) Infection at the incisional site ANS: 1 Deep vein thrombosis (DVT) is a clot in the veins that are deep under the muscles of the leg. DVT can occur after surgery, after lengthy bedrest, or after trauma. Symptoms include pain, warmth, redness, and swelling of the leg. Dorsiflexion of the foot (pulling toes forward) and Pratts sign (squeezing calf to trigger pain) have not been found to be reliable in diagnosing DVT. Dehiscence is the rupture of a suture line, whereas evisceration is the protrusion of internal organs through the rupture. Internal bleeding is a wound-healing complication associated with hematoma formation, pain, hypotension, and tachycardia. Infection is a complication of wound healing that causes warmth, pain, inflammation of the affected area, and changes in vital signs (i.e., elevated pulse and temperature).Multiple Response Identify one or more choices that best complete the statement or answer the question. 1. Nursing interventions to reduce the risk of clot formation in the legs include which of the following activities? Choose all that apply. 1) Keep the patients hips and knees flexed while the patient is in bed. 2) Apply compression devices (e.g., sequential compression devices). 3) Turn the patient frequently or encourage frequent position changes. 4) Promote adequate hydration by encouraging oral intake. ANS: 2, 3, 4 A Antiembolism stockings and SCDs are frequently used in perioperative patients to promote venous return and prevent clot formation. Turn patients frequently; teach patients to change positions frequently. This prevents vessel injury from prolonged pressure in one position. Promote adequate hydration to keep the blood from becoming viscous (thick). Viscous blood clots more readily.2. Which of the following medications would you expect to be included in the treatment of a patient with congestive heart failure? Choose all that apply. 1) Nitrates 2) Beta-adrenergic agents 3) Diuretics 4) Anticoagulants ANS: 2, 3 Beta-adrenergic agents block stimulation of beta receptors in the heart, lungs, and blood vessels and decrease heart rate, slow conduction through the AV node, and decrease myocardial oxygen demand by reducing myocardial contractility. Diuretics increase removal of sodium and water from the body through increased urine output. Diuretics reduce the volume of circulating blood and prevent accumulation of fluid in the pulmonary circulation. 3. As the nurse caring for a patient who has suffered a myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Choose all that apply. 1) Decreased heart rate 2)Increased heart rate 3) Decreased cardiac output 4) Decreased strength of ventricular contractions ANS: 1, 3 Normally, the SA node is the primary pacemaker for the heart and initiates a rate of 60 to 100 beats per minute. If the SA node fails, the atrioventricular node can take over as the pacemaker, but it generally triggers a slower heart rate. Cardiac output will decrease as a result of the decrease in heart rate. Damage to the SA node interferes with the electrical activity of the heart but does not directly affect the pumping action of the heart. 4. Which outcome statement is related to Decreased Cardiac Output? Choose all that apply. 1) No dyspnea or shortness of breath with exertion 2) Normal skin color 3) Respiratory rate less than 16 breaths/min 4) Brisk capillary refill ANS: 1, 2, 4 Individualized goals/outcome statements depend on nursing diagnoses you identify for the patient. However, for a patient with compromised cardiac output,you might plan goals, such as no shortness of breath with exertion, brisk capillary refill in nailbeds, and normal skin color with no pallor. Respiratory rate of less than 16 breaths/min is hypoventilation and can lead to poor oxygenation and tissue acidosis. (See Chapter 39 for more information about acidbase balance.) 5. Your client is a healthy, older adult who has come to the health clinic because she reports not feeling like herself. When you are gathering data in your clients health history, she tells you that she is feeling more fatigue when walking up stairs and doing her normal household activities. What normal physiologic changes in the cardiovascular system occur with aging? Choose all that apply. 1) Cardiac contractile strength is reduced. 2) Heart valves become more rigid. 3) Peripheral vessels lose elasticity. 4) Heart responds to increased oxygen demands. ANS: 1, 2, 3 Cardiac efficiency gradually declines as the heart muscle loses contractile strength and heart valves become thicker and more rigid. The peripheral vessels become less elastic, which creates more resistance to ejection of blood from the heart. As a result of these changes, the heart becomes less able to respond to increased oxygen demands, and it needs longer recovery times after responding. True or False Complete each statement.1.Nicotine increases the risk for thrombus (blood clot) formation. ANS: T Nicotine increases the risk for thrombus formation because of its constricting effects on blood vessel walls. PTS: 1 DIF: Easy REF: p. 1373 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension 2.A troponin level is a laboratory test performed to determine how well the cells, tissues, and organs are supplied with oxygen. ANS: F Troponin is a serum evaluation used to detect myocardial infarction (MI). Levels of these contractile proteins remain elevated for up to 7 days after MI. Organ function indirectly evaluates the extent to which oxygen demands have been met in the cells, organs, and tissues. 3. Heat causes vasodilation, which decreases cardiac output and oxygenation. ANS: F Heat causes vasodilation, which increases cardiac output and oxygenation. Chapter 20: Fluids and Electrolytes My Nursing Test Banks Chapter 20: Fluids and Electrolytes Cooper and Gosnell: Foundations and Adult Health Nursing, 7th Edition MULTIPLE CHOICE 1. What percentage of an adults body weight consists of water? a. 10% to 20%b. 30% to 40% c. 50% to 60% d. 70% to 80% ANS: C The percentage of water declines to 50% to 60% in adults. 2. When administering intravenous (IV) fluids, the nurse ensures that the IV fluids are infusing as ordered to prevent dehydration in an adult. When could dehydration become lethal? a. If the patient loses 5% of body fluid b. If the patient loses 10% of body fluid c. If the patient loses 15% of body fluid d. If the patient loses 20% of body fluid ANS: D A loss of 20% of body fluid in an adult is fatal. 3. The nurse uses a diagram to show that fluids in the interstitial and intravascular compartments are combined. What do they combine to form? a. Intercellular compartment b. Circulating compartment c. Vertical compartment d. Extracellular compartment ANS: D The fluids in the interstitial and intravascular compartments are combined to form the extracellular compartment. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 537 4. The nurse encourages a patient who has been vomiting to drink fluids because the body fluid lost daily must match the amount of fluid taken in to maintain homeostasis. What is the recommended daily amount of fluid for an adult?a. 1000 mL b. 1500 mL c. 2050 mL d. 2500 mL ANS: D Daily fluid intake and output is about mL/day, and urinary output is about mL/day. 5. The nurse must keep an accurate intake and output record to assess kidney efficiency. In order for the kidneys to remove waste, what is the least amount of hourly urine output the kidneys must produce to remove waste? a. 10 mL b. 20 mL c. 30 mL d. 40 mL ANS: C The kidneys must excrete a minimum of 30 mL/hour to eliminate waste products. 6. The nurse weighs a patient at the same time of day with the same scale and same clothing. What is this a simple and accurate method of determining? a. An accurate weight b. Water balance c. Adequate nutrition d. Urinary output ANS: B A simple and accurate method of determining water balance is to weigh the patient under the same conditions each day.7. When a patient takes substances into the body, they first enter the extracellular compartment. What must the substances enter to carry out their function? a. Horizontal compartment b. Intracellular compartment c. Compartmental d. Vertical compartment ANS: B To carry out their function, substances must enter the cell. 8. What is the method by which inhaled oxygen is moved into the intravascular compartment called? a. Active transport b. Oxygenation c. Passive transport d. Mass movement ANS: C Passive transport occurs when the patient inhales oxygen into the lungs, with the oxygen passing by diffusion into the intravascular compartment. 9. The nurse explains to a patient that the drug Lasix reduces edema by drawing water from the interstitial space into the intravascular space. What is this process called? a. Diffusion b. Filtration c. Osmosis d. Homeostasis ANS: COsmosis is the movement of water from an area of lower concentration to an area of higher concentration. 10. What does actively transporting electrolytes from an area of higher concentration to an area of lower concentration require? a. Hydrostatic pressure b. Osmotic pressure c. Blood pressure d. Pulse pressure ANS: A Electrolytes are moved by hydrostatic pressure, which is a form of active transport. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 541 11. Electrolytes are not measured by weight; their chemical activity is expressed in milliequivalents. What does 1 milliequivalent of potassium have the same combining power as? a. 1 mEq of nitrogen b. 1 mEq of oxygen c. 1 mEq of hydrogen d. 1 mEq of magnesium ANS: C Electrolytes are measured in milliequivalents: 1 mEq of any electrolyte is equal to 1 mEq of hydrogen. 12. Sodium is the most abundant electrolyte in the body. The location of electrolytes is important for maintaining homeostasis. Sodium is the major electrolyte in which fluid compartment? a. Intracellular b. Intravascular c. Extracellulard. Interstitial ANS: C Sodium is the major extracellular electrolyte. 13. The lactating mother is counseled by the nurse to eat adequate amounts of meat and legumes. What level will this help to increase? a. Potassium b. Chloride c. Magnesium d. Phosphorus ANS: D Phosphorus should be increased during pregnancy and lactation. 14.A nurse assesses an edematous cardiac patient. The nurse is aware that this condition is a result of retained fluid. What is the patient considered to be? a. Hyponatremic b. Hypokalemic c. Hypernatremic d. Hypercalcemic ANS: C Hypernatremia is a greater-than-normal concentration of sodium, which leads to retained fluids and edema. 15. What is the nurse closely assessing for in a patient with hypokalemia? a. Systemic edema b. Cardiac complications c. Muscle crampingd. Impaired kidney function ANS: B Hypokalemia can affect cardiac function. 16. The nurse modifies the care plan for the immobilized patient after assessing a calcium level of 6.2 mEq/L. What nursing assessment should the nurse include when modifying this care plan? a. Osteoporosis b. Tooth loss c. Renal calculi d. Contractures ANS: C Hypercalcemia occurs when calcium levels exceed 5.8 mEq/L. It may occur when calcium stored in the bone enters the circulation, for example, in patients who are immobilized. Renal calculi may develop because of high levels of calcium. 17. Homeostasis of the hydrogen ion concentration in body fluids depends on the ratio of carbonic acid to bicarbonate in the extracellular fluid. What is this ratio? a. 1:5 b. 1:10 c. 1:15 d. 1:20 ANS: D The ratio needed for homeostasis is 1 part carbonic acid to 20 parts bicarbonate. 18. When reading the laboratory report of a patient with excessive diarrhea, the nurse notes that the pH is 7.10, and the PaCO2 and the PaO2 are normal. What should the nurse recognize as this patients state from this information alone? a. Respiratory acidosis b. Metabolic acidosisc. Respiratory alkalosis d. Metabolic alkalosis ANS: B The profile of a patient in metabolic acidosis is that the blood pH will be below 7.35 and the oxygen readings are within normal limits. 19. What should the nurse expect when assessing a patient with respiratory alkalosis? a. Slow respirations b. Muscle weakness c. Strong, even heart rate d. Flushed face ANS: B Tetany and muscle weakness, tachypnea, and cardiac arrhythmias are symptomatic of respiratory alkalosis. 20. Three body systems work at different speeds to keep the pH in the narrow range of normal. What is the order of effectiveness for these three systems? a. Blood buffers, kidneys, and lungs b. Kidneys, lungs, and blood buffers c. Blood buffers, lungs, and kidneys d. Lungs, kidneys, and blood buffers ANS: C The three systems are blood buffers, lungs, and kidneys. The blood buffers speed is a fraction of a second, the lungs take minutes, and the kidneys take hours to days. 21.A patient admitted in a state of extreme anxiety has vital signs of: T 98.6 F, P 81, BP 130/86, R 32. What will result if this hyperventilation continues? a. Metabolic acidosisb. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: D Respiratory alkalosis is caused by hyperventilation as the lungs blow off large amounts of CO2. 22.A patient began vomiting and continued to do so for several hours. What is the result of this loss of stomach contents? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: B The most common cause of metabolic alkalosis is vomiting gastric contents. 23. What should the nurse focus on when creating a nursing care plan for a patient with metabolic acidosis? a. Frequent periods of ambulation b. Increasing fluid intake c. Decreasing fluid intake d. Deep-breathing exercises ANS: D Deep breathing will cause the patient to blow off CO2 and assist in increasing the pH and reduce the acidity. 24. The nurse is educating a patient regarding the need to avoid foods high in potassium. What food choices led the nurse to conclude that teaching was not effective? a. Apples and green beansb. Kiwis and onions c. Apricots and asparagus d. Grapes and lima beans ANS: C Apricots and asparagus are potassium-rich. MULTIPLE RESPONSE 25. What are the three types of passive transport? (Select all that apply.) a. Diffusion b. Titration c. Osmosis d. Distillation e. Filtration ANS: A, C, E The three types of passive transport are diffusion, osmosis, and filtration. 26.What are the three buffer systems of the body? (Select all that apply.) a. Bicarbonate/carbonic acid system b. Respiratory system c. Renal system d. GI system e. Integumentary system ANS: A, B, C The bicarbonate/carbonic acid system, the respiratory system, and the renal system are the buffer systems of the body. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 550 COMPLETION27. The nurse expects an adult with normal kidney function to void a minimum of mL of urine in 4 hours. ANS: 120 one hundred twenty The norm is to excrete at least 30 mL/hour. In 4 hours, the urine output is expected to be 120 mL. 28. A child has been having an asthma attack for the last 8 hours. Because of the childs inability to exhale effectively, the nurse assesses for respiratory . ANS: acidosis Retained CO2 will lead to respiratory acidosis. 29. The nurse explains that a normal adult will lose approximately mL of water through respiration in the course of a day. ANS: 350 three hundred fifty Adults lose about 350 mL of water daily through respiration. Chapter 18: Fluid, Electrolyte, and Acid-Base Balances My Nursing Test Banks Chapter 18: Fluid, Electrolyte, and Acid-Base BalancesPotter: Essentials for Nursing Practice, 8th Edition MULTIPLE CHOICE 1.A nurse is caring for a patient who is suffering from kidney failure and is receiving peritoneal dialysis. The nurse explains that peritoneal dialysis works by instilling a solution into the abdomen that contains dextrose that will pull extra fluid into the abdominal cavity. What is the name of this process? a. Diffusion b. Osmosis c. Filtration d. Active transport ANS: B Osmosis is movement of water across a semipermeable membrane from a compartment of lower particle concentration to one that has a higher particle concentration. Diffusion is passive movement of electrolytes or other particles from an area of higher concentration to an area of lower concentration. In other words, the electrolytes move down their concentration gradient until the electrolyte concentration is equal in all areas. Electrolytes cannot diffuse across cell membranes unless the membranes have proteins that serve as ion channels. Filtration is the net effect of several forces that tend to move fluid across a membrane. Active transport is the energy-requiring movement of electrolytes or other substances across cell membranes against their concentration gradient (from an area of low concentration to an area of higher concentration). 2.A patient has been admitted to the postsurgical nursing unit after surgery. The health care provider has ordered the patient to have an IV of 0.9% sodium chloride. The nurse who is caring for the patient recognizes this as what type of solution?a. Hypotonic b. Isotonic c. Hypertonic d. Hypnotic ANS: B Fluids that have the same osmolality as normal blood are called isotonic. Intravenous (IV) solutions are hypertonic, isotonic, or hypotonic. Isotonic solutions such as 0.9% sodium chloride (same osmolality as normal blood) expand the bodys extracellular fluid volume without causing water to shift in or out of cells. There is no hypnotic solution. 3. The patient is in a coma after a motor vehicle accident. In addition to IV medications, the patient is receiving an isotonic IV fluid. The primary purpose for this fluid infusion is to: a. cause cells to shrink and reduce swelling. b. move fluid from intravascular space into cells. c. pull fluid from cells into the intravascular space. d. expand the bodys intravascular fluid volume. ANS: D Fluids that have the same osmolality as normal blood are called isotonic. Intravenous (IV) solutions are hypertonic, isotonic, or hypotonic. Isotonic solutions such as 0.9% sodium chloride (same osmolality as normal blood) expand the bodys extracellular fluid volume without causing water to shift in or out of cells. Infusion of hypertonic intravenous solutions (more concentratedthan normal blood), such as 3% sodium chloride, pulls fluid from cells by osmosis, causing them to shrink. Physiologically hypotonic solutions (less concentrated than normal blood after they are infused) move water from the extracellular compartment into the cells by osmosis, causing them to swell. 4. Two nursing students were having pizza one evening as they were studying. One student remarked that whenever she ate pizza, she was incredibly thirsty. The second student explained that this th