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2204 Fluid & Electrolyte NCLEX Practice Questions Leave the first rating Students also studied Terms in this set (47) Science MedicineNursing Save
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12 terms ching_yang4Preview Immun 20 terms han What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused?
- risk of dehydration
- risk of kidney damage
- risk of stroke
- risk of bleeding
Answer: 1
Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality.Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & electrolyte issues.Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues.Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues.The nurse is planning care for a pt with severe burns.Which of the following is this pt at risk for developing?
- intracellular fluid deficit
- intracellular fluid overload
- extracellular fluid deficit
- interstitial fluid deficit
Answer: 1
Rationale 1: Because this pt was severely burned, the fluid within the cells is
diminished, leading to an intracellular fluid deficit.Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.
A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, & decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following?
- the body's natural compensatory mechanisms
- pharmacological effects of a diuretic
- effects of rapidly infused intravenous fluids
- cardiac failure
Answer: 1
Rationale 1: The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain & heart.Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in
urine output.Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of diabetes insipidus.The nurse chooses which of the following nursing diagnoses as most appropriate?
- Risk for Imbalanced Fluid Volume
- Excess Fluid Volume
- Imbalanced Nutrition
- Ineffective Tissue Perfusion
Answer: 1
Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can increase the serum levels of sodium.Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially during the early stages of treatment.
Rationale 3: Imbalanced Nutrition does not apply.
Rationale 4: Ineffective Tissue Perfusion does not apply
A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the pt's primary healthcare provider with which of the following 24-hour urine output volumes?
- 600 mL
- 750 mL
- 1000 mL
- 1200 mL
Answer: 1
Rationale 1: A urine output of less than 30 mL per hour must be reported to the
primary healthcare provider. This indicates inadequate renal perfusion, placing the pt at increased risk for acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication?
- fluid volume excess
- fluid volume deficit
- seizure activity
- liver failure
Answer: 1
Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following the stress response before, during, & immediately after surgery. This increase leads to sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system.Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, & stress upon the heart & circulatory system.Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances.Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid administration.A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented?
- seizure
- infection
- neutropenic
- high-risk fall
Answer: 1
Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such
as a quiet environment, raised side rails, & having an oral airway at the bedside would be included.
Rationale 2: Infection precautions not specifically indicated for a pt with
hyponatremia.
Rationale 3: Neutropenic precautions not specifically indicated for a pt with
hyponatremia.Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.
A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the following might have contributed to the pt's health problem?
- corticosteroid
- thiazide diuretic
- narcotic
- muscle relaxer
Answer: 1
Rationale 1: Excess potassium loss through the kidneys is often caused by such
meds as corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.
Rationale 2: Excessive sodium is lost with the use of thiazide diuretics.
Rationale 3: Narcotics do not typically affect electrolyte balance.
Rationale 4: Muscle relaxants do not typically affect electrolyte balance.
A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following?
- hyperkalemia
- hypokalemia
- hypercalcemia
- hypocalcemia
Answer: 1
Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L.
Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes.
Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide.
Rationale 3: Hypercalcemia has been associated with thiazide diuretics.
Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is not associated with diuretic use.The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt's plan of care?
- Restrict fluids.
- Administer intravenous fluids.
- Provide Kayexalate.
- Administer intravenous normal saline with furosemide.
Answer: 1
Rationale 1: The nursing care for a pt with hyponatremia is dependent on the
cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from dropping further due to dilution.Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit & hypernatremia.
Rationale 3: Kayexalate is used in pts with hyperkalemia.
Rationale 4: The administration of normal saline with furosemide is used to
increase calcium secretion.When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the pt?
- other electrolyte disturbances
- hypertension
- visual disturbances
- drug toxicity
Answer: 1
Rationale 1: The pt diagnosed with hypocalcemia may also have high phosphorus
or decreased magnesium levels.
Rationale 2: The pt with hypocalcemia may exhibit hypotension, & not
hypertension.
Rationale 3: Visual disturbances do not occur with hypocalcemia.
Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.
A pt with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this pt's plan of care?
- Request a dietitian consult for selecting foods high in
- Provide aluminum hydroxide antacids as prescribed.
- Instruct pt to avoid poultry, peanuts, & seeds.
- Instruct to avoid the intake of sodium phosphate.
phosphorous.
Answer: 1
Rationale 1: Treatment of hypophosphatemia includes treating the underlying
cause & promoting a high phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans & peas, eggs, fish, organ meats, Brazil nuts & peanuts, poultry, seeds & whole grains.
Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be
avoided.
Rationale 3: Poultry, peanuts, & seeds are part of a high phosphate diet.
Rationale 4: Mild hypophosphatemia may be corrected by oral supplements, such
as sodium phosphate.
When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms?
- The kidneys retain bicarbonate.
- The kidneys excrete bicarbonate.
- The lungs will retain carbon dioxide.
- The lungs will excrete carbon dioxide.
Answer: 1
Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate.
Rationale 2: Excreting bicarbonate causes acidosis to develop.
Rationale 3: Retaining carbon dioxide causes respiratory acidosis.
Rationale 4: Excreting carbon dioxide causes respiratory alkalosis
The nurse is caring for a pt diagnosed with renal failure.Which of the following does the nurse recognize as compensation for the acid-base disturbance found in pts with renal failure?
- The pt breathes rapidly to eliminate carbon dioxide.
- The pt will retain bicarbonate in excess of normal.
- The pH will decrease from the present value.
- The pt's oxygen saturation level will improve.
Answer: 1
Rationale 1: In metabolic acidosis compensation is accomplished through
increased ventilation or "blowing off" C02. This raises the pH by eliminating the volatile respiratory acid & compensates for the acidosis.
Rationale 2: Because compensation must be performed by the system other than
the affected system, the pt cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal bicarbonate value.
Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the
manifestation of the disease process, not the compensation.Rationale 4: Oxygenation disturbance is not part of the acid-base status of the pt with renal failure.When caring for a group of pts, the nurse realizes that which of the following health problems increases the risk for metabolic alkalosis?
- bulimia
- dialysis
- venous stasis ulcer
4. COPD
Answer: 1
Rationale 1: Metabolic alkalosis is cause by vomiting, diuretic therapy or
nasogastric suction, among others. A pt with bulimia may engage in vomiting or indiscriminate use of diuretics.
Rationale 2: A pt receiving dialysis has kidney failure, which causes metabolic
acidosis.
Rationale 3: A venous stasis ulcer does not result in an acid-base disorder.
Rationale 4: The pt diagnosed with COPD typically has hypercapnea & respiratory acidosis.The nurse is caring for a pt who is anxious & dizzy following a traumatic experience. The arterial blood gas
findings include: pH 7.48, PaO2 110, PaCO2 25, & HCO3
- The nurse would anticipate which initial intervention to
- Encourage the pt to breathe in & out slowly into a
- Immediately administer oxygen via a mask & monitor
- Prepare to start an intravenous fluid bolus using
- Anticipate the administration of intravenous sodium
correct this problem?
paper bag.
oxygen saturation.
isotonic fluids.
bicarbonate.
Answer: 1
Rationale 1: This pt is exhibiting signs of hyperventilation that is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the pt to retain carbon dioxide & lower oxygen levels to normal, correcting the cause of the problem.Rationale 2: The oxygen levels are high, so oxygen is not indicated, & would exacerbate the problem if given. Intravenous fluids would not be the initial intervention.
Rationale 3: Not enough information is given to determine the need for
intravenous fluids.
Rationale 4: Bicarbonate would be contraindicated as the pH is already high.
A pt is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the pt is receiving this replacement is
- to sustain respiratory function.
- to help regulate acid-base balance.
- to keep a vein open.
- to encourage urine output.
Answer: 2
Rationale 1: Potassium does not sustain respiratory function.
Rationale 2: Electrolytes have many functions. They assist in regulating water
balance, help regulate & maintain acid-base balance, contribute to enzyme reactions, & are essential for neuromuscular activity.
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