Fluids and Electrolytes Nursing Questions with Rationales

Fluids and Electrolytes Nursing Questions with Rationales ScienceMedicineNursing rebekahbeth22 Save Fluid & Electrolyte NCLEX Practice ...145 terms ngreen14Preview Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Electrolytes - Nursing 86 terms Erinl1972Preview Chapte 44 term Tim 1) 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 health-care provider should be notified?

• 20mL
• 30mL
• 80mL
• 120mL

Answer:

2

Rationale:

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 30mL, it indicates a deficient circulating fluid volume inadequate renal perfusion and/or kidney disease. THe primary health-care provider should be notified. The PCP should be notified long before the hourly urine output reaches 20mL, the hourly output of 60mL is close to the expected range of 30-50mL/hr, and the PCP should not be notified for 120mL because it it indicates adequate kidney perfusion.

2) 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

Answer:

3

Rationale:

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. Oncotic pressure is the force exerted by colloids that pull or keep fluid within the intravascular compartment, it is the major force opposing hydrostatic pressure in the capillaries.Diffusion is a continual intermingling of molecules with movement of molecules from a solution of higher concentration to lower. Intraventricular pressure is the pressure that exists in the left and right ventricles of the heart. They do not move fluid.3) 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 and 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

Answer:

1

Rationale:

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 kidenys and the endocrine, respiratory, cardiovascular, integumentary, and gastrointestinal systems. It can't be 2 because if total intake is higher than output the patient will develop an excess fluid volume. 3 isn't it because if the total intake is lower than the urine output, the patient will develop a deficient fluid volume. It can't be 4 because if intake and urine output are equal the pt will develop a deficient fluid volume because of fluid loss through routes other than the kidneys.4) 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

Answer:

2

Rationale:

Most diuretics affect the renal mechanisms for tubular secretion and reabsorption of electrolytes, particularly potassium. Because of potassium's narrow therapetuci window of 3.5-5.0mEq/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. It isn't 1 because even though loop and thiazide diuretics enhance magnesium excretion, which may produce mild hypomagnemesia, it does not require magnesium supplementation. It can't be 3 because serum calcium levels vary depending on the diuretic, thiazide diuretics such as HCTZ decrease calcium excretion, which may produce hypercalcemia. Loop diuretics increase calcium excretion, which may produce hypocalcemia. It can't be 4 because although hyponatremia may occur with diuretics usually it is mild and does not require sodium supplementation.

5) Which should a nurse do to encourage a confused patient to drink more fluid?

• SErve fluid at a tepid temperature
• Explain the reason for the desired intake.
• Offer the patient something to drink every hour
• Leavea pitcher of water at the patient's bedside

Answer:

3

Rationale:

Frequent smaller volumes of fluid (50-100mL/hr) are better tolerated physiologically and psychologically than infrequent larger volumes of fluid.6) 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

Answer:

2

Rationale:

Lab studies provide objective measurements of indicators of fluid, electrolyte, and acid-base balance. Common diagnostic tests include serum blood studies of electrolytes (eg sodium, potassium, chloride, and calcium) osmolarity, hemoglobin, hematocrit, and arterial blood gases.7) A patient has continuous bladder irrigation. Which should the nurse do with the irrigant on the I&O sheet when calculating the lfuid 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

Answer:

2

Rationale:

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.8) 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 (profound state of malnutrition)
• Fluid volume deficit
• Impaired skin integrity

Answer:

3

Rationale:

The production of excessive amounts of urine by the kidneys (polyuria) w/o 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.

9) 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 line
• Flush the line with normal saline
• Don sterile gloves

Answer:

1

Rationale:

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.10) 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
• Hypermagnesmia

Answer:

3

Rationale:

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.11) 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

Answer:

3

Rationale:

With an excess fluid volume the amount of circulating blood volume increases, resulting in full, bounding peripheral pulses.12) 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

Answer:

2

Rationale:

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)