chapter 51: fluid electrolytes: NCLEX? end of chapter questions

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51: Fluid, electrolyte, and Acid-Base ...

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Chapter 52: Fluid, and Electrolyte Te...

31 terms PharmRN85Preview Fundam 342 term jrbr 1) The 154-pound adult client has had vomiting and diarrhea for 4 days secondary to a viral infection. What hourly urine measurement would indicate that efforts to rehydrate this client have been unsuccessful and should continue?

• 35 mL per hour
• 80 mL per hour
• 50 mL per hour
• 30 mL per hour

4 The nurse suspects that a client's body is attempting to correct an acid-base imbalance. How will this imbalance be corrected?

• Slow but efficient respiratory regulation will occur.
• Primary regulation is through GI system losses.
• Kidney regulation is powerfully effective.
• The cardiovascular system is the major buffer.

3

• The nurse is caring for a client who is recovering from surgery. Which intervention should the nurse implement to decrease the client's

possibility of developing hypercalcemia?

• Measure vital signs every 4 hours.
• Assist the client to turn, cough, and deep-breathe every 2 hours.
• Assist the client to ambulate around the room at least three times daily.
• Irrigate the client's nasogastric tube every 2 hours.

3

The client is admitted to the acute care unit with a phosphorus level of 2.3 mg/dL. Which nursing intervention would support this client's homeostasis?

• Encourage consumption of milk and yogurt.
• Enforce strict isolation protocols.
• Encourage consumption of a high-calorie carbohydrate diet.
• Strain all urine

1 The mother of a 1-month-old infant is concerned because the infant has had vomiting and diarrhea for 2 days. What instruction should the nurse give this infant's mother?

• Have the infant be seen by a physician.
• Give the infant at least 2 ounces of juice every 2 hours.
• Measure the infant's urine output for 24 hours.
• Provide the infant with 50 mL of glucose water.

1 A client has had a subclavian central venous catheter inserted. What should the nurse assess as a priority for this client's care?

• Presence of bibasilar crackles
• Tachycardia
• Decreased pedal pulses
• Headache

2 The nurse is caring for a client who is receiving intravenous fluids that are not regulated on an electronic controller. In order to calculate the rate of the IV flow in drops per minute, the nurse must know the number of drops per milliliter of fluid the tubing delivers. Where should the nurse look for this information?

• On the packaging of the tubing
• In the charting from the nurse who started the infusion
• In the drug reference book
• On the roller clamp of the tubing

1 The physician has ordered 50 mL of an IV solution to infuse over the next 20 minutes. In order to accurately infuse this solution, the nurse should set the electronic controller to deliver how many mL/hr? Record your answer, rounding to the nearest whole number.

answer: 150 ml/hr

Explanation: 50 mL/20 minutes = × mL/60 minutes. 3000/20 = 150 mL/hr

The nurse is to administer 75 mL of an antibiotic solution by IV over the next 30 minutes. The tubing has a drop factor of 20. How many drops per minute should the nurse set the controller to deliver? Record your answer, rounding to the nearest whole number.

answer: 50 gtts/min

Explanation: 75 mL/1 hour × 20 drops/30 minutes = 50 drops per minute.

The nurse is caring for a client who is receiving IV therapy at a rate of 10 mL/hour. The 500-mL IV bottle was hung at 0900 Monday morning when the IV catheter was initiated. It is now 0900 on Tuesday morning. What nursing action should be taken?

• Refigure the rate of the IV.
• Infuse the remaining IV fluid before hanging a new bag.
• Discard the remaining IV fluid and hang a new bag.
• Discontinue the IV site and restart an IV in the opposite hand

3 A client tells the nurse about passing out after following a fasting diet for 5 days. Which acid-base imbalance should the nurse expect to assess in this client?

• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis

3 A client is admitted to the hospital after vomiting for 3 days. Which arterial blood gas results should the nurse expect to find in this client?

• pH 7.30; PaCO2 50; HCO3 27
• pH 7.47; PaCO2 43; HCO3 28
• pH 7.43; PaCO2 50; HCO3 28
• pH 7.47; PaCO2 30; HCO3 23

2 The nurse would expect that this client is alkalotic because stomach acids have been lost, so the pH would be above 7.45. This is a metabolic problem, so the PaCO2 is likely normal. The HCO3 will likely be high (above 26). The only option that includes all of these parameters is pH 7.47; PaCO2 43; HCO3 28.

• The client's arterial blood gas report reveals a pH of 6.58. In which way should the nurse evaluate this value?
• There is a slight elevation.
• This value is incompatible with life.
• This is a low normal value.
• This value is extremely elevated.

2 A client has experienced a narcotic overdose. What acid-base imbalance should the nurse expect to observe in this client?

• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis

1

Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client experiences a headache, shortness of breath, and a fever. What action by the nurse is priority?

• Notify the client's physician.
• Discontinue the transfusion.
• Slow the rate of the transfusion.
• Prepare to resuscitate the client.

2 A client on diuretic therapy has a serum potassium level of 3.4 mg/dL. Which food should the nurse encourage this client to choose from the dinner menu?

• Baked chicken
• Green beans
• Cantaloupe
• Iced tea

3 A client needs an IV for medication to start in several hours however but assistive personnel (AP) are preparing to bathe the client. Which action should the nurse take?

• Instruct the AP to wait until the IV is started to bathe the client.
• Let the AP start the bath on the opposite side of where the nurse will be starting the IV.
• Tell the AP to notify the nurse as soon as the bath is completed.
• Give the AP permission to skip the client's bath for today.

3 The nurse is preparing to start an IV in the hand of a client who has very small veins. Which actions would be useful in dilating the veins? (Select all that apply.)

• Position the hand at heart level.
• Stroke the vein.
• Have the client clench and unclench the fist.
• Slap the back of the client's hand.
• Massage the vein.

2, 3, 5

• The client complains of burning along the vein in which a medicated IV is infusing. Upon assessment, the nurse finds the IV site is slightly

reddened, but not warmer than the surrounding skin, and without swelling. What action should be taken by the nurse?

• Slow the IV infusion and reassess the area in 15 minutes.
• Apply ice over the IV site and vein.
• Discontinue the IV and place a warm pack on the area.
• Call the physician for direction.

3