3: EAQ Fluid & Electrolytes
The nurse is teaching a team of student nurses about acid-base balance. Which statements by
the nurse are appropriate? (Select all that apply).
a. "The kidneys excrete all acids produced in the patient's body."
b. "Patients with obstructive lung diseases may have more acid in the blood."
c. "Patients experience deeper respirations when the carbon dioxide level in the blood rises."
d. "Patients experience shallow respirations when the carbon dioxide level in the blood rises."
e. "Patients with kidney disease have difficulty excreting metabolic acids." -
b. "Patients with obstructive lung diseases may have more acid in the blood."
c. "Patients experience deeper respirations when the carbon dioxide level in the blood rises."
Rationale: Patients with obstructive lung diseases may have more acid in their blood. This
can be due to a difficulty in normal excretion of carbonic acid. When the level of carbon
dioxide in the blood rises, the chemoreceptors are triggered quickly. The patient
hyperventilates in order to excrete the excess carbonic acid. The excretion of metabolic acids
occurs in the renal tubules of the kidneys. This is one of the major contributing factors for
difficulty in normally excreting metabolic acids. The kidneys excrete all acids except
carbonic acid. When the carbon dioxide level in the blood rises, the chemoreceptors trigger
hyperventilation to facilitate excretion of excess carbonic acid. The patient also experiences
shallow respirations in response to decreased levels of carbon dioxide in the blood to enable
the cells to produce more carbon dioxide and make up for the deficit.
Which electrolyte abnormality is least likely to be caused by the use of laxatives?
a. Hyponatremia
b. Hypokalemia
c. Hypocalcemia
d. Hypomagnesemia -
a. Hyponatremia
Rationale: Hyponatremia can be caused by the use of antidepressants. Hypokalemia,
hypocalcemia, and hypomagnesemia can be caused by the use of laxatives. Therefore, in the
patients with these conditions laxatives are contraindicated.
Which electrolyte influences excitability of nerve and muscle cells and is necessary for
muscle contraction?
a. Calcium (Ca 2+)
1|Page
,b. Potassium (K +)
c. Phosphate (PO 4)
d. Magnesium (Mg 2+) -
a. Calcium (Ca 2+)
Rationale: Calcium influences the excitability of nerve and muscle cells and is necessary for
muscle contraction. Potassium maintains the resting membrane potential of skeletal, smooth,
and cardiac muscle, allowing for normal muscle function. Electrolyte phosphate is necessary
for the production of adenosine triphosphate (ATP), the energy source for cellular
metabolism. Electrolyte magnesium influences the function of neuromuscular junctions and
is a cofactor for numerous enzymes.
How can the nurse prevent the development of febrile nonhemolytic reactions in the patient
during blood transfusions? (Select all that apply).
a. By adjusting the transfusion volume
b. By pretreating with antipyretics
c. By pretreating with antihistamine
d. By implementing blood-banking standards
e. By considering leukocyte-poor blood products -
b. By pretreating with antipyretics
e. By considering leukocyte-poor blood products
Rationale: Blood transfusions may result in febrile nonhemolytic reactions. They can be
prevented by pretreatment with antipyretics, especially if the patient has a previous history of
febrile nonhemolytic reactions. Leukocytes in the blood are responsible for febrile reactions;
therefore, the use of leukocyte-poor blood products (filtered, washed, or frozen) can prevent
febrile reactions to blood transfusions. Adjusting the transfusion volume is useful in reducing
the circulatory overload and has no role in reducing nonhemolytic reactions. Antihistamines
are helpful for allergic reactions but not for febrile reactions. The implementation of blood-
banking standards is helpful in reducing the incidence of sepsis.
A patient with blood type O needs platelets. What should the nurse consider when choosing a
donor for platelet transfusion?
a. Rh compatibility is excluded.
b. Donor can be of any blood group.
c. Donor should be of blood group O.
d. Donor can be exempted from screening for infections. -
2|Page
, c. Donor should be of blood group O.
Rationale: For platelet transfusion to a patient with blood group O, the donor must be of
blood group O only. Any other blood type may cause a mismatch and lead to a transfusion
reaction. Rh compatibility should be checked before transfusion, because it can also lead to a
transfusion reaction. Donor specifications exist for platelet transfusions; not just any blood
group is acceptable. The donor must be screened for all communicable diseases, including
human immunodeficiency virus (HIV).
The nurse understands that various mechanisms in the body help move fluid from one
compartment to another. Which transport mechanism is governed by oncotic and hydrostatic
pressures?
a. Osmosis
b. Diffusion
c. Filtration
d. Active transport -
c. Filtration
Rationale: A filtration process determines fluid movement in and out of capillaries and is
governed by hydrostatic and oncotic pressure within the vascular and interstitial space.
Osmosis is the movement of water molecules across semipermeable membranes. Diffusion is
the passive movement of electrolytes down the concentration gradient. Active transport refers
to the transportation of electrolytes against the concentration gradient via adenosine
triphosphate (ATP).
While caring for a patient on intravenous therapy, the nurse elevates the patient's extremity.
What is the rationale behind this intervention?
a. Phlebitis
b. Extravasation
c. Local infection
d. Circulatory overload -
b. Extravasation
Rationale: Elevating the extremity would benefit a patient with extravasations (tissue
damage). Applying warm and moist compresses would benefit a patient with phlebitis. A new
intravenous line should be started in another extremity if a patient develops a local infection.
Circulatory overload of intravenous solutions occurs when a patient receives fluids too
rapidly or receives an excessive amount of fluids. This condition can lead to excessive fluid
volume deficit; raising the head of the bed is an appropriate intervention in this case.
3|Page
, The primary health care provider orders the nurse to infuse 500 mL normal saline over 4
hours to a patient with a blood pressure of 100/70 mm Hg. What is the flow rate of infusion?
Record your answer in mL per hour. ___________mL/hr -
125 mL/hr
Rationale: A patient with a blood pressure of 100/70 mm Hg is hypotensive. Normal saline
solution is used to maintain the patient's sodium level. The formula used to calculate the flow
rate is the total infusion volume (mL) divided by the hours of infusion. Therefore, 500 mL of
normal saline is divided by 4 hours to calculate the infusion rate, which is 125 mL per hour.
The nurse works in an acute care facility. Which patients should the nurse monitor for
development of hypokalemia? (Select all that apply).
a. Patients with adrenal insufficiency
b. Patients with end-stage renal disease
c. Patients with diarrhea
d. Patients with vomiting
e. Patients using potassium-wasting diuretics -
c. Patients with diarrhea
d. Patients with vomiting
e. Patients using potassium-wasting diuretics
Rationale: Hypokalemia is common when potassium output is increased. Diarrhea and
vomiting can increase potassium loss through the gastrointestinal tract. Potassium-wasting
diuretics may increase potassium loss in urine. Adrenal insufficiency leads to hyperkalemia
by decreasing excretion of potassium. Oliguria in end-stage renal disease may cause
decreased excretion of potassium in the urine, leading to hyperkalemia.
Which symptom can be seen in a patient with phlebitis?
a. Blanched skin
b. Edematous skin
c. Purulent drainage
d. Redness of the skin -
d. Redness of the skin
Rationale: Inflammation of the inner layer of a vein is known as phlebitis. In this condition,
the patient will have redness of the skin. Blanched skin and edematous skin are associated
with extravasation. Purulent drainage is a sign of a local infection.
4|Page
The nurse is teaching a team of student nurses about acid-base balance. Which statements by
the nurse are appropriate? (Select all that apply).
a. "The kidneys excrete all acids produced in the patient's body."
b. "Patients with obstructive lung diseases may have more acid in the blood."
c. "Patients experience deeper respirations when the carbon dioxide level in the blood rises."
d. "Patients experience shallow respirations when the carbon dioxide level in the blood rises."
e. "Patients with kidney disease have difficulty excreting metabolic acids." -
b. "Patients with obstructive lung diseases may have more acid in the blood."
c. "Patients experience deeper respirations when the carbon dioxide level in the blood rises."
Rationale: Patients with obstructive lung diseases may have more acid in their blood. This
can be due to a difficulty in normal excretion of carbonic acid. When the level of carbon
dioxide in the blood rises, the chemoreceptors are triggered quickly. The patient
hyperventilates in order to excrete the excess carbonic acid. The excretion of metabolic acids
occurs in the renal tubules of the kidneys. This is one of the major contributing factors for
difficulty in normally excreting metabolic acids. The kidneys excrete all acids except
carbonic acid. When the carbon dioxide level in the blood rises, the chemoreceptors trigger
hyperventilation to facilitate excretion of excess carbonic acid. The patient also experiences
shallow respirations in response to decreased levels of carbon dioxide in the blood to enable
the cells to produce more carbon dioxide and make up for the deficit.
Which electrolyte abnormality is least likely to be caused by the use of laxatives?
a. Hyponatremia
b. Hypokalemia
c. Hypocalcemia
d. Hypomagnesemia -
a. Hyponatremia
Rationale: Hyponatremia can be caused by the use of antidepressants. Hypokalemia,
hypocalcemia, and hypomagnesemia can be caused by the use of laxatives. Therefore, in the
patients with these conditions laxatives are contraindicated.
Which electrolyte influences excitability of nerve and muscle cells and is necessary for
muscle contraction?
a. Calcium (Ca 2+)
1|Page
,b. Potassium (K +)
c. Phosphate (PO 4)
d. Magnesium (Mg 2+) -
a. Calcium (Ca 2+)
Rationale: Calcium influences the excitability of nerve and muscle cells and is necessary for
muscle contraction. Potassium maintains the resting membrane potential of skeletal, smooth,
and cardiac muscle, allowing for normal muscle function. Electrolyte phosphate is necessary
for the production of adenosine triphosphate (ATP), the energy source for cellular
metabolism. Electrolyte magnesium influences the function of neuromuscular junctions and
is a cofactor for numerous enzymes.
How can the nurse prevent the development of febrile nonhemolytic reactions in the patient
during blood transfusions? (Select all that apply).
a. By adjusting the transfusion volume
b. By pretreating with antipyretics
c. By pretreating with antihistamine
d. By implementing blood-banking standards
e. By considering leukocyte-poor blood products -
b. By pretreating with antipyretics
e. By considering leukocyte-poor blood products
Rationale: Blood transfusions may result in febrile nonhemolytic reactions. They can be
prevented by pretreatment with antipyretics, especially if the patient has a previous history of
febrile nonhemolytic reactions. Leukocytes in the blood are responsible for febrile reactions;
therefore, the use of leukocyte-poor blood products (filtered, washed, or frozen) can prevent
febrile reactions to blood transfusions. Adjusting the transfusion volume is useful in reducing
the circulatory overload and has no role in reducing nonhemolytic reactions. Antihistamines
are helpful for allergic reactions but not for febrile reactions. The implementation of blood-
banking standards is helpful in reducing the incidence of sepsis.
A patient with blood type O needs platelets. What should the nurse consider when choosing a
donor for platelet transfusion?
a. Rh compatibility is excluded.
b. Donor can be of any blood group.
c. Donor should be of blood group O.
d. Donor can be exempted from screening for infections. -
2|Page
, c. Donor should be of blood group O.
Rationale: For platelet transfusion to a patient with blood group O, the donor must be of
blood group O only. Any other blood type may cause a mismatch and lead to a transfusion
reaction. Rh compatibility should be checked before transfusion, because it can also lead to a
transfusion reaction. Donor specifications exist for platelet transfusions; not just any blood
group is acceptable. The donor must be screened for all communicable diseases, including
human immunodeficiency virus (HIV).
The nurse understands that various mechanisms in the body help move fluid from one
compartment to another. Which transport mechanism is governed by oncotic and hydrostatic
pressures?
a. Osmosis
b. Diffusion
c. Filtration
d. Active transport -
c. Filtration
Rationale: A filtration process determines fluid movement in and out of capillaries and is
governed by hydrostatic and oncotic pressure within the vascular and interstitial space.
Osmosis is the movement of water molecules across semipermeable membranes. Diffusion is
the passive movement of electrolytes down the concentration gradient. Active transport refers
to the transportation of electrolytes against the concentration gradient via adenosine
triphosphate (ATP).
While caring for a patient on intravenous therapy, the nurse elevates the patient's extremity.
What is the rationale behind this intervention?
a. Phlebitis
b. Extravasation
c. Local infection
d. Circulatory overload -
b. Extravasation
Rationale: Elevating the extremity would benefit a patient with extravasations (tissue
damage). Applying warm and moist compresses would benefit a patient with phlebitis. A new
intravenous line should be started in another extremity if a patient develops a local infection.
Circulatory overload of intravenous solutions occurs when a patient receives fluids too
rapidly or receives an excessive amount of fluids. This condition can lead to excessive fluid
volume deficit; raising the head of the bed is an appropriate intervention in this case.
3|Page
, The primary health care provider orders the nurse to infuse 500 mL normal saline over 4
hours to a patient with a blood pressure of 100/70 mm Hg. What is the flow rate of infusion?
Record your answer in mL per hour. ___________mL/hr -
125 mL/hr
Rationale: A patient with a blood pressure of 100/70 mm Hg is hypotensive. Normal saline
solution is used to maintain the patient's sodium level. The formula used to calculate the flow
rate is the total infusion volume (mL) divided by the hours of infusion. Therefore, 500 mL of
normal saline is divided by 4 hours to calculate the infusion rate, which is 125 mL per hour.
The nurse works in an acute care facility. Which patients should the nurse monitor for
development of hypokalemia? (Select all that apply).
a. Patients with adrenal insufficiency
b. Patients with end-stage renal disease
c. Patients with diarrhea
d. Patients with vomiting
e. Patients using potassium-wasting diuretics -
c. Patients with diarrhea
d. Patients with vomiting
e. Patients using potassium-wasting diuretics
Rationale: Hypokalemia is common when potassium output is increased. Diarrhea and
vomiting can increase potassium loss through the gastrointestinal tract. Potassium-wasting
diuretics may increase potassium loss in urine. Adrenal insufficiency leads to hyperkalemia
by decreasing excretion of potassium. Oliguria in end-stage renal disease may cause
decreased excretion of potassium in the urine, leading to hyperkalemia.
Which symptom can be seen in a patient with phlebitis?
a. Blanched skin
b. Edematous skin
c. Purulent drainage
d. Redness of the skin -
d. Redness of the skin
Rationale: Inflammation of the inner layer of a vein is known as phlebitis. In this condition,
the patient will have redness of the skin. Blanched skin and edematous skin are associated
with extravasation. Purulent drainage is a sign of a local infection.
4|Page
