Nursing Fundamentals, Fluid, Electrolyte, and Acid- Base Balance

Fluid, Electrolyte, and Acid- Base Balance. 1.Which body fluid is the fluid within the cells, constituting about 70% of the total body water? A) Extracellular fluid (ECF) B) Intracellular fluid (ICF) C) Intravascular fluid D) Interstitial fluid Ans: Intracellular fluid (ICF) Feedback: Intracellular fluid is the fluid within the cells, constituting about 70% of total body fluid. Extracellular fluid is all flu outside the cells and includes intravascular and interstitial fluids. 2.Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why would the nurse do this? A) Infants have less total body fluid and ECF than adults. B) Infants have more total body fluid and ECF than adults. C) Infants drink less fluid than adults. D) Infants lose more fluids through output than adults. Ans: Infants have more total body fluid and ECF than adults Feedback: An infant has considerably more total body fluid and ECF than an adult does. Because ECF is more easily lost from body than ICF, infants are more prone to fluid volume deficits. 3.What is the average adult fluid intake and loss in each 24 hours? A) 500 to 1,000 mL B) 1,000 to 1,500 Ml C) 1,500 to 2,000 mL D) 1,500 to 3500 mL Ans: 1,500 to 3500 mL Feedback: The desirable amount of fluid intake and loss in adults ranges from 1,500 to 3,500 mL each 24 hours, with most people averaging 2,500 to 2,600 mL per day. 4.A nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body fluid is lost via the gastrointestinal tract? A)300 mL B)1,000 mL C)1,300 mL D)2,600 mL Ans: 300 mL Feedback: Generally, fluid intake averages 2,600 mL per day, with approximately 1,300 mL coming from ingested water, 1,000 mL coming from ingested food, and 300 mL from metabolic oxidation. 5.A nurse reads the laboratory report and notes that the client has hyponatremia. What physical assessment should be made? A) Observe skin color and texture. B) Auscultate bowel sounds. C) Percuss lung density. D) Monitor for GI symptoms. Ans: Monitor for GI symptoms. Feedback: Hyponatremia is an ECF sodium deficit, resulting in osmotic pressure changes as ECF moves into the cells. When this occurs, anorexia, nausea, and vomiting may occur; the nurse should monitor for these symptoms. Skin color and texture, bowel sounds, and lung density are not affected with hypernatremia. 6.A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level. What is the rationale for this request? A) The nurse is concerned that the client’s diet has caused sodium loss. B) The nurse recognizes these symptoms of hypokalemia. C) The client is actively seeking increased attention. D) The client had bananas and orange juice for breakfast. Ans: The nurse recognizes these symptoms of hypokalemia. Feedback: Hypokalemia is a potassium deficit in the ECF. When the ECF potassium falls, potassium moves out of the cells, creating an intracellular potassium deficiency. Typical symptoms include muscle weakness and leg cramps. 7.A client’s PaCO2 is abnormal on an ABG report. Which of is the most likely be the medical diagnosis? A) Rheumatoid arthritis B) Sexually transmitted infection C) Chronic obstructive pulmonary disease D) Infection of the bladder and ureters Ans: Chronic obstructive pulmonary disease Feedback: Arterial blood gases are laboratory tests used to assess and treat acid–base disorders. PaCO2 is the abbreviation for the partial pressure of carbon dioxide. The PaCO2 is influenced almost entirely by respiratory activity, with a disease such as chronic obstructive pulmonary disease resulting in abnormal results. 8.Which question about fluid balance would be appropriate when conducting a health history for a client? A) “Describe your usual urination habits.” B) “Describe your problems with constipation.” C) “How did you feel when your calcium was low?” D) “Do you eat fruits and vegetables each day?” Ans: Describe your usual urination habits.” Feedback: Questions and leading statements about fluid balance are part of a comprehensive health history. The usual urinary output is one factor to consider in fluid balance 9.A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan? A) Impaired Skin Integrity B) Risk for Deficient Fluid Volume C) Impaired Urinary Elimination D) Urinary Retention Ans: Risk for Deficient Fluid Volume Feedback: An appropriate nursing diagnosis for a client taking a diuretic that increases urinary output would be Risk for Deficient Fluid Volume. The nurse would educate the client on the symptoms of dehydration, how to increase fluid intake, and the need to maintain a record of daily weights. 10.A nurse measures a client’s 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information? A) Compare the client’s intake with the normal range of adult fluid intake. B) Report the exact milliliter of intake to the physician’s office nurse. C) Compare the total intake and output of fluids for the 24 hours. D) Ensure that the information is included in the verbal end-of-shift report. Ans: C) Compare the total intake and output of fluids for the 24 hours. Feedback: The nurse must pay attention to certain parameters when assessing a client’s fluid status. This means comparing the total intake and output of fluids for a given period of time. 11.A physician writes an order to “force fluids.” What will be the first action the nurse will take in implementing this order? A) Explain to the client why this is needed. B) Tell the client and family to increase oral intake. C) Decide how much fluid to increase each eight hours. D) Divide the intake so the largest amount is at night. Ans: A) Explain to the client why this is needed Feedback: Several techniques are recommended to help the client drink greater than average amounts of fluids. Begin by explaining to the client in understandable terms the rationale for the increased fluids and the specific goal of taking the daily amount of fluids prescribed. 12.A client has an order to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem? A) Back rubs B) Chewing gum C)Hair care D) Oral hygiene Ans: D) Oral hygiene Feedback: Clients with restrictions on fluid intake often complain of thirst or a dry mouth. Provide oral hygiene at regular intervals. Offering hard candy or gum is no longer recommended. 13.A nurse is administering a potassium supplement to a client. What will the nurse do to disguise the taste and decrease gastric irritation? A) Dilute it B) Give it after meals C) Mix it with food D) Freeze it Ans: A) Dilute it Feedback: Nurses must accurately administer supplements, following manufacturer’s guidelines. Potassium supplements should be diluted to disguise the unpleasant taste and decrease gastric irritation. 14.A student is learning how to administer intravenous fluids, including accessing a vein. Although all of the following may occur, which is the most potentially harmful risk posed for the client when accessing the vein? A) Discomfort B) Pain C) Minor bleeding D) Infection Ans: D) Infection Feedback: Accessing a vein increases the risk for infection. Sterile technique must be used when puncturing the vein. 15.Which location might the nurse use to assess the condition of an insertion site for a central venous access device? A) Below the sternum B) Over the fourth intercostal space C) Over the jugular vein D)The back of the hand Ans: C) Over the jugular vein Feedback: Central venous access devices are usually introduced into the subclavian or jugular vein and passed to the superior vena cava, just above the atrium. The nurse would assess the insertion site over the jugular vein in this question. 16.A specially trained nurse has inserted a PICC line. What would be done next? A) Start administration of prescribed fluids. B) Explain the procedure to the client and family. C) Place the client on restricted oral fluids. D) Send the client to the radiology department. Ans: D) Send the client to the radiology department Feedback: Radiographic verification of proper placement is always required before using a PICC line. 17.Cross-matching of blood is ordered for a client before major surgery. What does this process do? A) Determines compatibility between blood specimens B) Determines a person’s blood type C) Predicts the amount of needed blood replacement D) Specifies the donor and the recipient of the blood Ans: A) Determines compatibility between blood specimens Feedback: Before any blood can be given to a client, it must be determined that the blood of the donor is compatible with that of the client. The process of determining compatibility between blood specimens is cross-matching. The examination to determine a person’s blood type is called typing. 18.A client asks a nurse if it is possible to contract a disease by donating blood. How would the nurse respond? A) “There is only a very small chance; I know you will be safe. B) “Although hepatitis is possible, AIDS is not.” C) “If I were you, I would request special handling of my blood.” D) “There is no way you can contract a disease by giving blood.” Ans: D) “There is no way you can contract a disease by giving blood.” Feedback: Blood donors are carefully assessed and screened. There is no way that donors can contract any disease by giving blood. 19.A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this? A) The client’s family members have been donors. B) The client donates his or her own blood. C) The client’s blood has been rendered sterile. D) The client will only need fluids, not blood. Ans: B) The client donates his or her own blood. Feedback: Some patients who know in advance that they will need blood can donate their own blood for transfusion. This is called autologous transfusion or autotransfusion. 20.A client is having a blood transfusion, but the fluid is dripping very slowly. The blood has been infusing for more than four hours. What should the nurse do next? A) Continue with the transfusion and document the drip rate. B) Report to the next shift the amount of blood left to infuse. C) Take and record vital signs more often. D) Discontinue the blood transfusion. Ans: D) Discontinue the blood transfusion. Feedback: Blood that has been transfusing for more than four hours must be discontinued to prevent the risk of bacterial contamination. 21.Which client would be the most likely candidate for the administration of total parenteral nutrition? A) A client with severe pancreatitis B) A client with a myocardial infarction C)A client with hepatitis B D)A client with mild malnutrition Ans: A) A client with severe pancreatitis Feedback: Total parenteral nutrition (TPN) is a highly concentrated nutrient solution consisting of dextrose, amino acids, and select electrolytes, vitamins, minerals, and trace elements that must be infused through a central vein because of its hypertonic nature. TPN frequently is given to clients with severe inflammatory bowel disease, severe pancreatitis, or acquired immunodeficiency syndrome (AIDS), who are unable to meet their nutritional needs through the oral or enteral routes. 22.A nurse is initiating a peripheral venous access IV infusion ordered for a client presurgically. In what position would the nurse place the client to perform this skill? A) High-Fowler’s B) Low-Fowler’s C) Sims’ D) Dorsal recumbent Ans: B) Low-Fowler’s Feedback: The low-Fowler’s position permits either arm to be used and allows for good body alignment. 23.A client with dehydration is being administered IV fluids. During her rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible? A) Phlebitis B) Thrombus formation C) Pulmonary embolus D) Air embolism Ans: A) Phlebitis Feedback: The nurse should record that the client has phlebitis, which is an inflammation of the vein. Thrombus formation is a situation in which there is a stationary blood clot. Pulmonary embolus is a situation in which the blood clot travels to the lung. Air embolism is a bubble of air traveling within the vascular system 24. A nurse is caring for a client with phlebitis. The nurse notices that the client’s forearm, which has the tubing, has become red and slightly warm. Which of the following actions should the nurse perform to avoid further complications and provide relief to the client? A) Administer oxygen. B) Call for help. C) Discontinue the IV promptly. D) Elevate the affected arm. Ans: C) Discontinue the IV promptly. Feedback: When there is phlebitis, the nurse should discontinue the IV promptly and apply warm compresses to the affected site to provide immediate relief to the client. The nurse elevates the client’s affected arm when there is infiltration. When there is pulmonary embolus, the nurse should call for help and administer oxygen. 25.A client has a physician’s order for NPO (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose? A) Replace fluid and electrolytes B) Administer blood products C) Provide protein supplements D) Treat the client’s infection Ans: A) Replace fluid and electrolytes Feedback: The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost due to the NPO order, and the loss of fluid and electrolytes due to the nasogastric suctioning. 26.Which client will have more adipose tissue and less fluid? A) A woman B) A man C) An infant D) A child Ans: A) A woman Feedback: Women have a lower fluid content because they have more adipose tissue then men. 27.Which of the following individuals with diarrhea for three days is more likely to suffer from fluid and electrolyte imbalance? A) Infant B) School-age child C) Adolescent D) Young adult Ans: Infant Feedback: The very young child and older adults are at greatest risk for fluid or electrolyte imbalances. 28.Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? A) Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea B) Congestive heart failure related to edema C)Fluid volume excess related to loss of sodium and potassium D)Fluid volume deficit related to congestive heart failure, as evidenced by shortness of breath Ans: A) Extracellular volume excess related to heart failure, as evidenced by edema and orthopnea Feedback: Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid. 29.A nurse is caring for a client with dehydration. Which of the following signs is observed in a client with dehydration? Select all that apply. A) Decreased skin turgor over sternum B) Decreased blood pressure C) Low urine output D) Increased pulse rate E) Increased respiratory rate Ans: A, B, C Feedback: The nurse should note decreased skin turgor, decreased blood pressure, and low urine output in a client with dehydration. The client’s pulse and respiratory rate would decrease, instead of increase, with dehydration. 30.A nurse assessing the IV site of a client observes swelling and pallor around the site and notes a significant decrease in the flow rate. The client complains of coldness around the infusion site. What IV complication does this describe? A) Infiltration B) Sepsis C) Thrombus D) Speed shock Ans: A) Infiltration Feedback: Infiltration is the escape of fluid into the subcutaneous tissue due to a dislodged needle that has penetrated a vessel wall. Signs and symptoms include swelling, pallor, coldness, or pain around the infusion site, and significant decrease in the flow rate. The signs of sepsis include red and tender insertion site, fever, malaise, and other vital sign changes. The symptoms of thrombus are local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site. The signs of speed shock are pounding headache, fainting, rapid pulse rate, apprehension, chills, back pains, and dyspnea. 31.A nursing responsibility in managing IV therapy is to monitor the fluid infusions and to replace the fluid containers as needed. Which of the following is an accurate guideline for IV management that the nurse should consider? A) The nurse should use new tubing when attaching additional IV solutions. B) As one bag is infusing, the nurse should prepare the next bag, so it is ready for a change when less than 10 mL of fluid remains in the original container. C) It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician’s order. D) the nurse should change the administration sets of simple IV solutions every 24 hours. Ans: C) It is the responsibility of the nurse to provide ongoing verification of the IV solution and the infusion rate with the physician’s order. Feedback: The nurse’s ongoing verification of the IV solution and the infusion rate with the physician’s order is essential. If more than one IV solution or medication is ordered, the nurse should make sure the additional IV solution can be attached to the existing tubing. As one bag is infusing, the nurse should prepare the next bag, so it is ready for a change when less than 50 mL of fluid remains in the original container. Every 72 hours is recommended for changing the administration sets of simple IV solutions. 32.A nurse is changing a peripheral venous access dressing for a client. Which of the following is a recommended step in this procedure? A) Observe clean technique to minimize the possibility of contamination. B) Cleanse site thoroughly with sterile saline, or according to facility policy. C) Apply chlorhexidine using a back and forth friction scrub for at least 30 seconds. D) Wipe or blot the site dry and allow to dry completely before covering. Ans: C) Apply chlorhexidine using a back and forth friction scrub for at least 30 seconds. Feedback: The nurse should do the following: observe meticulous aseptic technique to minimize the possibility of contamination; cleanse site with an antiseptic solution, such as chlorhexidine, or according to facility policy; press applicator against the skin and apply chlorhexidine using a back and forth friction scrub for at least 30 seconds. The nurse should not wipe or blot and should allow to dry completely before reapplying dressing. 33.A nurse flushing a capped, peripheral venous access device finds that the IV does not flush easily. What is the appropriate intervention in this situation? A) If infiltration or phlebitis is present, apply a sterile dressing to the site. B) Aspirate and attempt to flush the line again. C) If resistance remains after aspirating and flushing, forcefully flush the line. D) If catheter has pulled out a short distance, push back in and flush line again. Ans: B) Aspirate and attempt to flush the line again. Feedback: If the IV does not flush easily, assess the insertion site. Infiltration and/or phlebitis may be present. If present, remove and restart in another location. In addition, the catheter may be blocked or clotted due to a kinked catheter at the insertion site. Aspirate and attempt to flush again. If resistance remains, do not force. Forceful flushing can dislodge a clot at the end of the catheter. Remove and restart in another location. If assessment reveals the catheter has pulled out a short distance, do not reinsert it; it is no longer sterile. Remove and restart in another location. 34.A nurse inadvertently partially dislodges a PICC line when changing the dressing. What would be the appropriate intervention in this situation? A) Swab the line with sterile saline and gently reinsert the line. B) Sedate the client, remove the PICC line, and then notify the physician. C) Set up a sonogram for the client to determine the end point of the line. D) Reapply the dressing and notify the physician for further instructions. Ans: D) Reapply the dressing and notify the physician for further instructions. Feedback: When a PICC line is not all the way out, the nurse should notify the physician. The physician will most likely order a chest x-ray to determine where the end of the PICC line is. A dressing should be reapplied before the chest x-ray, to prevent further dislodgement. 35.The client is admitted to the nurse’s unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is which of the following? A) Fluid volume deficit B) Myocardial Infarction C) Fluid volume excess D) Atelectasis Ans: C) Fluid volume excess Feedback: A common cause of fluid volume excess is failure of the heart to function as a pump, resulting in accumulation of fluid in the lungs and dependent parts of the body. Fluid volume deficit does not manifest itself as edema and abnormal lung sounds, but results in poor skin turgor, sunken eyes, and dry mucous membranes. Atelectasis is a collapse of the lung and does not have to do with fluid abnormalities. Myocardial infarction results from a blocked coronary artery and may result in heart failure, but is not a term for fluid volume excess