C HAPTER 25: F LUID , E LECTROLYTE , AND
A CID -B ASE B ALANCE
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. An anxious adult patient is experiencing a respiratory rate of 40
breaths/min. The most appropriate intervention that the nurse could do is
to instruct the patient to:
a. sit up.
b. lie down.
c. breathe through a re -breather mask.
d. pant with mouth open.
ANS: C
Anxiet y can lead to hyperventil ation, causing respiratory alkalosis; the
treatment is to have the patient breathe through a re -breather mask. In
the home setting, the patient can be asked to breathe into a paper bag.
DIF: Cognitive Level: Application REF: p. 449 OBJ:
Theory #5 TOP: Acid-Base Balance KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
,2. The nurse is aware that a more dynamic process that moves molecules into
cells regardless of their electrical charge or concentrati on in the cell is:
a. filtration.
b. osmosis.
c. active transport.
d. hydrostatic pressures.
ANS: C
Active transport can move molecules into cells regardless of their
electrical charge or concentration already in the cell.
DIF: Cognitive Level: Knowledge REF: p. 440 OBJ:
Theory #3 TOP: Active Transport KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological Integrit y:
Pharmacological and Parenteral Therapies
3. For the accurate measurement to detect fluid retention, the nurse instructs
the nursing assistants to measure the weight with the same scale:
a. each morning before breakfast after the patient has voided.
b. each day at noon before lunch, dressed in light clothing.
c. in between meals, dressed in light clothing after voiding.
d. just before bedtime, while the patient is in a hospital gown or
pajamas.
ANS: A
Weight is measured at the same time every morning on the same scale,
after the patient has voided and before eating.
, DIF: Cognitive Level: Application REF: p. 450 OBJ:
Clinical Practice #1 TOP: Ass essment: Fluid and
Electrol ytes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrit y: Basic Care and
Comfort
4. A patient with heart failure has gained 1.1 pounds over the last 24 hours.
The nurse is aware that this weight gain r epresents a fluid retention of:
a. 0.25 L.
b. 0.5 L.
c. 1.0 L.
d. 2.0 L.
ANS: B
Each 2.2 pounds of weight equals 1 kg, which in turn equals 1.0 L of
fluid. Therefore 1.1 pounds equals 0.5 kg and is equal to 0.5 L of fluid.
DIF: Cognitive Level: Anal ysis REF: p. 450 OBJ:
Theory #4 TOP: Calculation KEY: Nursing Process Step:
Assessment MSC: NCLEX: Physiological Integrit y:
Physiological Adaptation
5. The nurse is comparing sitting and standing vital signs for a patient who
has been diagnosed with dehydration. Th e pulse rate has increased by 10
beats/min at 1 minute. The nurse then anticipates the blood pressure to
show a(n):
a. increase of 5 mm Hg.
b. drop of 40 mm Hg.
A CID -B ASE B ALANCE
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. An anxious adult patient is experiencing a respiratory rate of 40
breaths/min. The most appropriate intervention that the nurse could do is
to instruct the patient to:
a. sit up.
b. lie down.
c. breathe through a re -breather mask.
d. pant with mouth open.
ANS: C
Anxiet y can lead to hyperventil ation, causing respiratory alkalosis; the
treatment is to have the patient breathe through a re -breather mask. In
the home setting, the patient can be asked to breathe into a paper bag.
DIF: Cognitive Level: Application REF: p. 449 OBJ:
Theory #5 TOP: Acid-Base Balance KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Basic Care and Comfort
,2. The nurse is aware that a more dynamic process that moves molecules into
cells regardless of their electrical charge or concentrati on in the cell is:
a. filtration.
b. osmosis.
c. active transport.
d. hydrostatic pressures.
ANS: C
Active transport can move molecules into cells regardless of their
electrical charge or concentration already in the cell.
DIF: Cognitive Level: Knowledge REF: p. 440 OBJ:
Theory #3 TOP: Active Transport KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological Integrit y:
Pharmacological and Parenteral Therapies
3. For the accurate measurement to detect fluid retention, the nurse instructs
the nursing assistants to measure the weight with the same scale:
a. each morning before breakfast after the patient has voided.
b. each day at noon before lunch, dressed in light clothing.
c. in between meals, dressed in light clothing after voiding.
d. just before bedtime, while the patient is in a hospital gown or
pajamas.
ANS: A
Weight is measured at the same time every morning on the same scale,
after the patient has voided and before eating.
, DIF: Cognitive Level: Application REF: p. 450 OBJ:
Clinical Practice #1 TOP: Ass essment: Fluid and
Electrol ytes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrit y: Basic Care and
Comfort
4. A patient with heart failure has gained 1.1 pounds over the last 24 hours.
The nurse is aware that this weight gain r epresents a fluid retention of:
a. 0.25 L.
b. 0.5 L.
c. 1.0 L.
d. 2.0 L.
ANS: B
Each 2.2 pounds of weight equals 1 kg, which in turn equals 1.0 L of
fluid. Therefore 1.1 pounds equals 0.5 kg and is equal to 0.5 L of fluid.
DIF: Cognitive Level: Anal ysis REF: p. 450 OBJ:
Theory #4 TOP: Calculation KEY: Nursing Process Step:
Assessment MSC: NCLEX: Physiological Integrit y:
Physiological Adaptation
5. The nurse is comparing sitting and standing vital signs for a patient who
has been diagnosed with dehydration. Th e pulse rate has increased by 10
beats/min at 1 minute. The nurse then anticipates the blood pressure to
show a(n):
a. increase of 5 mm Hg.
b. drop of 40 mm Hg.
