FLUID AND ELECTROLYTE NUR 112
QUESTIONS WITH ACCURATE ANSWERS
.Which assessments will alert the nurse that a patient's IV has
infiltrated? (Select all that apply.)
a.
Edema of the extremity near the insertion site
b.
Reddish streak proximal to the insertion site
c.
Skin discolored or pale in appearance
d.
Pain and warmth at the insertion site
e.
Palpable venous cord
f.
Skin cool to the touch correct answer ANS: A, C, F
Infiltration results in skin that is edematous near the IV insertion
site. Skin is cool to the touch and may be pale or discolored. Pain,
warmth, erythema, a reddish streak, and a palpable venous cord
are all symptoms of phlebitis.
1. A nurse assesses a client who is admitted for treatment of fluid
overload. Which manifestations should the nurse expect to find?
(Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skine. Skeletal muscle weakness correct answer
ANS: A, B, E Manifestations of fluid overload include increased
pulse rate, distended neck veins, increased blood pressure, pale
and cool skin, and skeletal muscle weakness.
6. The patient with which diagnosis should have the highest
priority for teaching regarding foods that are high in magnesium?
a.Severe hemorrhage
b.Diabetes insipidus
c.Oliguric renal disease
d.Adrenal insufficiency correct answer ANS: C
,When renal excretion is decreased, magnesium intake must be
decreased also, to prevent hypermagnesemia. The other
conditions are not likely to require adjustment of magnesium
intake.
A 2-year-old child is brought into the emergency department after
ingesting a medication that causes respiratory depression. For
which acid-base imbalance will the nurse most closely monitor
this child?
a.
Respiratory alkalosis
b.
Respiratory acidosis
c.
Metabolic acidosis
d.
Metabolic alkalosis correct answer ANS: B
Respiratory depression leads to hypoventilation. Hypoventilation
results in retention of CO2 and respiratory acidosis. Respiratory
alkalosis would result from hyperventilation, causing a decrease
in CO2 levels. Metabolic acid-base imbalance would be a result of
kidney dysfunction, vomiting, diarrhea, or other conditions that
affect metabolic acids.
A chemotherapy patient has gained 5 pounds in 2 days. Which
assessment question by the nurse is most appropriate?
a.
"Are you following any weight loss program?"
b.
"How many calories a day do you consume?"
c.
"Do you have dry mouth or feel thirsty?"
d.
"How many times a day do you urinate?" correct answer ANS: D
A rapid gain in weight usually indicates extracellular volume (ECV)
excess if the person began with normal ECV. Asking the patient
about urination habits will help determine whether the body is
trying to excrete the excess fluid or if renal dysfunction is
contributing to ECV excess. This is too rapid a weight gain to be
,dietary; it is fluid retention. Asking about following a weight loss
program will not help determine the cause of the problem. Caloric
intake does not account for rapid weight changes. Dry mouth and
thirst accompany ECV deficit, which would be associated with
rapid weight loss.
A client at risk for developing hyperkalemia states, I love fruit and
usually eat it every day, but now I cant because of my high
potassium level. How should the nurse respond?
a. Potatoes and avocados can be substituted for fruit.
b. If you cook the fruit, the amount of potassium will be lower.
c. Berries, cherries, apples, and peaches are low in potassium.
d. You are correct. Fruit is very high in potassium. correct answer
ANS: C Not all fruit is potassium rich. Fruits that are relatively low
in potassium and can be included in the diet include apples,
apricots, berries, cherries, grapefruit, peaches, and pineapples.
Fruits high in potassium include bananas, kiwi, cantaloupe,
oranges, and dried fruit. Cooking fruit does not alter its potassium
content.
A nurse assesses a client who is prescribed a medication that
inhibits aldosterone secretion and release. For which potential
complications should the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L
e. Blood osmolality of 250 mOsm/L correct answer ANS: B,
EAldosterone is a naturally occurring hormone of the
mineralocorticoid type that increases the reabsorption of water
and sodium in the kidney at the same time that it promotes
excretion of potassium. Any drug or condition that disrupts
aldosterone secretion or release increases the clients risk for
excessive water loss (increased urine output), increased
potassium reabsorption, decreased blood osmolality, and
increased urine specific gravity. The client would not be at risk for
sodium imbalance.
A nurse assesses a client who is prescribed a medication that
, inhibits angiotensin I from converting into angiotensin II
(angiotensin-converting enzyme [ACE] inhibitor). For which
expected therapeutic effect should the nurse assess?
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b. Daily weight increase from 55 kg to 57 kg
c. Heart rate decrease from 100 beats/min to 82 beats/mind.
d. Respiratory rate increase from 12 breaths/min to 15
breaths/min correct answer ANS: A ACE inhibitors will disrupt the
reninangiotensin II pathway and prevent the kidneys from
reabsorbing water and sodium. The kidneys will excrete more
water and sodium, decreasing the clients blood pressure.
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on
Monday and programs the pump to infuse at 50 mL/hr. At what
time should the infusion be completed?
a.
2300 Monday
b.
2345 Monday
c.
0015 Tuesday
d.
0045 Tuesday correct answer ANS: B
250 mL ÷ 50 mL/hr = 5 hr
1845 + 5 hr = 2345, which would be 2345 on Monday.
A nurse cares for a client who has a serum potassium of 7.5
mEq/L and is exhibiting cardiovascular changes. Which
prescription should the nurse implement first?
a. Prepare to administer sodium polystyrene sulfate (Kayexalate)
15 g by mouth.
b. Provide a heart healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular
insulin IV push.
d. Prepare the client for hemodialysis treatment. correct answer
ANS: CA client with a high serum potassium level and cardiac
changes should be treated immediately to reduce the
extracellular potassium level. Potassium movement into the cells
is enhanced by insulin by increasing the activity of sodium-
QUESTIONS WITH ACCURATE ANSWERS
.Which assessments will alert the nurse that a patient's IV has
infiltrated? (Select all that apply.)
a.
Edema of the extremity near the insertion site
b.
Reddish streak proximal to the insertion site
c.
Skin discolored or pale in appearance
d.
Pain and warmth at the insertion site
e.
Palpable venous cord
f.
Skin cool to the touch correct answer ANS: A, C, F
Infiltration results in skin that is edematous near the IV insertion
site. Skin is cool to the touch and may be pale or discolored. Pain,
warmth, erythema, a reddish streak, and a palpable venous cord
are all symptoms of phlebitis.
1. A nurse assesses a client who is admitted for treatment of fluid
overload. Which manifestations should the nurse expect to find?
(Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skine. Skeletal muscle weakness correct answer
ANS: A, B, E Manifestations of fluid overload include increased
pulse rate, distended neck veins, increased blood pressure, pale
and cool skin, and skeletal muscle weakness.
6. The patient with which diagnosis should have the highest
priority for teaching regarding foods that are high in magnesium?
a.Severe hemorrhage
b.Diabetes insipidus
c.Oliguric renal disease
d.Adrenal insufficiency correct answer ANS: C
,When renal excretion is decreased, magnesium intake must be
decreased also, to prevent hypermagnesemia. The other
conditions are not likely to require adjustment of magnesium
intake.
A 2-year-old child is brought into the emergency department after
ingesting a medication that causes respiratory depression. For
which acid-base imbalance will the nurse most closely monitor
this child?
a.
Respiratory alkalosis
b.
Respiratory acidosis
c.
Metabolic acidosis
d.
Metabolic alkalosis correct answer ANS: B
Respiratory depression leads to hypoventilation. Hypoventilation
results in retention of CO2 and respiratory acidosis. Respiratory
alkalosis would result from hyperventilation, causing a decrease
in CO2 levels. Metabolic acid-base imbalance would be a result of
kidney dysfunction, vomiting, diarrhea, or other conditions that
affect metabolic acids.
A chemotherapy patient has gained 5 pounds in 2 days. Which
assessment question by the nurse is most appropriate?
a.
"Are you following any weight loss program?"
b.
"How many calories a day do you consume?"
c.
"Do you have dry mouth or feel thirsty?"
d.
"How many times a day do you urinate?" correct answer ANS: D
A rapid gain in weight usually indicates extracellular volume (ECV)
excess if the person began with normal ECV. Asking the patient
about urination habits will help determine whether the body is
trying to excrete the excess fluid or if renal dysfunction is
contributing to ECV excess. This is too rapid a weight gain to be
,dietary; it is fluid retention. Asking about following a weight loss
program will not help determine the cause of the problem. Caloric
intake does not account for rapid weight changes. Dry mouth and
thirst accompany ECV deficit, which would be associated with
rapid weight loss.
A client at risk for developing hyperkalemia states, I love fruit and
usually eat it every day, but now I cant because of my high
potassium level. How should the nurse respond?
a. Potatoes and avocados can be substituted for fruit.
b. If you cook the fruit, the amount of potassium will be lower.
c. Berries, cherries, apples, and peaches are low in potassium.
d. You are correct. Fruit is very high in potassium. correct answer
ANS: C Not all fruit is potassium rich. Fruits that are relatively low
in potassium and can be included in the diet include apples,
apricots, berries, cherries, grapefruit, peaches, and pineapples.
Fruits high in potassium include bananas, kiwi, cantaloupe,
oranges, and dried fruit. Cooking fruit does not alter its potassium
content.
A nurse assesses a client who is prescribed a medication that
inhibits aldosterone secretion and release. For which potential
complications should the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L
e. Blood osmolality of 250 mOsm/L correct answer ANS: B,
EAldosterone is a naturally occurring hormone of the
mineralocorticoid type that increases the reabsorption of water
and sodium in the kidney at the same time that it promotes
excretion of potassium. Any drug or condition that disrupts
aldosterone secretion or release increases the clients risk for
excessive water loss (increased urine output), increased
potassium reabsorption, decreased blood osmolality, and
increased urine specific gravity. The client would not be at risk for
sodium imbalance.
A nurse assesses a client who is prescribed a medication that
, inhibits angiotensin I from converting into angiotensin II
(angiotensin-converting enzyme [ACE] inhibitor). For which
expected therapeutic effect should the nurse assess?
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b. Daily weight increase from 55 kg to 57 kg
c. Heart rate decrease from 100 beats/min to 82 beats/mind.
d. Respiratory rate increase from 12 breaths/min to 15
breaths/min correct answer ANS: A ACE inhibitors will disrupt the
reninangiotensin II pathway and prevent the kidneys from
reabsorbing water and sodium. The kidneys will excrete more
water and sodium, decreasing the clients blood pressure.
A nurse begins infusing a 250-mL bag of IV fluid at 1845 on
Monday and programs the pump to infuse at 50 mL/hr. At what
time should the infusion be completed?
a.
2300 Monday
b.
2345 Monday
c.
0015 Tuesday
d.
0045 Tuesday correct answer ANS: B
250 mL ÷ 50 mL/hr = 5 hr
1845 + 5 hr = 2345, which would be 2345 on Monday.
A nurse cares for a client who has a serum potassium of 7.5
mEq/L and is exhibiting cardiovascular changes. Which
prescription should the nurse implement first?
a. Prepare to administer sodium polystyrene sulfate (Kayexalate)
15 g by mouth.
b. Provide a heart healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular
insulin IV push.
d. Prepare the client for hemodialysis treatment. correct answer
ANS: CA client with a high serum potassium level and cardiac
changes should be treated immediately to reduce the
extracellular potassium level. Potassium movement into the cells
is enhanced by insulin by increasing the activity of sodium-
