Chapter 40: Fluids, Electrolytes, and Acid-Base Balances Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except:

a.

Crackles

b.

A bounding pulse

c.

Engorged peripheral veins

d.

An elevated hematocrit level

ANS: d

d. An elevated hematocrit would be expected with a deficit of body fluid in the intravascular compartment. When an excess of body fluid exists in the intravascular compartment, a decreased hematocrit would be expected.

a. Crackles (in lungs) are consistent findings with fluid volume excess.

b. An assessment finding associated with fluid volume excess is a bounding pulse.

c. Engorged peripheral veins may be seen with fluid volume excess.

REF: Text Reference: p. 1144

2. A homeless client is brought into the emergency department with indications of extremely poor nutrition. Arterial blood gases are assessed and the nurse anticipates that this client will demonstrate the following results:

a.

pH, 7.3; PaCO2, 38 mm Hg; HCO3, 19 mEq/L

b.

pH, 7.5; PaCO2, 34 mm Hg; HCO3, 20 mEq/L

c.

pH, 7.35; PaCO2, 35 mm Hg; HCO3, 24 mEq/L

d.

pH, 7.52; PaCO2, 48 mm Hg; HCO3, 28 mEq/L

ANS: a

a. Metabolic acidosis may be found in cases of starvation. The clients pH is below the normal of 7.35 (at 7.3), the PaCO2 is in the normal range of 35 to 45 mm Hg (at 38 mm Hg), and the HCO3 is below the normal of 22 mEq/L (at 19 mEq/ml). These findings demonstrate metabolic acidosis.

b. These values are consistent with respiratory alkalosis, compensated. This would not be typical of malnutrition.

c. These are normal arterial blood gas results.

d. These values are consistent with metabolic alkalosis, compensated. This would not be an expected finding with extremely poor nutrition.

REF: Text Reference: p. 1145

3. When a clients serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?

a.

Neurological

b.

Gastrointestinal

c.

Pulmonary

d.

Hepatic

ANS: a

a. Because sodium is necessary for nerve-impulse transmission, the priority nursing assessment with hyponatremia is the neurological system.

b. The gastrointestinal system is not the body system for priority assessment.

c. The priority assessment is not the pulmonary system. Neurological changes will occur first.

d. The priority assessment is not the hepatic system.

REF: Text Reference: p. 1139, Text Reference: p. 1141

4. An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment, the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist crackles. The nurse determines that the child has:

a.

Metabolic acidosis

b.

Respiratory acidosis

c.

Respiratory alkalosis

d.

Metabolic alkalosis

ANS: b

b. These assessment findings (i.e., warm and flushed skin, lethargy, and medical diagnosis of pneumonia) are indicative of respiratory acidosis.

a. Lethargy and flushed skin may be seen with metabolic acidosis, but this child has a respiratory problem with difficulty breathing which is consistent with respiratory acidosis.

c. Respiratory alkalosis also may be caused with hyperventilation as a result of pneumonia, but this childs assessment findings are not consistent with respiratory alkalosis.

d. The clients diagnosis and assessment findings are not indicative of metabolic alkalosis.

REF: Text Reference: p. 1145

5. Arterial blood gases are obtained for the client. The clients results of pH, 7.48; CO2, 42; HCO3, 32; indicates which one of the following acid-base imbalances?

a.

Metabolic acidosis

b.

Respiratory acidosis

c.

Respiratory alkalosis

d.

Metabolic alkalosis

ANS: d

d. The clients pH is elevated at 7.48 (normal, 7.35 to 7.45), the CO2 is normal at 42 (normal, 35 to 45 mm Hg), and the bicarbonate is elevated at 32 (normal, 22 to 26 mEq/L). The client is experiencing metabolic alkalosis.

a. In metabolic acidosis, the clients pH would be below 7.35, and the bicarbonate would be below 22 mEq/L. The client is not experiencing metabolic acidosis.

b. In respiratory acidosis, the clients pH would be below 7.35, and the CO2 would be elevated above 45 mm Hg. The client is not experiencing respiratory acidosis.

c. In respiratory alkalosis, the clients pH would be above 7.45, and the CO2 would be below 35 mm Hg. The client is not experiencing respiratory alkalosis.

REF: Text Reference: p. 1145, Text Reference: p. 1154

6. The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is:

a.

Hyperventilation to decrease the CO2 levels

b.

Hypoventilation to increase the CO2 levels

c.

Retention of HCO3 by the kidneys to increase the pH level

d.

Excretion of HCO3 by the kidneys to decrease the pH level

ANS: c

c. The compensating mechanism in the presence of respiratory acidosis is retention of bicarbonate by the kidneys to increase the pH level.

a. Hyperventilation would be the compensating mechanism in metabolic acidosis to decrease CO2 levels.

b. Hypoventilation would be the compensating mechanism in metabolic alkalosis to increase CO2 levels.

d. The compensating mechanism in the presence of metabolic alkalosis is excretion of bicarbonate to decrease the pH level.

REF: Text Reference: p. 1145, Text Reference: p. 1154

7. Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is:

a.

A 6-month-old learning to drink from a cup

b.

A 12-year-old who is moderately active in 80 F weather

c.

A 42-year-old with severe diarrhea

d.

A 90-year-old with frequent headaches

ANS: c

c. The client at greatest risk for a fluid volume deficit is the client who has severe diarrhea. Any condition that results in the loss of GI fluids predisposes the client to dehydration and a variety of electrolyte disturbances.

a. The very young are at risk for a fluid volume deficit because their body-water loss is proportionately greater per kilogram of weight. However, the very young client is not the individual at most risk for fluid volume deficit.

b. A 12-year-old who is moderately active in warm weather will lose body water through sweating, but is not the individual at greatest risk for a fluid volume deficit.

d. The very old are at increased risk for fluid volume deficit as they have a decreased thirst sensation and a decreased number of filtering nephrons. However, the older adult client is not the individual at greatest risk for a fluid volume deficit.

REF: Text Reference: p. 1149

8. A client experiences a loss of intracellular fluid. The nurse anticipates that the IV therapy that will be used to replace this type of loss is:

a.

0.45% normal saline (NS)

b.

10% dextrose

c.

5% dextrose in lactated Ringers

d.

Dextrose 5% in 1/2 NS

ANS: a

a. The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid.

b. 10% dextrose is a hypertonic solution that will draw fluid into the vascular space.

c. 5% dextrose in lactated Ringers is a hypertonic solution. Hypertonic solutions pull fluid into the vascular space by osmosis.

d. Dextrose 5% in 1/2 NS is a hypertonic solution. Hypertonic solutions pull fluid into the vascular space by osmosis. The client needs a hypotonic solution to rehydrate the cells.

REF: Text Reference: p. 1160, Text Reference: p. 1161

9. The client has been experiencing right flank and lower back pain. Which of the following laboratory values would be most desirable for the nurse to obtain based on the clients assessment?

a.

Serum potassium

b.

Serum sodium

c.

Serum magnesium

d.

Serum calcium

ANS: d

d. Flank pain and lower back pain may be indicative of kidney stones from excess calcium. The laboratory value for the nurse to obtain would be a serum calcium level.

a. Flank pain and lower back pain is not indicative of a problem with serum potassium being too high or too low.

b. The client is not having symptoms suggesting an altered serum sodium level.

c. The client is not displaying symptoms consistent with an altered magnesium level.

REF: Text Reference: p. 1142

10. The physician orders 1000 ml of D5RL with 20 mEq KC1 to run for 8 hours. With an infusion set with a drop factor of 15 gtt/ml, the nurse calculates the flow rate to be:

a.

12 drops per minute

b.

22 drops per minute

c.

32 drops per minute

d.

42 drops per minute

ANS: c

c. 1000 ml 8 hr = 125ml/hr; 15 gtt/ml

60 min 125 ml = 32 gtts/min

a. This is an inaccurate flow rate.

b. This is an inaccurate flow rate.

d. This is an inaccurate flow rate.

REF: Text Reference: p. 1175, Text Reference: p. 1176

11. The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should:

a.

Start with the most proximal site

b.

Look for hard, cord-like veins

c.

Use the dominant arm

d.

Inspect sites on the extremity away from a dialysis graft

ANS: d

d. The nurse should avoid veins in an extremity with compromised circulation, such as a dialysis graft.

a. The nurse should use the most distal site in the nondominant arm, if possible.

b. The nurse should avoid hardened cord-like veins.

c. The nurse should use the nondominant arm, if possible.

REF: Text Reference: p. 1167

12. A client has intravenous therapy for the administration of antibiotics and is stating that the IV site hurts and is swollen. Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration?

a.

Intensity of the pain

b.

Warmth of integument surrounding the IV site

c.

Amount of subcutaneous edema

d.

Skin discoloration of a bruised nature

ANS: b

b. Signs of phlebitis may include increased temperature over the vein, erythema, pain and edema. With phlebitis, the area is warm to the touch; with infiltration, the area is cool to the touch.

a. The intensity of pain is not a differentiating factor between phlebitis and infiltration. Pain may occur with both.

c. The amount of subcutaneous edema is not a differentiating factor between phlebitis and infiltration. Edema may occur with both.

d. Skin discoloration of a bruised nature is not the best way to differentiate phlebitis from infiltration. With phlebitis, the area is typically reddened. With infiltration, the area is typically pale.

REF: Text Reference: p. 1189

13. A client complains of a headache and nausea and vomiting during a blood transfusion. Which one of the following actions should the nurse take immediately?

a.

Check the vital signs.

b.

Stop the blood transfusion.

c.

Slow the rate of blood flow.

d.

Notify the physician and blood bank personnel. 

ANS: b

b. If a blood reaction is suspected, the nurse stops the blood transfusion immediately.

a. The nurse should take the clients vital signs, but the initial action should be to stop the blood transfusion.

c. The nurse should not slow the rate of blood flow. The nurse should stop the blood transfusion.

d. The nurse should first stop the blood transfusion. The nurse may notify the physician and blood bank personnel after the transfusion is stopped.

REF: Text Reference: p. 1192

14. For a client with a nursing diagnosis of Fluid volume excess, the nurse is alert to which one of the following signs and symptoms?

a.

Weak, thready pulse

b.

Hypertension

c.

Dry mucous membranes

d.

Flushed skin

ANS: b

b. Hypertension is a symptom of fluid volume excess.

a. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess.

c. Dry mucous membranes are symptomatic of fluid volume deficit, not excess.

d. Flushed skin is a symptom of fluid volume deficit.

REF: Text Reference: p. 1150

15. A client is currently taking furosemide (Lasix) and digoxin. As a result of the medication regimen, the nurse is alert to the presence of:

a.

Cardiac dysrhythmias

b.

Severe diarrhea

c.

Hyperactive reflexes

d.

Peripheral cyanosis

ANS: a

a. Furosemide (Lasix) is a nonpotassium-sparing diuretic. Without a potassium supplement, the client may become hypokalemic. Hypokalemia increases the risk for digoxin toxicity. Both hypokalemia and digoxin toxicity can cause cardiac dysrhythmias.

b. Clients with hypokalemia from diuretic use may experience intestinal distention and decreased bowel sounds. Severe diarrhea may be a cause, not a result, of hypokalemia.

c. Clients with hyperactive reflexes may have hypocalcemia. Furosemide (Lasix) and digoxin do not predispose a client to hypocalcemia.

d. Peripheral cyanosis is not a potential problem related to the clients medication regimen.

REF: Text Reference: p. 1141

16. A rapid infusion of citrated blood has been given to the client. The nurse observes for:

a.

Diaphoresis

b.

Anxiety

c.

Chvosteks sign

d.

Nausea and vomiting

ANS: c

c. Chvosteks sign is seen with hypocalcemia. Rapid administration of blood transfusions containing citrate may cause hypocalcemia. Citrate solution is used to prevent clotting of the blood so that it can be stored in the refrigerator until it is needed for transfusion. If cold blood is administered too rapidly, it may cause cardiac dysrhythmia. If a client receives a rapid blood transfusion, the kidneys may not be able to excrete phosphorus quickly enough, and the phosphorus level increases while the calcium level decreases. Sepsis also may increase the risk for developing hypocalcemia.

a. The client who has a rapid blood transfusion of citrated blood would not be expected to experience excessive sweating. The client who experiences an anaphylactic reaction or sepsis typically has cool, clammy skin.

b. Anxiety may be related to an anaphylactic or febrile, nonhemolytic reaction to a blood transfusion. However, it is not the best indication of a possible reaction as the client may be anxious because of receiving a blood transfusion, having nothing to do with a physiological reaction to the transfusion.

d. Nausea and vomiting may or may not indicate a reaction to a blood transfusion.

REF: Text Reference: p. 1142

17. For a child who has ingested the remaining contents of an aspirin bottle, is breathing rapidly, and has a blood pH of 7.47, the nurse suspects signs and symptoms consistent with:

a.

Metabolic acidosis.

b.

Metabolic alkalosis.

c.

Respiratory acidosis.

d.

Respiratory alkalosis.

ANS: d

d. A salicylate overdose may cause respiratory alkalosis due to hyperventilation.

a. a. Metabolic acidosis may occur with salicylate poisoning, but the pH demonstrates an alkalosis state.

b. Metabolic alkalosis is not consistent with aspirin overdose.

c. An aspirin overdose does not cause respiratory acidosis.

REF: Text Reference: p. 1145

18. The single best indicator of fluid status is the nurses assessment of the clients:

a.

Skin turgor

b.

Intake and output

c.

Serum electrolyte levels

d.

Daily body weight.

ANS: d

d. Daily weights are the single most important indicator of fluid status.

a. Skin turgor is a measure of hydration, but it is not the single best indicator of a clients fluid status.

b. Intake and output measurements are an important nursing intervention for monitoring fluid status; however, daily weights are the best indicator.

c. Serum electrolytes help monitor fluid status. Daily weights are the single best indicator of a clients fluid status.

REF: Text Reference: p. 1158

19. An IV of 125 ml is to be infused over a 1-hour period. A microdrip infusion set will be used. The nurse calculates the infusion rate as:

a.

32 gtt/min

b.

60 gtt/min

c.

125 gtt/min

d.

250 gtt/min

ANS: c

c. 60 gtt/ml

60 min 125 ml = 125 gtt/min

a. This calculation is incorrect.

b. This calculation is incorrect.

d. This calculation is incorrect.

REF: Text Reference: p. 1176

20. A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete the admission history, the nurse anticipates that the client will have experienced:

a.

Decreased muscle tone

b.

Hypertension

c.

Diarrhea

d.

Fever

ANS: c

c. A cause of hyponatremia is an adrenal insufficiency. The client with hyponatremia may experience diarrhea, abdominal cramping, and nausea and vomiting.

a. Decreased muscle tone is a symptom of hypokalemia. Hypokalemia is not caused by adrenal insufficiency.

b. A client with adrenal insufficiency is not likely to experience hypertension. Resultant hyponatremia with adrenal insufficiency may be exhibited as postural hypotension.

d. Fever is a symptom of hypernatremia, not hyponatremia. Hypernatremia is not caused by adrenal insufficiency.

REF: Text Reference: p. 1141

21. In reviewing the results of the clients blood work, the nurse recognizes that the unexpected value that should be reported to the physician is:

a.

Calcium, c.9 mEq/L

b.

Sodium, 140 mEq/L

c.

Potassium, c.5 mEq/L

d.

Magnesium, b.1 mEq/L

ANS: a

a. A calcium level of c.9 mEq/L should be reported to the physician. A normal calcium level is d.5 to 5.5 mEq/L.

b. A sodium level of 140 mEq/L is within the normal range of 135 to 145 mEq/L.

c. A potassium level of c.5 mEq/L is within the normal range of c.5 to 5.0 mEq/L.

d. A magnesium level of b.1 mEq/L is within the normal range of a.5 to b.5 mEq/L.

REF: Text Reference: p. 1136

22. The nurse anticipates that the client with a fluid volume excess will manifest a(n):

a.

Increased urine specific gravity

b.

Decreased body weight

c.

Increased blood pressure

d.

Decreased pulse strength

ANS: c

c. Hypertension is manifested with fluid volume excess.

a. The urine specific gravity would be decreased with fluid volume excess. The nurse would anticipate an increased urine specific gravity with fluid volume deficit.

b. The nurse would anticipate an increase, not a decrease, in body weight with fluid volume excess.

d. The nurse would anticipate an increase, not a decrease, in pulse strength, in fluid volume excess.

REF: Text Reference: p. 1144

23. The nurse recognizes that the client, based on the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the physician is:

a.

0.45% saline

b.

Lactated Ringers

c.

5% dextrose in normal saline

d.

5% dextrose in lactated Ringers

ANS: b

b. Lactated Ringers is an isotonic solution.

a. 0.45% Saline is a hypotonic solution.

c. 5% Dextrose in normal saline is a hypertonic solution.

d. 5% Dextrose in lactated Ringers is a hypertonic solution.

REF: Text Reference: p. 1160

24. A client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain. After stopping the transfusion, the nurse should:

a.

Administer an antipyretic

b.

Begin an infusion of epinephrine

c.

Run normal saline through the blood tubing

d.

Obtain and send a urine specimen to the lab

ANS: d

d. After stopping the blood transfusion the nurse should obtain and send a urine specimen to the lab to determine the presence of hemoglobin as a result of RBC hemolysis.

a. In an acute hemolytic reaction, management of the reaction does not include the administration of an antipyretic.

b. The nurse does not begin an infusion of epinephrine. The nurse should be prepared to administer emergency drugs, such as diuretics, per the physicians order.

c. The nurse should not turn off the blood and simply turn on the normal saline that is connected to the Y-tubing set. This would cause blood remaining in the Y-tubing to infuse into the client. Even a small amount of mismatched blood can cause a major reaction. The nurse should run normal saline directly into the IV line (not through the blood tubing).

REF: Text Reference: p. 1192

Copyright 2005 by Mosby, Inc. All rights reserved.

Leave a Reply