Chapter 11: Clients with Fluid Imbalances Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 11: Clients with Fluid Imbalances

MULTIPLE CHOICE

1. A client has a serum sodium level of 115 mEq/L. The nurse has initiated a slow IV infusion of hypertonic saline solution per IV pump in a large vein. Which other intervention should the nurse implement as a priority?

a.

Assess the client for dysphagia.

b.

Have on-hand a calcium-channel blocker in case of overdose.

c.

Initiate seizure and safety precautions.

d.

Start a second IV in case the first one infiltrates.

ANS: C

When serum sodium concentrations fall to around 115 mEq/L or below, severe neurologic changes occur, such as confusion, hallucinations, behavioral changes, and seizures. The client may also have postural hypotension. The nurse needs to institute safety and seizure precautions. Dysphagia is not a concern. A calcium-channel blocker would not be used in case of sodium overdose, which should be prevented by the use of the IV pump. All seriously ill clients should have two IV lines, but this client does not need a second line specifically because of the sodium infusion.

DIF: Application/Applying REF: p. 144 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

2. A nurse is caring for four clients who are at risk for or who have an actual fluid volume deficit. Which client should the nurse assess first? The nurse should first assess the client who

a.

is confused and spits out oral foods/fluids.

b.

is on a tube-feeding running at 85 ml/hour.

c.

was admitted with polyuria.

d.

has diarrhea and now is restless.

ANS: D

Cellular dehydration can cause neurologic manifestations such as restlessness and apprehension. Neurologic manifestations are always considered serious because coma and even death can result. The nurse should see the client in option d first. Options a and b describe clients who are definitely at risk for dehydration. Option c describes a client who could be at risk for dehydration or who may already be dehydrated, depending on how long the polyuria has been occurring and whether or not the client is already on IV fluids.

DIF: Analysis/Analyzing REF: p. 130 OBJ: Assessment

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

3. A client with severe malnutrition has pedal edema and ascites. The nurse notes that the weight is unchanged for the last 2 days. The most appropriate action by the nurse is to

a.

ask the assistive personnel to re-weigh the client.

b.

assess vital signs, level of consciousness, and urine output.

c.

call the physician to request IV diuretics.

d.

have biomedical engineering check the scale.

ANS: B

Manifestations of third-spaced fluids are similar to those of dehydration because the fluid is not in the vascular space. However, body weight does not change because the fluid has not been lost; it has just been redistributed. In this client, the malnutrition has probably led to a decrease in serum albumin level, leading to decreased oncotic pressure and the fluid shifts. The nurse should assess the client further for manifestations of hypovolemia because severe shock can result. IV fluids need to be continued until there is evidence that the fluid is returning to the vascular space.

DIF: Analysis/Analyzing REF: p. 142 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

4. The nurse notes that a client with renal disease has a plasma osmolality of 200 mOsm/kg and a plasma sodium level of 122 mEq/L. The nurse would further assess the client for other manifestations of

a.

extracellular fluid volume excess.

b.

hyperosmolar fluid volume deficit.

c.

intracellular fluid volume excess.

d.

iso-osmolar fluid volume deficit.

ANS: A

Causes for ECFVE include renal and heart failure, cirrhosis of the liver, and increased ingestion of high-sodium foods. The plasma osmolality and serum sodium levels are low, indicating overhydration. The extra fluid is either in the vascular space (hypervolemia) or in the interstitial spaces (third-spacing).

DIF: Analysis/Analyzing REF: p. 138 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

5. A client who regularly exercises vigorously is being discharged from the emergency department after suffering from dehydration that was corrected. The nurse would realize that the client needs additional instructions when the client says

a.

Drinking water too fast just goes through the kidneys and doesnt help.

b.

I will try to avoid exercising outside in high humidity.

c.

OK, Ill stop trying to lose weight by wearing sweats all summer long.

d.

When I get thirsty, I know to stop and drink something then.

ANS: D

Health promotion education for people who exercise, especially those who exercise outdoors in warm/hot weather, includes instructing them about options a, b, and c, plus the importance of heat acclimatization, drinking cool water before exercising and then drinking an additional 150-200 ml every 15 minutes during exercise and after finishing, eating carbohydrates if exercising for a prolonged period, and not waiting to drink until thirst is felt.

DIF: Evaluation/Evaluating REF: p. 135 OBJ: Evaluation

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Self Care

6. A client with dehydration is being weighed on a standing scale next to the bed. The most important action by the nurse is to

a.

assist the client to prevent falls.

b.

calibrate the scale per manufacturers directions.

c.

document the weight and compare it with prior ones.

d.

explain to the client what is going to happen.

ANS: A

All options are valid activities by the nurse, or by the unlicensed assistive personnel who may be weighing the client. However, client safety comes first, so the most important action by the nurse is to assist the client, who may have orthostatic hypotension, so as to prevent falls.

DIF: Application/Applying REF: pp. 131-132 OBJ: Assessment

MSC: Physiological Integrity Safety and Infection Control-Injury Prevention

7. The nurse has a client who received large amounts of IV fluids during and following surgery, yet the clients urinary output is low and the client is agitated. The nurse realizes the IV fluid that most likely has caused this problem is

a.

D5W.

b.

0.45% NS.

c.

0.9% NS.

d.

3% saline.

ANS: A

Water intoxication can occur in clients who receive large amounts of D5W or other hypotonic IV solution. D5W becomes hypotonic as soon as it is infused because the dextrose is used immediately. The water in the vascular space moves by osmosis to areas of higher sodium concentration, resulting in vascular depletion and cellular swelling. The most sensitive cells to this condition are the neurologic cells.

DIF: Analysis/Analyzing REF: pp. 140-141 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

8. The nurse who is caring for a client prescribed diuretics and fluid restriction to control edema can most easily evaluate the effectiveness of the medical protocol by

a.

calculating plasma osmolality.

b.

careful weight assessment.

c.

checking the lab report on serum sodium level.

d.

measuring the ankle circumference.

ANS: B

A careful recording of the daily weight at the same time of day on the same scale is the easiest method to evaluate the effectiveness of diuretic therapy. It is also the most accurate as it captures insensible fluid losses. Plasma osmolality and serum sodium level also are useful to determine fluid status but they are neither the easiest nor the most reliable. Measuring ankle circumference indicates the presence or absence of edema, which is also an indicator of fluid status.

DIF: Application/Applying REF: p. 129 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

9. The nurse makes the evaluation that the intake of one of the adult clients in her care is adequate when she measures the total daily intake as

a.

750 ml.

b.

900 ml.

c.

1000 ml.

d.

2000 ml.

ANS: D

The adequate daily fluid intake of an adult is between 1500 and 2000 ml.

DIF: Knowledge/Remembering REF: p. 127 OBJ: Evaluation

MSC: Physiological Integrity Basic Care and Comfort-Nutrition and Oral Hydration

10. The nurse anticipates that an order for an isotonic intravenous (IV) solution will read

a.

0.45% sodium chloride.

b.

0.9% sodium chloride.

c.

3% sodium chloride.

d.

5% dextrose in water.

ANS: B

The solution of 0.9% sodium chloride, or normal saline, is isotonic. Options a and d are hypotonic; option c is hypertonic.

DIF: Comprehension/Understanding REF: p. 132 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Parenteral/Intravenous Therapies

11. A client has hypervolemic hyponatremia. The assessment finding the nurse would find inconsistent with this condition is

a.

dysrhythmias

b.

hypotension.

c.

jugular vein distention.

d.

S3 gallop.

ANS: B

If the client is hypervolemic, the nurse would expect to see hypertension, not hypotension.

DIF: Comprehension/Understanding REF: p. 147 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

12. When assessing the laboratory values for an assigned client with fluid excess, the nurse finds the value that is consistent with this diagnosis to be

a.

BUN 12 mg/dl.

b.

hematocrit of 46%.

c.

plasma osmolality of 285 mOsm/kg.

d.

plasma sodium level of 129 mEq/L.

ANS: D

With fluid overload, the concentration of solutes is decreased by the excess fluid. Typical findings include plasma osmolality of less than 275 mOsm/kg, plasma sodium level less than 135 mEq/L, hematocrit less than 45%, BUN less than 8 mg/dl.

DIF: Knowledge/Remembering REF: p. 138 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

13. A client had a stroke and is now being tube-fed. An important intervention the nurse should include in the care plan related to fluid and electrolyte balance is to

a.

consult with a dietitian about providing sufficient calories.

b.

check the sodium concentration of the formula.

c.

prevent too-rapid infusion by using a feeding pump.

d.

provide 1 ml of water per 1 kilocalorie of formula.

ANS: D

Many tube-feeding formulae are hypertonic. In order to prevent dehydration, the nurse must provide water boluses with them. The appropriate amount is 1 ml of water per every 1 kilocalorie of feeding. Consulting with the dietitian is important but not specifically related to fluid and electrolyte balance. A feeding pump should be used for continuous feedings; however, many feedings are given by boluses.

DIF: Application/Applying REF: p. 134 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Nutrition and Oral Hydration

14. A client is taking an IV diuretic for fluid volume excess. Which of the following assessments should the nurse report to the physician?

a.

Decrease in edema

b.

Decrease in potassium level

c.

Increase in urine output

d.

Weight loss

ANS: B

Increased urine output and decrease of edema and weight are expected outcomes of diuretic therapy. Loss of potassium can cause dysrhythmias and seizures.

DIF: Analysis/Analyzing REF: p. 140 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Adverse Reactions/Complications

MULTIPLE RESPONSE

1. A client has gastroenteritis and frequent diarrhea. The nurse should assess the client for (Select all that apply)

a.

bradycardia.

b.

decrease in blood pressure.

c.

decrease in urine output.

d.

temperature of 96 F.

e.

tenting of skin.

ANS: B, D, E

The nurse would expect to see a decreased blood pressure and urine output, tachycardia, poor skin turgor (except in the elderly), weight loss, thirst (sometimes), and a rise in temperature.

DIF: Application/Applying REF: pp. 129-130 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Fluid and Electrolyte Imbalances

2. A client with hyponatremia is on a fluid restriction diet and complains of extreme dry mouth. Interventions the nurse can include in the plan of care include (Select all that apply)

a.

encouraging the client to take warm, not cold, fluids.

b.

giving the client ice chips instead of water.

c.

increasing the frequency of oral care.

d.

instructing the client to hold ice chips in the mouth.

e.

using a commercial mouthwash every 2 hours.

ANS: B, C, D

Clients on fluid restriction often complain of dry mouth, which may be intolerable. The nurse should give the client cold fluids or ice chips, increase the frequency of oral care, and instruct the client to hold ice chips/fluids in the mouth to hydrate the tongue. Warm fluids are not as soothing as cold ones. Commercial mouthwashes usually contain alcohol, which is drying and should be avoided.

DIF: Application/Applying REF: p. 146 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Nutrition and Oral Hydration

3. The nurse working with elderly clients in a nursing home assesses them for dehydration closely because the clients (Select all that apply)

a.

are more susceptible to developing ascites and anasarca.

b.

experience interactions among drugs they may take for chronic illnesses.

c.

have a decreased proportion of body water as compared to fat.

d.

may be demented and not realize they need to drink.

e.

probably have a diminished sense of thirst.

ANS: B, C, D, E

The elderly are at risk for dehydration from numerous causes. In addition to the options listed above, they may be at risk because they have decreased renal concentration of urine, an altered ADH response, and multiple chronic illnesses.

DIF: Application/Applying REF: p. 127 OBJ: Assessment

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Age Related Differences

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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