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Chapter 25: Fluid, Electrolyte, and Acid-Base Balance
MULTIPLE CHOICE
1. A 10-month old infant has had watery green stool for 2 days and refuses the bottle. The nurse
is aware that the primary concern for this baby is:
a. metabolic acidosis.
b. metabolic alkalosis.
c. weight loss.
d. diaper rash.
ANS: A
Loss of bowel contents leads to metabolic acidosis. The child will lose weight and will
probably have diaper rash, but the primary concern is the electrolyte imbalance.
DIF: Cognitive Level: Analysis REF: p. 499 OBJ: Clinical Practice #1
TOP: Dehydration KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The patient who was admitted after vomiting for 3 days would show an abnormally low blood
pressure because of a fluid shift from:
a. intracellular to the extracellular.
b. interstitial to intravascular.
c. intravascular to the interstitial.
d. interstitial to the intracellular.
ANS: C
If intravascular fluid, a type of extracellular fluid within the blood vessels, shifts from the
plasma in the vascular space out to the interstitial space, a drop in blood volume occurs.
DIF: Cognitive Level: Comprehension REF: p. 438 OBJ: Theory #3
TOP: Distribution of Body Fluids KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. An isotonic state exists within a patient’s body fluids when the solute concentration of:
a. interstitial fluid is less than the transcellular.
b. intracellular and extracellular fluid is equal.
c. intracellular fluid is greater than extracellular fluid.
d. extracellular fluid is lesser than intracellular fluid.
ANS: B
When the intracellular and extracellular fluid has the same concentration of particles, the
solution is called isotonic (equal solute concentration).
DIF: Cognitive Level: Comprehension REF: p. 439 OBJ: Theory #3
TOP: Movement of Fluid KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. The nurse is aware that an infant is more at risk for dehydration because the infant:
a. has kidneys that reabsorb water from the intravascular space.
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b. has a larger body surface compared with body weight.
c. urinates more frequently.
d. has fat that absorbs water.
ANS: B
Infants are more at risk for dehydration because they have a larger body surface compared
with body weight. Their immature kidneys cannot reabsorb water as well as an adult, and fat
does not absorb water.
DIF: Cognitive Level: Comprehension REF: p. 437 OBJ: Clinical Practice #1
TOP: Dehydration KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. The nurse points out that nonelectrolyte products of metabolism are as important to health as
electrolytes. Nonelectrolytes include:
a. magnesium.
b. amino acids.
c. calcium.
d. phosphates.
ANS: B
The nonelectrolytes that are products of metabolism and serve to promote health in the body
are amino acids, glucose, and fatty acids.
DIF: Cognitive Level: Knowledge REF: p. 438 OBJ: Theory #2
TOP: Non electrolytes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. The nurse assesses that the patient has developed abdominal pain, urinary retention, and
confusion. The nurse concludes these signs are the results of an inadequate supply of:
a. calcium (Ca2+).
b. sodium (NA+).
c. phosphates (PO43).
d. potassium (K+).
ANS: D
The symptoms of a potassium level below 3.5 mEq/L are abdominal pain, urinary retention,
confusion, decreased reflexes, and ECG changes.
DIF: Cognitive Level: Analysis REF: p. 444|Table 25-4
OBJ: Theory #4 TOP: Hypokalemia
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. A nurse gets a positive Chvostek’s sign on a young woman with bulimia who has been giving
herself frequent enemas containing phosphate. The nurse anticipates a laboratory finding of:
a. sodium 140 mEq/L.
b. potassium 4.5 mEq/L.
c. magnesium 1.6 mEq/L.
d. calcium 6.5 mEq/L.
ANS: D
Chapter 25: Fluid, Electrolyte, and Acid-Base Balance
MULTIPLE CHOICE
1. A 10-month old infant has had watery green stool for 2 days and refuses the bottle. The nurse
is aware that the primary concern for this baby is:
a. metabolic acidosis.
b. metabolic alkalosis.
c. weight loss.
d. diaper rash.
ANS: A
Loss of bowel contents leads to metabolic acidosis. The child will lose weight and will
probably have diaper rash, but the primary concern is the electrolyte imbalance.
DIF: Cognitive Level: Analysis REF: p. 499 OBJ: Clinical Practice #1
TOP: Dehydration KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The patient who was admitted after vomiting for 3 days would show an abnormally low blood
pressure because of a fluid shift from:
a. intracellular to the extracellular.
b. interstitial to intravascular.
c. intravascular to the interstitial.
d. interstitial to the intracellular.
ANS: C
If intravascular fluid, a type of extracellular fluid within the blood vessels, shifts from the
plasma in the vascular space out to the interstitial space, a drop in blood volume occurs.
DIF: Cognitive Level: Comprehension REF: p. 438 OBJ: Theory #3
TOP: Distribution of Body Fluids KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. An isotonic state exists within a patient’s body fluids when the solute concentration of:
a. interstitial fluid is less than the transcellular.
b. intracellular and extracellular fluid is equal.
c. intracellular fluid is greater than extracellular fluid.
d. extracellular fluid is lesser than intracellular fluid.
ANS: B
When the intracellular and extracellular fluid has the same concentration of particles, the
solution is called isotonic (equal solute concentration).
DIF: Cognitive Level: Comprehension REF: p. 439 OBJ: Theory #3
TOP: Movement of Fluid KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. The nurse is aware that an infant is more at risk for dehydration because the infant:
a. has kidneys that reabsorb water from the intravascular space.
, Stuvia.com - The Marketplace to Buy and Sell your Study Material
b. has a larger body surface compared with body weight.
c. urinates more frequently.
d. has fat that absorbs water.
ANS: B
Infants are more at risk for dehydration because they have a larger body surface compared
with body weight. Their immature kidneys cannot reabsorb water as well as an adult, and fat
does not absorb water.
DIF: Cognitive Level: Comprehension REF: p. 437 OBJ: Clinical Practice #1
TOP: Dehydration KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. The nurse points out that nonelectrolyte products of metabolism are as important to health as
electrolytes. Nonelectrolytes include:
a. magnesium.
b. amino acids.
c. calcium.
d. phosphates.
ANS: B
The nonelectrolytes that are products of metabolism and serve to promote health in the body
are amino acids, glucose, and fatty acids.
DIF: Cognitive Level: Knowledge REF: p. 438 OBJ: Theory #2
TOP: Non electrolytes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. The nurse assesses that the patient has developed abdominal pain, urinary retention, and
confusion. The nurse concludes these signs are the results of an inadequate supply of:
a. calcium (Ca2+).
b. sodium (NA+).
c. phosphates (PO43).
d. potassium (K+).
ANS: D
The symptoms of a potassium level below 3.5 mEq/L are abdominal pain, urinary retention,
confusion, decreased reflexes, and ECG changes.
DIF: Cognitive Level: Analysis REF: p. 444|Table 25-4
OBJ: Theory #4 TOP: Hypokalemia
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. A nurse gets a positive Chvostek’s sign on a young woman with bulimia who has been giving
herself frequent enemas containing phosphate. The nurse anticipates a laboratory finding of:
a. sodium 140 mEq/L.
b. potassium 4.5 mEq/L.
c. magnesium 1.6 mEq/L.
d. calcium 6.5 mEq/L.
ANS: D
