Exam (elaborations) Medical Surgical Nursing 14th Edition TB Chapter 1

Chapter 13: Fluid and Electrolytes: Balance and Disturbance 1. You are caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your clients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the registered nurse to assess what aspect of the clients health? A) Nutritional status B) Potassium balance C) Calcium balance D) Fluid volume status Correct Answer D Response: A specific gravity will detect if the client has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated. 2. You are caring for a client admitted with a diagnosis of acute kidney injury. When you review your clients most recent laboratory reports, you note that the clients magnesium levels are high. You should prioritize assessment for which of the following health problems? A) Diminished deep tendon reflexes B) Tachycardia C) Cool, clammy skin D) Acute flank pain Correct Answer A Response: To gauge a clients magnesium status, the registered nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia. 3. You are working on a burns unit and one of your acutely ill clients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the client to exhibit signs and symptoms of what imbalance? A) Metabolic alkalosis B) Hypermagnesemia C) Hypercalcemia D) Hypovolemia Correct Answer D Response: Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis. 4. A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage registered nurse notes upon assessment that the client is hyperventilating. The triage registered nurse is aware that hyperventilation is the most common cause of which acidbase imbalance? A) Respiratory acidosis B) Respiratory alkalosis C) Increased PaCO2 D) CNS disturbances Correct Answer B Response: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. CNS disturbances are found in extreme hyponatremia and fluid overload. 5. You are an emergency-room registered nurse caring for a trauma client. Your client has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results? A) Respiratory acidosis with no compensation B) Metabolic alkalosis with a compensatory alkalosis C) Metabolic acidosis with no compensation D) Metabolic acidosis with a compensatory respiratory alkalosis Correct Answer D Response: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem. 6. You are making initial shift assessments on your clients. While assessing one clients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy? A) Air emboli B) Phlebitis C) Infiltration D) Fluid overload Correct Answer C Response: Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration. 7. You are performing an admission assessment on an older adult client newly admitted for end-stage liver disease. What principle should guide your assessment of the clients skin turgor? A) Overhydration is common among healthy older adults. B) Dehydration causes the skin to appear spongy. C) Inelastic skin turgor is a normal part of aging. Skin turgor cannot be assessed in clients over 70. Correct Answer C Response Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older clients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. 8. The physician has ordered a peripheral IV to be inserted before the client goes for computed tomography. What should the registered nurse do when selecting a site on the hand or arm for insertion of an IV catheter? A) Choose a hairless site if available. B) Consider potential effects on the clients mobility when selecting a site. C) Have the client briefly hold his arm over his head before insertion. D) Leave the tourniquet on for at least 3 minutes. Correct Answer B Response: Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the client to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair. 9. A registered nurse in the neurologic ICU has orders to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the clients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following? A) Hydrostatic pressure B) Osmosis and osmolality C) Diffusion D) Active transport Correct Answer B Response: Osmosis is the movement of fluid from a region of low solute c