Chapter 16: Fluid, Electrolyte, and
Acid-Base Imbalances Lewis:
Medical-Surgical Nursing, 10th Edition
A nurse is assessing a newly admitted patient with persistent heart failure who forgot to take
prescribed medicines and appears harassed. The affected person complains of "just blowing
up" and has peripheral edema and shortness of breath. Which assessment need to the nurse
entire first?
A. Skin turgor
b. Heart sounds
c. Mental reputation
d. Capillary replenish - ANS-ANS: C
Increases in extracellular fluid (ECF) can cause swelling of cells in the central fearful machine,
to start with causing confusion, which might also progress to coma or seizures. Although pores
and skin turgor, capillary refill, and heart sounds also may be tormented by will increase in ECF,
those are signs that do not have as instantaneous impact on patient results as cerebral edema.
A nurse is assessing a newly admitted patient with persistent coronary heart failure who forgot
to take prescribed medicinal drugs and appears careworn. The affected person has peripheral
edema and shortness of breath. Which evaluation must the nurse complete first?
A. Skin turgor
b. Heart sounds
c. Mental fame
d. Capillary top off - ANS-ANS: C
Increases in extracellular fluid (ECF) can result in swelling of cells in the vital apprehensive
machine, to begin with inflicting confusion, which might also progress to coma or seizures.
Although pores and skin turgor, capillary fill up, and heart sounds may also be laid low with
increases in ECF, those are signs and symptoms that do not have as instant effect on patient
consequences as cerebral edema.
A affected person comes to the clinic complaining of frequent, watery stools for the past 2 days.
Which motion should the nurse take first?
A. Obtain the baseline weight.
B. Check the patient's blood pressure.
C. Draw blood for serum electrolyte levels.
D. Ask approximately extremity numbness or tingling. - ANS-NS: B
Because the patient's records shows that fluid volume deficit can be a trouble, evaluation for
good enough stream is the very best priority. The different actions are also appropriate, but are
not as essential as determining the patient's perfusion popularity.
, A patient has a magnesium stage of one.3 mg/dL. Which evaluation would help the nurse pick
out a possible motive of this fee?
A. Daily alcohol intake
b. Dietary protein intake
c. Multivitamin/mineral use
d. Over-the-counter (OTC) laxative use - ANS-ANS: A
Hypomagnesemia is associated with alcoholism. Protein consumption could now not have a big
impact on magnesium degree. OTC laxatives (which includes milk of magnesia) and use of
multivitamin/mineral dietary supplements generally tend to boom magnesium stages.
A patient has a parenteral vitamins infusion of 25% dextrose. A student nurse asks the nurse
why a peripherally inserted important catheter was inserted. Which reaction with the aid of the
nurse is correct?
A. "The prescribed infusion may be given greater rapidly when the patient has a important
line."
b. "The hypertonic answer could be more rapidly diluted when given thru a central
line."
c. "There is a decreased chance for infection whilst 25% dextrose is infused through a
crucial line."
d. "The required blood glucose tracking is based on samples obtained from a
crucial line." - ANS-ANS: B
The 25% dextrose solution is hypertonic. Shrinkage of crimson blood cells can occur when
answers with dextrose concentrations greater than 10% are administered IV. Blood glucose
checking out is not greater accurate while samples are obtained from a central line. The
infection risk is higher with a vital catheter than with peripheral IV traces. Hypertonic or focused
IV solutions are not given hastily.
A affected person has a serum calcium stage of 7.0 mEq/L. Which evaluation locating is most
vital for the nurse to file to the health care company?
A. The affected person is experiencing laryngeal stridor.
B. The affected person complains of generalized fatigue.
C. The patient's bowels have no longer moved for 4 days.
D. The affected person has numbness and tingling of the lips. - ANS-ANS: A
Hypocalcemia can purpose laryngeal stridor, which may result in respiratory arrest. Rapid
movement is needed to accurate the affected person's calcium degree. The different records
also are steady with hypocalcemia, however do now not suggest a need for as immediately
movement as laryngospasm.
A affected person gets three% NaCl solution for correction of hyponatremia. Which assessment
is most vital for the nurse to monitor for even as the affected person is receiving this infusion?
A. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema - ANS-ANS: A
Hypertonic solutions purpose water retention, so the patient have to be monitored for signs of
fluid excess. Crackles inside the lungs can also imply the onset of pulmonary edema and are a
extreme manifestation of fluid excess. Peripheral pulses, peripheral edema, or modifications in
Acid-Base Imbalances Lewis:
Medical-Surgical Nursing, 10th Edition
A nurse is assessing a newly admitted patient with persistent heart failure who forgot to take
prescribed medicines and appears harassed. The affected person complains of "just blowing
up" and has peripheral edema and shortness of breath. Which assessment need to the nurse
entire first?
A. Skin turgor
b. Heart sounds
c. Mental reputation
d. Capillary replenish - ANS-ANS: C
Increases in extracellular fluid (ECF) can cause swelling of cells in the central fearful machine,
to start with causing confusion, which might also progress to coma or seizures. Although pores
and skin turgor, capillary refill, and heart sounds also may be tormented by will increase in ECF,
those are signs that do not have as instantaneous impact on patient results as cerebral edema.
A nurse is assessing a newly admitted patient with persistent coronary heart failure who forgot
to take prescribed medicinal drugs and appears careworn. The affected person has peripheral
edema and shortness of breath. Which evaluation must the nurse complete first?
A. Skin turgor
b. Heart sounds
c. Mental fame
d. Capillary top off - ANS-ANS: C
Increases in extracellular fluid (ECF) can result in swelling of cells in the vital apprehensive
machine, to begin with inflicting confusion, which might also progress to coma or seizures.
Although pores and skin turgor, capillary fill up, and heart sounds may also be laid low with
increases in ECF, those are signs and symptoms that do not have as instant effect on patient
consequences as cerebral edema.
A affected person comes to the clinic complaining of frequent, watery stools for the past 2 days.
Which motion should the nurse take first?
A. Obtain the baseline weight.
B. Check the patient's blood pressure.
C. Draw blood for serum electrolyte levels.
D. Ask approximately extremity numbness or tingling. - ANS-NS: B
Because the patient's records shows that fluid volume deficit can be a trouble, evaluation for
good enough stream is the very best priority. The different actions are also appropriate, but are
not as essential as determining the patient's perfusion popularity.
, A patient has a magnesium stage of one.3 mg/dL. Which evaluation would help the nurse pick
out a possible motive of this fee?
A. Daily alcohol intake
b. Dietary protein intake
c. Multivitamin/mineral use
d. Over-the-counter (OTC) laxative use - ANS-ANS: A
Hypomagnesemia is associated with alcoholism. Protein consumption could now not have a big
impact on magnesium degree. OTC laxatives (which includes milk of magnesia) and use of
multivitamin/mineral dietary supplements generally tend to boom magnesium stages.
A patient has a parenteral vitamins infusion of 25% dextrose. A student nurse asks the nurse
why a peripherally inserted important catheter was inserted. Which reaction with the aid of the
nurse is correct?
A. "The prescribed infusion may be given greater rapidly when the patient has a important
line."
b. "The hypertonic answer could be more rapidly diluted when given thru a central
line."
c. "There is a decreased chance for infection whilst 25% dextrose is infused through a
crucial line."
d. "The required blood glucose tracking is based on samples obtained from a
crucial line." - ANS-ANS: B
The 25% dextrose solution is hypertonic. Shrinkage of crimson blood cells can occur when
answers with dextrose concentrations greater than 10% are administered IV. Blood glucose
checking out is not greater accurate while samples are obtained from a central line. The
infection risk is higher with a vital catheter than with peripheral IV traces. Hypertonic or focused
IV solutions are not given hastily.
A affected person has a serum calcium stage of 7.0 mEq/L. Which evaluation locating is most
vital for the nurse to file to the health care company?
A. The affected person is experiencing laryngeal stridor.
B. The affected person complains of generalized fatigue.
C. The patient's bowels have no longer moved for 4 days.
D. The affected person has numbness and tingling of the lips. - ANS-ANS: A
Hypocalcemia can purpose laryngeal stridor, which may result in respiratory arrest. Rapid
movement is needed to accurate the affected person's calcium degree. The different records
also are steady with hypocalcemia, however do now not suggest a need for as immediately
movement as laryngospasm.
A affected person gets three% NaCl solution for correction of hyponatremia. Which assessment
is most vital for the nurse to monitor for even as the affected person is receiving this infusion?
A. Lung sounds
b. Urinary output
c. Peripheral pulses
d. Peripheral edema - ANS-ANS: A
Hypertonic solutions purpose water retention, so the patient have to be monitored for signs of
fluid excess. Crackles inside the lungs can also imply the onset of pulmonary edema and are a
extreme manifestation of fluid excess. Peripheral pulses, peripheral edema, or modifications in
