Fluid and Electrolytes EXAM 4 questions

Fluid and Electrolytes EXAM #4 questions Leave the first rating Students also studied Terms in this set (40) Science MedicineNursing Save Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Fluid & Electrolyte NCLEX Practice ...145 terms ngreen14Preview ATI Fluid, Electrolyte, and Acid-Bas...30 terms whitney_flansburg Preview ATI Eng 30 terms Rom A nurse is caring for a critically ill patient with a urinary retention catheter. Which hourly urine output should first alert the nurse that the primary healthcare provider should be notified?

• 20 mL
• 30 mL
• 60 mL
• 120 mL
• The circulating blood volume perfuses the kidneys, producing a glomerular

filtrate of which varying amounts are either reabsorbed or excreted to maintain fluid balance. When a person's hourly urine output is only 30 mL, it indicates a deficient circulating fluid volume, inadequate renal perfusion, and/or kidney disease. The primary health-care provider should be notified.A nurse is caring for a patient who has dependent edema.Which pressure has caused the excess fluid in the interstitial compartment?

• Oncotic pressure
• Diffusion pressure
• Hydrostatic pressure
• Intraventricular pressure
• Hydrostatic pressure is the pressure exerted by a fluid within a compartment,

such as blood within the vessels. Hydrostatic pressure moves fluid from an area of greater pressure to an area of lesser pressure. Hydrostatic pressure within vessels of the body moves fluid from the intravascular compartment into the interstitial compartment. Interstitial fluid is extracellular fluid that surrounds cells.A nurse evaluates a patient’s fluid balance by monitoring the patient’s intake and output. Which must the nurse understand about the ratio of the patient’s fluid intake to output?

• Intake should be slightly more than the output.
• Intake should be higher than the fluid output.
• Intake should be lower than the urine output.
• Intake should be equal to the urine output.
• The volume and composition of body fluids are kept in a delicate balance (total

intake is slightly more than total output) by a harmonious interaction of the kidneys and the endocrine, respiratory, cardiovascular, integumentary, and gastrointestinal systems.

Hydrochlorothiazide (HCTZ), a diuretic, is prescribed for a patient who is retaining fluid. The nurse should encourage the patient to ingest nutrients that contain which electrolyte?

• Magnesium
• Potassium
• Calcium
• Sodium
• Most diuretics affect the renal mechanisms for tubular secretion and

reabsorption of electrolytes, particularly potassium. Because of potassium’s narrow therapeutic window of 3.5 to 5.0 mEq/L and its role in the sodium- potassium pump and muscle contraction, depleted potassium must be supplemented by increasing the dietary intake of foods high in potassium and/or the administration of potassium drug therapy.Which should a nurse do to encourage a confused patient to drink more fluid?

• Serve fluid at a tepid(lukewarm) temperature.
• Explain the reason for the desired intake.
• Offer the patient something to drink every hour.
• Leave a pitcher of water at the patient’s bedside.
• Frequent smaller volumes of fluid (50 to 100 mL/hr) are better tolerated

physiologically and psychologically than infrequent larger volumes of fluid.A nurse suspects that an older adult may have a fluid and electrolyte imbalance. Which assessment best reflects fluid and electrolyte balance in an older adult?

• Intake and output results
• Serum laboratory values
• Condition of the skin
• Presence of tenting
• Laboratory studies provide objective measurements of indicators of fluid,

electrolyte, and acid-base balance. Common diagnostic tests include serum blood studies of electrolytes (e.g., sodium, potassium, chloride, and calcium), osmolarity, hemoglobin, hematocrit, and arterial blood gases.A patient has continuous bladder irrigation. Which should the nurse do with the irrigant on the I&O sheet when calculating the fluid balance for this patient?

• Add it to the oral intake column.
• Deduct it from the total urine output.
• Subtract it from the intravenous flow sheet as output.
• Document the intake hourly in the urine output column.
• When continuous bladder irrigation is in use, drainage from the urinary bladder

will consist of both urine and the instilled irrigant. To determine the patient's urinary output, the amount of the irrigant instilled must be deducted from the total urinary output.A nurse is caring for two patients; one has oliguria and the other has polyuria. Which is the priority problem that is a concern for the nurse regarding both of these patients?

• Diarrhea
• Cachexia (malnutrition)
• Fluid volume deficit
• Impaired skin integrity
• The production of excessive amounts of urine by the kidneys (polyuria) without

an increase in fluid intake can precipitate a fluid volume deficit. Oliguria, the production of excessively small amounts of urine by the kidney, is reflected as a negative balance in the intake and output. A negative balance of intake and output is a characteristic of fluid volume deficit.A primary health-care provider orders a patient’s IV fluids to be discontinued. Which is an essential nursing intervention when discontinuing the patient’s intravenous infusion?

• Withdraw the intravenous catheter along the same

angle of its insertion.

• Use an alcohol swab to scrub the insertion site.
• Flush the line with normal saline.
• Don sterile gloves.
• Removing an intravenous catheter by withdrawing it along the same path of its

insertion minimizes injury to the vein and trauma to the surrounding tissue. This action limits seepage of blood and promotes healing of the puncture wound.

A patient is admitted to the hospital for a fever of unknown origin. The nursing assessment reveals profuse diaphoresis, dry, sticky mucous membranes, weakness, disorientation, and a decreasing level of consciousness.Which electrolyte imbalance does this data support?

• Hyperkalemia
• Hypercalcemia
• Hypernatremia
• Hypermagnesemia
• With profuse diaphoresis, the water loss exceeds the sodium loss, resulting in

hypernatremia. Excess serum sodium precipitates changes in the musculoskeletal (weakness), neurological (disorientation and decreased level of consciousness), and integumentary (dry, sticky mucous membranes) systems.A patient exhibits an increasing blood pressure and 2-lb weight gain over 2 days. Which additional clinical manifestation can be clustered with these data?

• Decrease in heart rate
• Increase in skin turgor
• Increase in pulse volume
• Decrease in pulse pressure
• With an excess fluid volume the amount of circulating blood volume increases,

resulting in full, bounding peripheral pulses.An assessment of which of the following is most important when a nurse is caring for an adult patient experiencing vomiting?

• Oral mucous membranes
• Electrolyte values
• Bowel function
• Body weight
• Vomiting results in a loss of chloride (greatest amount), sodium (next greatest

amount), and potassium (least amount, but of greatest importance because it can cause dysrhythmias and cardiac arrest).A primary health-care provider orders an intravenous infusion containing potassium for a patient. Which is the most important nursing intervention before administering this solution to the patient?

• Assess the skin turgor.
• Obtain the blood pressure.
• Measure the depth of edema.
• Determine the presence of urinary output.
• Serum potassium has a narrow therapeutic window (3.5 to 5.0 mEq/L). When

kidney function is impaired, potassium can accumulate in the body and exceed the therapeutic level of 5.0 mEq/L, which can cause cardiac dysrhythmias and arrest.Which is the best choice for an appetizer when teaching a patient about a 2-g sodium diet?

• Pigs in a blanket
• Stuffed mushrooms
• Cheese and crackers
• Fresh vegetable sticks
• As a food group, fresh vegetables have low sodium content. The sodium

content of vegetables includes 1 cup of broccoli, 17 mg; 1 cup of cauliflower, 20 mg; 1 carrot, 25 mg; 1 pepper, 2 mg; 1 radish, 1 mg; 1 cup of mushrooms, 3 mg; and

• slices of cucumber, 1 mg.

A nurse is documenting a patient’s I&O. Which should be recorded at approximately half its volume?

• Ice chips given by mouth
• A continuous bladder irrigation
• Solution used to maintain patency of a tube
• A tube feeding of half formula and half water
• Ice chips are particles of frozen water that take up more volume when they are

frozen than when they melt. When ice chips change from a solid to a liquid, the resulting fluid is approximately half the volume of the ice chips.

Several patients are taking supplemental calcium daily.The nurse teaches them to maintain their fluid intake at a minimum of 2,500 mL. The nurse explains that this intervention is designed to prevent which complication?

• Mobilization of calcium from bone
• Irritation of the bladder mucosa
• Occurrence of muscle cramps
• Formation of kidney stones
• A high fluid intake increases the volume of urine produced. The resulting

frequent urination of dilute urine prevents the formation of renal calculi, which may occur because of the increased precipitation of calcium salts associated with calcium supplementation.A patient receiving an enteral feeding develops diarrhea.Which characteristic of the tube feeding formula does the nurse conclude precipitated the diarrhea?

• Icteric
• Isotonic
• Hypotonic
• Hypertonic
• Hypertonic solutions have a greater concentration of solutes than does the

blood. The high osmolarity of a hypertonic enteral feeding exerts an osmotic force that pulls fluid into the gastrointestinal tract, resulting in intestinal cramping and diarrhea.A nurse identifies that an older adult patient may have a problem with excess fluid volume. Which characteristics of the patient’s skin support this conclusion?

• Dry and scaly
• Taut and shiny
• Red and irritated
• Thin and inelastic
• With excessive fluid volume, the increased hydrostatic pressure moves fluid

from the intravascular compartment into the interstitial compartment. As fluid collects in the interstitial compartment (edema), the skin appears taut and shiny.When a patient is under extreme stress, there is an increased production of antidiuretic hormone (ADH) and aldosterone. The nurse plans to monitor the patient routinely because an increase in these hormones will cause a decrease in which of the following?

• Blood pressure
• Urinary output
• Body temperature
• Sweat gland secretions
• Both hormones are involved with water reabsorption, which conserves fluid and

results in a decreased urinary output. With decreased kidney perfusion, the juxtaglomerular cells of the kidneys release angiotensin II, which stimulates the release of aldosterone from the adrenal cortex. Aldosterone promotes the excretion of potassium and reabsorption of sodium, which results in the passive reabsorption of water. As the concentration of the blood (osmolality) increases, the anterior pituitary releases antidiuretic hormone (ADH). ADH causes the collecting ducts in the kidneys to become more permeable to water, thus promoting its reabsorption into the blood.A nurse checks a meal tray for a patient on a clear liquid diet. Which item is acceptable on this diet?

• Ginger ale
• Lemon sherbet
• Vanilla ice cream
• Cream of chicken soup
• Ginger ale is an easily ingested and digested liquid that is permitted on a clear

liquid diet. It relieves thirst, prevents dehydration, and minimizes stimulation of the gastrointestinal tract.A nurse is caring for a patient who has a reduced fluid intake. The nurse assesses the patient for which response to this reduced fluid intake?

• Urinary retention
• Frequent urination
• Incontinence of urine
• Decreased urine output
• When the serum osmolarity increases because of insufficient fluid intake,

antidiuretic hormone increases the permeability of the collecting tubules in the kidneys, which increases the reabsorption of water and decreases urine output.