Ch. 40 Fluid, Electrolyte, and Acid-Base Balance NCLEX Questions

Ch. 40 Fluid, Electrolyte, and Acid-Base Balance NCLEX Questions ScienceMedicineNursing hcps-rockechrr Save Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Fluid & Electrolyte NCLEX Practice ...145 terms ngreen14Preview

Chapter 17: Fluid, Electrolyte, and A...

30 terms PRISCILLA_PETERS... Preview Chapte 14 terms mia 1. A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What patient teaching would the nurse provide for this patient? Select all that apply.a."Try to drink at least six to eight glasses of water each day." b."Try to limit your fluid intake to one quart of water daily." c."Limit sugar, salt, and alcohol in your diet." d."Report side effects of medications you are taking, especially diarrhea." e."Temporarily increase foods containing caffeine for their diuretic effect." f."Weigh yourself daily and report any changes in your weight." a, c, d, f.Generally, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of medications, especially diarrhea and water loss from diuretics.

• A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the

nurse documents: "Pitting edema; 6 mm pit; pit remains several seconds after pressing with obvious skin swelling." What grade of edema has this nurse documented?a.1+ pitting edema b.2+ pitting edema c.3+ pitting edema d.4+ pitting edema

• 3+ pitting edema is represented by a deep pit (6 mm) that remains seconds after pressing with skin swelling obvious by general inspection. 1+

is a slight indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+ is a 4-mm pit that lasts longer than 1+ with fairly normal contour. +4 is a deep pit (8 mm) that remains for a prolonged time after pressing with frank swelling.

• A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best choices for this condition? Select all that

apply.a.5% dextrose in 0.9% NaCl b.0.9% NaCl (normal saline) c.Lactated Ringer's solution d.0.33% NaCl (¹∕³-strength normal saline) e.0.45% NaCl (½-strength normal saline) f.5% dextrose in Lactated Ringer's solution d, e 0.33% NaCl (¹∕³-strength normal saline), and 0.45% NaCl (½-strength normal saline) are used to treat hypernatremia.

• A nurse is assessing infants in the NICU for fluid balance status. Which nursing action would the nurse depend on as the most reliable

indicator of a patient's fluid balance status?a.Recording intake and output b.Testing skin turgor c.Reviewing the complete blood count d.Measuring weight daily

• Daily weight is the most reliable indicator of a person's fluid balance status. Intake and output are not always as accurate and may involve a

subjective component. Measurement of skin turgor is subjective, and the complete blood count does not necessarily reflect fluid balance.

• Which acid-base imbalance would the nurse suspect after assessing the following arterial blood gas values: pH, 7.30; PaCO2, 36 mm Hg;

HCO3−, 14 mEq/L?a.Respiratory acidosis b.Respiratory alkalosis c.Metabolic acidosis d.Metabolic alkalosis

• A low pH indicates acidosis. This, coupled with a low bicarbonate, indicates metabolic acidosis. The pH and bicarbonate would be elevated

with metabolic alkalosis. Decreased PaCO2 in conjunction with a low pH indicates respiratory acidosis; increased PaCO2 in conjunction with an elevated pH indicates respiratory alkalosis.

• A patient has been encouraged to increase fluid intake. Which measure would be most effective for the nurse to implement?

a.Explaining the mechanisms involved in transporting fluids to and from intracellular compartments b.Keeping fluids readily available for the patient c.Emphasizing the long-term outcome of increasing fluids when the patient returns home d.Planning to offer most daily fluids in the evening

• Having fluids readily available helps promote intake. Explanation of the fluid transportation mechanisms (a) is inappropriate and does not

focus on the immediate problem of increasing fluid intake. Meeting short-term outcomes rather than long-term ones (c) provides further reinforcement, and additional fluids should be taken earlier in the day.

• A nurse is flushing a patient's peripheral venous access device. The nurse finds that the access device is leaking fluid during flushing. What

would be the nurse's priority intervention in this situation?

• remove the IV from the site and start at another location
• immediately notify the primary care provider
• use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes
• aspirate the catheter and attempt to flush again
• if the peripheral venous access site leaks fluid when flushed the nurse should remove it from site, evaluate the need for continued access, and

if clinical need is present, restart in another location

• A nurse is monitoring a patient who is receiving an IV infusion of normal saline. The patient is apprehensive and presents with a pounding

headache, rapid pulse rate, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms?a.Discontinue the infusion immediately, monitor vital signs, and report findings to primary care provider immediately.b.Slow the rate of infusion, notify the primary care provider immediately and monitor vital signs.c.Pinch off the catheter or secure the system to prevent entry of air, place the patient in the Trendelenburg position, and call for assistance.d.Discontinue the infusion immediately, apply warm, moist compresses to the site, and restart the IV at another site.

• The nurse is observing the signs and symptoms of speed shock: the body's reaction to a substance that is injected into the circulatory system

too rapidly. The nursing interventions for this condition are: discontinue the infusion immediately, report symptoms of speed shock to primary care provider immediately, and monitor vital signs once signs develop. Answer (b) is interventions for fluid overload, answer (c) is interventions for air embolus, and answer (d) is interventions for phlebitis.

• A nurse carefully assesses the acid-base balance of a patient who is unable to effectively control his carbonic acid supply. This is most likely a

patient with damage to which of the following?a.Kidneys b.Lungs c.Adrenal glands d.Blood vessels

• The lungs are the primary controller of the body's carbonic acid supply and thus, if damaged, can affect acid-base balance. The kidneys are

the primary controller of the body's bicarbonate supply. The adrenal glands secrete catecholamines and steroid hormones. The blood vessels act only as a transport system.

• A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?

a.Encourage foods and fluids with high sodium content.b.Administer oral K supplements as ordered.c.Caution the patient about eating foods high in potassium content.d.Discuss calcium-losing aspects of nicotine and alcohol use.

• Nursing interventions for a patient with hypokalemia include encouraging foods high in potassium and administering oral K as ordered.

Encouraging foods with high sodium content is appropriate for a patient with hyponatremia. Cautioning the patient about foods high in potassium is appropriate for a patient with hyperkalemia, and discussing the calcium-losing aspects of nicotine and alcohol use is appropriate for a patient with hypocalcemia.

• A nurse is administering 500 mL of saline solution to a patient over 10 hours. The administration set delivers 60 gtts/min. Determine the infusion

rate to administer via gravity infusion.Ans: 50 gtts/min. When administering 500 mL of solution over 10 hours, and the set delivers 60 gtts/mL, gtt/min = (500 x 60)/600

• A nurse is initiating a peripheral venous access IV infusion for a patient. Following the procedure, the nurse observes that the fluid does not

flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings?a.Reposition the extremity and raise the height of the IV pole.b.Apply pressure to the dressing on the IV.c.Pull the catheter out slightly and reinsert it.d.Put on gloves; remove the catheter; apply pressure with a sterile pad.

• This IV has been infiltrated. The nurse should put on gloves and remove the catheter. The nurse should also apply pressure with a sterile gauze

pad, secure the gauze with tape over the insertion site, and restart the IV in a new location.

• When monitoring an IV site and infusion, a nurse notes pain at the access site with erythema and edema. What grade of phlebitis would the

nurse document?a.1 b.2 c.3 d.4

• Grade 2 phlebitis presents with pain at access site with erythema and/or edema. Grade 1 presents as erythema at access site with or without

pain. Grade 3 presents as grade 2 with a streak formation and palpable venous cord. Grade 4 presents as grade 3 with a palpable venous cord >1 inch and with purulent drainage.

• A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry

cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms?a.Slow or stop the infusion; monitor vital signs, notify the physician, place the patient in upright position with feet dependent.b.Stop the transfusion immediately and keep the vein open with normal saline, notify the physician stat, administer antihistamine parenterally as needed.c.Stop the transfusion immediately and keep the vein open with normal saline, notify the physician, and treat symptoms.d.Stop the infusion immediately, obtain a culture of the patient's blood, monitor vital signs, notify the physician, administer antibiotics stat.

• The patient is displaying signs and symptoms of circulatory overload: too much blood administered. In answer (b) the nurse is providing

interventions for an allergic reaction. In answer (c) the nurse is responding to a febrile reaction, and in answer (d) the nurse is providing interventions for a bacterial reaction.

• A nurse is performing physical assessments for patients with fluid imbalance. Which finding indicates a fluid volume excess?
• a pinched and drawn facial expression
• deep, rapid respirations
• moist crackles heard upon auscultation
• tachycardia
• moist crackles may indicate fluid volume excess Terms (15)

Hide definitions