NU 214 Chapter 16 Fluids and Electrolytes Questions With
Complete Solutions
25. A patient with renal failure has been taking aluminum
hydroxide/magnesium hydroxide suspension (Maalox) at home
for indigestion. The patient arrives for outpatient hemodialysis
and is unresponsive to questions and has decreased deep tendon
reflexes. Which action should the dialysis nurse take first?
a. Notify the patients health care provider.
b. Obtain an order to draw a potassium level.
c. Review the magnesium level on the patients chart.
d. Teach the patient about the risk of magnesium-containing
antacids Correct Answers ANS: A
The health care provider should be notified immediately. The
patient has a history and manifestations consistent with
hypermagnesemia. The nurse should check the chart for a recent
serum magnesium level and make sure that blood is sent to the
laboratory for immediate electrolyte and chemistry
determinations. Dialysis should correct the high magnesium
levels. The patient needs teaching about the risks of taking
magnesium-containing antacids. Monitoring of potassium levels
also is important for patients with renal failure, but the patient's
current symptoms are not consistent with hyperkalemia
26. A patient who had a transverse colectomy for diverticulosis
18 hours ago has nasogastric suction and is complaining of
anxiety and incisional pain. The patient's respiratory rate is 32
breaths/minute and the arterial blood gases (ABGs) indicate
respiratory alkalosis. Which action should the nurse take first?
a. Discontinue the nasogastric suction.
,b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the ABG results.
d. Teach the patient how to take slow, deep breaths when
anxious. Correct Answers ANS: B
The patient's respiratory alkalosis is caused by the increased
respiratory rate associated with pain and anxiety. The nurse's
first action should be to medicate the patient for pain. Although
the nasogastric suction may contribute to the alkalosis, it is not
appropriate to discontinue the tube when the patient needs
gastric suction. The health care provider may be notified about
the ABGs but is likely to instruct the nurse to medicate for pain.
The patient will not be able to take slow, deep breaths when
experiencing pain.
27. Which action can the registered nurse (RN) who is caring for
a critically ill patient with multiple IV lines delegate to an
experienced licensed practical/vocational nurse (LPN/LVN)?
a. Administer IV antibiotics through the implantable port.
b. Monitor the IV sites for redness, swelling, or tenderness.
c. Remove the patient's nontunneled subclavian central venous
catheter.
d. Adjust the flow rate of the 0.9% normal saline in the
peripheral IV line. Correct Answers ANS: B
, An experienced LPN/LVN has the education, experience, and
scope of practice to monitor IV sites for signs of infection.
Administration of medications, adjustment of infusion rates, and
removal of central catheters in critically ill patients require RN
level education and scope of practice
28. A patient has a serum calcium level of 7.0 mEq/L. Which
assessment finding is most important for the nurse to report to
the health care provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient's bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips. Correct
Answers ANS: A
Hypocalcemia can cause laryngeal stridor, which may lead to
respiratory arrest. Rapid action is required to correct the patient's
calcium level. The other data are also consistent with
hypocalcemia, but do not indicate a need for as immediate
action as laryngospasm
29. Following a thyroidectomy, a patient complains of a tingling
feeling around my mouth. Which assessment should the nurse
complete immediately?
a. Presence of the Chvosteks sign
b. Abnormal serum potassium level
c. Decreased thyroid hormone level
d. Bleeding on the patients dressing Correct Answers ANS: A
The patient's symptoms indicate possible hypocalcemia, which
can occur secondary to parathyroid injury/removal during
thyroidectomy. There is no indication of a need to check the
potassium level, the thyroid hormone level, or for bleeding
Complete Solutions
25. A patient with renal failure has been taking aluminum
hydroxide/magnesium hydroxide suspension (Maalox) at home
for indigestion. The patient arrives for outpatient hemodialysis
and is unresponsive to questions and has decreased deep tendon
reflexes. Which action should the dialysis nurse take first?
a. Notify the patients health care provider.
b. Obtain an order to draw a potassium level.
c. Review the magnesium level on the patients chart.
d. Teach the patient about the risk of magnesium-containing
antacids Correct Answers ANS: A
The health care provider should be notified immediately. The
patient has a history and manifestations consistent with
hypermagnesemia. The nurse should check the chart for a recent
serum magnesium level and make sure that blood is sent to the
laboratory for immediate electrolyte and chemistry
determinations. Dialysis should correct the high magnesium
levels. The patient needs teaching about the risks of taking
magnesium-containing antacids. Monitoring of potassium levels
also is important for patients with renal failure, but the patient's
current symptoms are not consistent with hyperkalemia
26. A patient who had a transverse colectomy for diverticulosis
18 hours ago has nasogastric suction and is complaining of
anxiety and incisional pain. The patient's respiratory rate is 32
breaths/minute and the arterial blood gases (ABGs) indicate
respiratory alkalosis. Which action should the nurse take first?
a. Discontinue the nasogastric suction.
,b. Give the patient the PRN IV morphine sulfate 4 mg.
c. Notify the health care provider about the ABG results.
d. Teach the patient how to take slow, deep breaths when
anxious. Correct Answers ANS: B
The patient's respiratory alkalosis is caused by the increased
respiratory rate associated with pain and anxiety. The nurse's
first action should be to medicate the patient for pain. Although
the nasogastric suction may contribute to the alkalosis, it is not
appropriate to discontinue the tube when the patient needs
gastric suction. The health care provider may be notified about
the ABGs but is likely to instruct the nurse to medicate for pain.
The patient will not be able to take slow, deep breaths when
experiencing pain.
27. Which action can the registered nurse (RN) who is caring for
a critically ill patient with multiple IV lines delegate to an
experienced licensed practical/vocational nurse (LPN/LVN)?
a. Administer IV antibiotics through the implantable port.
b. Monitor the IV sites for redness, swelling, or tenderness.
c. Remove the patient's nontunneled subclavian central venous
catheter.
d. Adjust the flow rate of the 0.9% normal saline in the
peripheral IV line. Correct Answers ANS: B
, An experienced LPN/LVN has the education, experience, and
scope of practice to monitor IV sites for signs of infection.
Administration of medications, adjustment of infusion rates, and
removal of central catheters in critically ill patients require RN
level education and scope of practice
28. A patient has a serum calcium level of 7.0 mEq/L. Which
assessment finding is most important for the nurse to report to
the health care provider?
a. The patient is experiencing laryngeal stridor.
b. The patient complains of generalized fatigue.
c. The patient's bowels have not moved for 4 days.
d. The patient has numbness and tingling of the lips. Correct
Answers ANS: A
Hypocalcemia can cause laryngeal stridor, which may lead to
respiratory arrest. Rapid action is required to correct the patient's
calcium level. The other data are also consistent with
hypocalcemia, but do not indicate a need for as immediate
action as laryngospasm
29. Following a thyroidectomy, a patient complains of a tingling
feeling around my mouth. Which assessment should the nurse
complete immediately?
a. Presence of the Chvosteks sign
b. Abnormal serum potassium level
c. Decreased thyroid hormone level
d. Bleeding on the patients dressing Correct Answers ANS: A
The patient's symptoms indicate possible hypocalcemia, which
can occur secondary to parathyroid injury/removal during
thyroidectomy. There is no indication of a need to check the
potassium level, the thyroid hormone level, or for bleeding
