Fluids, Electrolytes and Acid-Base Balance Practice NCLEX questions

Fluids, Electrolytes and Acid-Base Balance Practice NCLEX questions Leave the first rating Students also studied Terms in this set (44) Science Biology Physiology Save leg muscle anatomy 31 terms aleahponder2 Preview

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ATI- TE

Teacher ann What are the functions of body fluids? Select all that apply.

1.Body fluids maintain blood volume.

2.Body fluids regulate body temperature.

3.Body fluids promote gas exchange in the lungs.

4.Body fluids aid in conduction between neurons.

5.Body fluids transport materials to and from cells.

6.Body fluids facilitate the excretion of bodily wastes.

Answer: 1, 2, 5, 6

Rationales

Option 1:

Body fluids help maintain blood volume, as they are part of the plasma.

Option 2:

Body fluids such as water allow the body to release or retain heat during changes in temperature.

Option 3:

Red blood cells contain hemoglobin and work in the capillary level to promote gas exchange. This does not involve body fluids.

Option 4:

Neurotransmitters, not fluids, aid in conduction between neurons.

Option 5:

Body fluids provide the medium for moving materials such as electrolytes, nutrients, and wastes between body cells.

Option 6:

Water is eliminated in both urine and feces.

[Page reference: 1465]

Which electrolytes would be found in the intracellular fluid? Select all that apply.

1.Sodium 2.Chloride 3.Phosphate 4.Potassium 5.Magnesium

Answer: 3, 4, 5

Rationales

Option 1:

Sodium is an electrolyte found in the extracellular fluid.

Option 2:

Chloride is an electrolyte found in the extracellular fluid.

Option 3:

Phosphate is a major anion that is found in the intracellular fluid.

Option 4:

Potassium is a major cation that is found in the intracellular fluid.

Option 5:

Magnesium is a major anion located in the intracellular fluid.

[Page reference: 1466-1467]

Which hormones are responsible for working on the kidneys to regulate fluid balance? Select all that apply.

1.Antidiuretic hormone (ADH) 2.Renin-angiotensin system (RAAS) 3.Aldosterone 4.Luteinizing hormone 5.Adrenocorticotropic hormone

Answer: 1, 2, 3

Rationales

Option 1:

ADH is released from the pituitary gland and works on the kidneys to retain fluid.

Option 2:

The RAAS system is initiated when blood volume and blood pressure is low. Renin is converted to angiotensin I and then angiotensin II. Angiotensin II targets the nephrons to retain sodium and water.

Option 3:

Aldosterone is stimulated by angiotensin II to reabsorb sodium. This leads to passive water retention.

Option 4:

Luteinizing hormone works on the ovaries to stimulate ovulation. It does not control fluid volume.

Option 5:

Adrenocorticotropic hormone works on the adrenal cortex and produces epinephrine and norepinephrine. This initiates the fight-or-flight response and is not related to fluid volume.

[Page reference: 1465]

The nurse is gathering supplies to perform a central venous catheter dressing change. Which finding in the medical record requires the nurse to slightly change the procedure?

1.Allergy to shellfish 2.History of a right mastectomy 3.Prescription for intravenous vancomycin 4.Methicillin-resistant staph infection (MRSA)

Answer: 1

Rationales

Option 1:

A client with an allergy to shellfish would most likely have an iodine allergy. Since the central venous catheter exit site is cleaned with povidone-iodine, the nurse would use chlorhexidine instead.

Option 2:

A client who has had a right mastectomy would not need the procedure altered for changing the central venous catheter dressing. The mastectomy would affect which limb could be used to insert an intravenous line.

Option 3:

The selection of an intravenous device would be dependent on the medication being administered; however, the administration of vancomycin would not affect the central venous catheter dressing change procedure.

Option 4:

The nurse would not change the procedure for the central venous catheter dressing change if the client has a MRSA infection.

[Page reference: 1504]

Which assessment finding of an older adult would most concern the nurse?

1.Weight loss of 6% of body weight in 1 week 2.Blood pressure drop of 10 mm Hg with position change 3.Serum sodium level of 135 mEq/L 4.Arterial blood gas pH level of 7.35

Answer: 1

Rationales

Option 1:

Weight is a sensitive measure of fluid loss. An older client who loses more than 5% body weight in a short amount of time has developed significant fluid loss and should greatly concern the nurse.

Option 2:

A blood pressure drop of 10 mm Hg with position change is not clinically significant. If the client had a drop of 20 mm Hg, it would be considered orthostatic hypotension. This should not cause the nurse great concern.

Option 3:

A serum sodium level of 135 mEq/L is a normal finding and should not cause the nurse any concern.

Option 4:

The normal range for arterial pH is 7.35 to 7.45. This would not concern the nurse, as it is a normal finding.

[Page reference: 1470]

The nurse is reviewing laboratory values for a client

admitted with the following laboratory data:HCO3 20

mEq/LpH 7.30PaCO2 60 mm HgHow would this be documented in the client’s medical record?

1.Metabolic acidosis 2.Metabolic alkalosis 3.Respiratory acidosis 4.Respiratory alkalosis

Answer: 1

Rationales

Option 1:

The client is experiencing metabolic acidosis, as the pH and the HCO3 are low while the PaCO2 is elevated.

Option 2:

A client with metabolic alkalosis would present with a high pH and an elevated HCO3.

Option 3:

A client with respiratory acidosis will have a low pH, an elevated PaCO2, and a normal HCO3.

Option 4:

The client with respiratory alkalosis would exhibit an increased pH, an elevated PaCO2, and a normal HCO3.

[Page reference: 1473]

Which laboratory value would be increased when a client is dehydrated?

1.Hematocrit 2.Platelet count 3.Potassium level 4.White blood cells

Answer: 1

Rationales

Option 1:

The hematocrit is the percentage of red blood cells that are found in the blood. If a client is dehydrated, there is less fluid and the red blood cells are more concentrated. Therefore, the hematocrit would increase.

Option 2:

The platelet count changes in response to trauma. It is not affected by dehydration.

Option 3:

The potassium level decreases, not increases, when a client has gastrointestinal fluid losses from diarrhea.

Option 4:

The white blood cell count increases due to infection, not dehydration.

[Page reference: 1475]

The health-care provider instructs the nurse to force fluids of 2,500 mL in 24 hours for a client with dehydration. Which interventions should the nurse include to meet this goal? Select all that apply.

1.Determine the client’s fluid preferences.

2.Provide a cup with milliliter markings.

3.Make fluid rounds every 3 hours.

4.Keep a pitcher of water at the bedside.

5.Restrict family members from offering fluids.

Answer: 1, 2, 4

Rationales

Option 1:

The nurse should determine the client’s fluid preferences. If the client is to take in 2,500 mL in 24 hours, it may be achieved by providing fluid sources the client prefers.

Option 2:

In order to meet fluid needs, the client should be provided a cup with milliliter markings so the client can keep track of intake.

Option 3:

The nurse should make fluid rounds every hour to ensure adequate fluid intake.

Option 4:

The nurse should make sure that a pitcher of water is kept at the client’s bedside.This allows the client to drink frequently.

Option 5:

Family members should be included in the teaching plan to increase fluid intake.This can encourage the client to comply with increasing fluids.

[Page reference: 1480]

A client presents to the emergency room with third- degree burns to 25% of the body. Which fluid replacement would the nurse expect the health-care provider to prescribe?

1.Isotonic 2.Hypotonic 3.Hypertonic 4.Volume expanders

Answer: 4

Rationales

Option 1:

Isotonic fluids will stay in the intravascular compartment. These fluids will be used to treat dehydration.

Option 2:

Hypotonic fluids would be given to a client in diabetic ketoacidosis, as it draws fluid from the intravascular compartment to the interstitial tissues.

Option 3:

Hypertonic fluids are given to clients who need fluid to shift from the intracellular compartment into the intravascular compartment. These fluids help stabilize blood pressure.

Option 4:

Volume expanders such as dextran and albumin are used to treat severe fluid losses from burns.

[Page reference: 1481]

The health-care provider prescribes 0.9% sodium chloride to infuse at 100 mL/hour. The nurse hangs a new

• liter bag at 0800. The nurse returns to the room at 1200

and notices only 200 mL of the solution has infused. What is the most appropriate intervention for the nurse to perform?

1.Increase the rate of infusion to make up the difference.

2.Change the prescription to reflect the rate of 50 mL/hour.

3.Adjust the rate of infusion to 100 mL/hour and document the intake.

4.Notify the health-care provider of the error and document the error in the medical record.

Answer: 3

Rationales

Option 1:

The nurse should never attempt to play catch-up when fluids are behind. This can lead to fluid excesses in the client.

Option 2:

The nurse should not modify the prescription without discussing it with the health- care provider.

Option 3:

The nurse should adjust the rate of infusion to the prescribed rate of 100 mL/hour and document the fluid volume that infused.

Option 4:

The nurse should not document an error in the client’s medical record. The nurse would document findings on an internal form of an incident report.

[Page reference: 1486]