Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances
Test Bank
MULTIPLE CHOICE
1. The nurse obtains all of the following assessment data about a patient with deficient fluid
volume caused by a massive burn injury. Which of the following assessment data will be of
greatest concern?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 ml over the last hour.
c. Oral fluid intake is 100 ml for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
ANS: A
The blood pressure indicates that the patient may be developing hypovolemic shock as a result
of fluid loss. This will require immediate intervention to prevent the complications associated
with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting
all indicate the need for increasing the patient’s fluid intake but not as urgently as the
hypotension.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. A recently admitted patient has a small cell carcinoma of the lung, which is causing the
syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully
for
a. increased total urinary output.
b. elevation of serum hematocrit.
c. decreased serum sodium level.
d. rapid and unexpected weight loss.
ANS: C
SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased
urine output, and elevated serum hematocrit may be associated with excessive loss of water,
but not with SIADH and water retention.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia
associated with multiple draining wounds, the most accurate assessment to include is
a. skin turgor.
b. daily weight.
c. presence of edema.
, d. hourly urine output.
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take
account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the
gastrointestinal tract or wounds.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
4. When caring for an alert and oriented elderly patient with a history of dehydration, the home
health nurse will teach the patient to increase fluid intake
a. in the late evening hours.
b. if the oral mucosa feels dry.
c. when the patient feels thirsty.
d. as soon as changes in level of consciousness (LOC) occur.
ANS: B
An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral
secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in
the evening to improve sleep quality. The patient will not be likely to notice and act
appropriately when changes in LOC occur.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
5. A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will
teach the patient to report symptoms of adverse effects such as
a. personality changes.
b. frequent loose stools.
c. facial muscle spasms.
d. generalized weakness.
ANS: D
Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances, although
changes in mental status are common manifestations with sodium excess or deficit.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
,6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic.
Which statement by the patient indicates that the teaching about this medication has been
effective?
a. “I will try to drink at least 8 glasses of water every day.”
b. “I will use a salt substitute to decrease my sodium intake.”
c. “I will increase my intake of potassium-containing foods.”
d. “I will drink apple juice instead of orange juice for breakfast.”
ANS: D
Since spironolactone is a potassium-sparing diuretic, patients should be taught to choose low
potassium foods such as apple juice rather than foods that have higher levels of potassium,
such as citrus fruits. Because the patient is using spironolactone as a diuretic, the nurse would
not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes,
which are high in potassium.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
7. When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate
taking?
a. Restrict patient’s oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solution of 5% dextrose in 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, [ADH]).
ANS: A
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the patient’s sodium level. Administration of vasopressin or hypotonic
IV solutions will decrease the serum sodium level further.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
8. Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with
severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a liter of IV fluid.
ANS: B
, Intravenous KCl is administered at a maximal rate of 20 mEq/hr. Rapid IV infusion of KCl
can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40
mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause
inflammation of peripheral veins, but it can be administered by this route.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
9. A postoperative patient who has been receiving nasogastric suction for 3 days has a serum
sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the
patient has been receiving should the nurse question?
a. Infuse 5% dextrose in water at 125 ml/hr.
b. Administer IV morphine sulfate 4 mg every 2 hours PRN.
c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.
ANS: A
Because the patient’s gastric suction has been depleting electrolytes, the IV solution should
include electrolyte replacement. Solutions such as lactated Ringer’s solution would usually be
ordered for this patient. The other orders are appropriate for a postoperative patient with
gastric suction.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
10. A patient who has required prolonged mechanical ventilation has the following arterial blood
gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse
interprets these results as
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.
ANS: D
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory
cause. The other responses are incorrect based on the pH and the normal HCO3.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
11. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep
respirations. Which action should the nurse take?
a. Notify the patient’s health care provider.
b. Give the prescribed PRN lorazepam (Ativan).
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
Test Bank
MULTIPLE CHOICE
1. The nurse obtains all of the following assessment data about a patient with deficient fluid
volume caused by a massive burn injury. Which of the following assessment data will be of
greatest concern?
a. The blood pressure is 90/40 mm Hg.
b. Urine output is 30 ml over the last hour.
c. Oral fluid intake is 100 ml for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
ANS: A
The blood pressure indicates that the patient may be developing hypovolemic shock as a result
of fluid loss. This will require immediate intervention to prevent the complications associated
with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting
all indicate the need for increasing the patient’s fluid intake but not as urgently as the
hypotension.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. A recently admitted patient has a small cell carcinoma of the lung, which is causing the
syndrome of inappropriate antidiuretic hormone (SIADH). The nurse will monitor carefully
for
a. increased total urinary output.
b. elevation of serum hematocrit.
c. decreased serum sodium level.
d. rapid and unexpected weight loss.
ANS: C
SIADH causes water retention and a decrease in serum sodium level. Weight loss, increased
urine output, and elevated serum hematocrit may be associated with excessive loss of water,
but not with SIADH and water retention.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. When the nurse is evaluating the fluid balance for a patient admitted for hypovolemia
associated with multiple draining wounds, the most accurate assessment to include is
a. skin turgor.
b. daily weight.
c. presence of edema.
, d. hourly urine output.
ANS: B
Daily weight is the most easily obtained and accurate means of assessing volume status. Skin
turgor varies considerably with age. Considerable excess fluid volume may be present before
fluid moves into the interstitial space and causes edema. Hourly urine outputs do not take
account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the
gastrointestinal tract or wounds.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
MSC: NCLEX: Physiological Integrity
4. When caring for an alert and oriented elderly patient with a history of dehydration, the home
health nurse will teach the patient to increase fluid intake
a. in the late evening hours.
b. if the oral mucosa feels dry.
c. when the patient feels thirsty.
d. as soon as changes in level of consciousness (LOC) occur.
ANS: B
An alert, elderly patient will be able to self-assess for signs of oral dryness such as thick oral
secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an
accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in
the evening to improve sleep quality. The patient will not be likely to notice and act
appropriately when changes in LOC occur.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Health Promotion and Maintenance
5. A patient is taking a potassium-wasting diuretic for treatment of hypertension. The nurse will
teach the patient to report symptoms of adverse effects such as
a. personality changes.
b. frequent loose stools.
c. facial muscle spasms.
d. generalized weakness.
ANS: D
Generalized weakness progressing to flaccidity is a manifestation of hypokalemia. Facial
muscle spasms might occur with hypocalcemia. Loose stools are associated with
hyperkalemia. Personality changes are not associated with electrolyte disturbances, although
changes in mental status are common manifestations with sodium excess or deficit.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
,6. Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient as a diuretic.
Which statement by the patient indicates that the teaching about this medication has been
effective?
a. “I will try to drink at least 8 glasses of water every day.”
b. “I will use a salt substitute to decrease my sodium intake.”
c. “I will increase my intake of potassium-containing foods.”
d. “I will drink apple juice instead of orange juice for breakfast.”
ANS: D
Since spironolactone is a potassium-sparing diuretic, patients should be taught to choose low
potassium foods such as apple juice rather than foods that have higher levels of potassium,
such as citrus fruits. Because the patient is using spironolactone as a diuretic, the nurse would
not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes,
which are high in potassium.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
7. When caring for a patient admitted with hyponatremia, which actions will the nurse anticipate
taking?
a. Restrict patient’s oral free water intake.
b. Avoid use of electrolyte-containing drinks.
c. Infuse a solution of 5% dextrose in 0.45% saline.
d. Administer vasopressin (antidiuretic hormone, [ADH]).
ANS: A
To help improve serum sodium levels, water intake is restricted. Electrolyte-containing
beverages will improve the patient’s sodium level. Administration of vasopressin or hypotonic
IV solutions will decrease the serum sodium level further.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
8. Intravenous potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with
severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 20 mEq/hour.
c. Give the KCl only through a central venous line.
d. Add no more than 40 mEq/L to a liter of IV fluid.
ANS: B
, Intravenous KCl is administered at a maximal rate of 20 mEq/hr. Rapid IV infusion of KCl
can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40
mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause
inflammation of peripheral veins, but it can be administered by this route.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
9. A postoperative patient who has been receiving nasogastric suction for 3 days has a serum
sodium level of 125 mEq/L (125 mmol/L). Which of these prescribed therapies that the
patient has been receiving should the nurse question?
a. Infuse 5% dextrose in water at 125 ml/hr.
b. Administer IV morphine sulfate 4 mg every 2 hours PRN.
c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
d. Administer 3% saline if serum sodium drops to less than 128 mEq/L.
ANS: A
Because the patient’s gastric suction has been depleting electrolytes, the IV solution should
include electrolyte replacement. Solutions such as lactated Ringer’s solution would usually be
ordered for this patient. The other orders are appropriate for a postoperative patient with
gastric suction.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
10. A patient who has required prolonged mechanical ventilation has the following arterial blood
gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L. The nurse
interprets these results as
a. metabolic acidosis.
b. metabolic alkalosis.
c. respiratory acidosis.
d. respiratory alkalosis.
ANS: D
The pH indicates that the patient has alkalosis and the low PaCO2 indicates a respiratory
cause. The other responses are incorrect based on the pH and the normal HCO3.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
11. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep
respirations. Which action should the nurse take?
a. Notify the patient’s health care provider.
b. Give the prescribed PRN lorazepam (Ativan).
c. Start the prescribed PRN oxygen at 2 to 4 L/min.
