Question 1

A patient with a history of renal failure is admitted to the hospital because of decreasing urine output and a potassium level of 5.9 mEq/L.Which food should the nurse teach the patient to avoid?

Accepted Answer

B.A potassium level of 5.9 is high (nl 3.5 to 5 mEq/L).Since potatoes are high in potassium,this is the food that the nurse should instruct the patient to avoid.A.C.D.These food items are not high in potassium.

Question 2

A student nurse is reviewing the use of intravenous (IV)fluids for a school paper.Which definition should the student use to explain the process of diffusion?

Accepted Answer

C.Diffusion is a process in which a substance moves from an area of higher concentration to an area of lower concentration.D.Movement of water refers to osmosis.A.Active transport involves expenditure of energy.B.Filtration is promoted by hydrostatic pressure differences between areas.

Question 3

While assessing an older adult patient with fluid excess,the nurse notes the following: T = 98.6°F,P = 92,R = 18,BP = 166/88 mm Hg,bilateral crackles,oxygen saturation = 95%.Which action should the nurse take first?

Accepted Answer

B.To facilitate ease in breathing,the head of the patient's bed should be in semi-Fowler's or high Fowler's position.These positions allow greater lung expansion and thus aid respiratory effort.A.Oxygen is not necessary at this time,as the pulse oximeter reading is within normal limits.C.Voiding will not relieve fluid overload in the absence of diuretic therapy.D.Laying the patient flat in bed may cause dyspnea.

Question 4

An older patient with a colostomy was admitted for weakness,nausea,vomiting,and loose stools.Which action should the nurse take first to determine the effectiveness of this patient's care?

Accepted Answer

A.This patient is at risk for dehydration.Daily weight is the most reliable indicator of fluid loss or gain.B.Specific gravity is an indirect measure of fluid balance.C.Pulse oximetry reflects oxygenation status and is not related to hydration.D.Creatinine clearance is a measure of kidney function.

Question 5

A patient is prescribed furosemide (Lasix).Which electrolyte should the nurse monitor carefully because of this medication?

Accepted Answer

All the listed electrolytes may be lost with furosemide therapy,but the one of most concern is potassium,as it can cause cardiac complications when out of balance.

Question 6

A patient with acute abdominal pain has a serum potassium level of 2 mEq/L.What should the nurse do first?

Accepted Answer

A.A serum potassium level of 2 mEq/L is dangerously low and places the patient at risk for cardiac complications.B.Kayexalate will lower the potassium level further and is inappropriate.C.The result can be documented after the physician is notified STAT.D.Waiting to notify the physician during morning rounds places the patient at risk for a cardiac event.

Question 7

An older adult with gastroenteritis is disoriented and weak and has the following laboratory test results:
Hct 56% (normal 40% to 51%)
BUN 32 mg/dL (normal 6 mg/dL to 20 mg/dL)
Which nursing diagnosis should the nurse select for this patient?

Accepted Answer

C.Elevated blood urea nitrogen (BUN)and hematocrit (Hct)show concentration due to Deficient fluid volume.B.Excess fluid volume would be associated with low BUN and Hct.A.D.Impaired skin integrity and Risk for injury are possible,but they are not indicated by the data provided.

Question 8

The nurse is concerned that a patient has a high volume of insensible water loss.What is the patient experiencing that is causing the nurse this concern?

Accepted Answer

D.Insensible losses may occur without the person recognizing the loss.Perspiration and water lost through respiration and feces are examples of insensible losses.A.B.C.Sensible losses are those of which the person is aware such as urination,vomiting,and diarrhea.

Question 9

A patient with severe diarrhea has a potassium imbalance.Which symptoms should the nurse expect the patient to demonstration because of this imbalance?

Accepted Answer

A.Skeletal muscle activity diminishes with hypokalemia,resulting in shallow,ineffective respirations.The motility of the gastrointestinal (GI)system is slowed,causing nausea,vomiting,abdominal distention,and constipation.B.Edema and bounding pulse occur in fluid excess.C.A Positive Chvostek's sign is associated with hypocalcemia.D.Kussmaul breathing is a sign of acidosis.

Question 10

A 22-year-old patient with inflammatory bowel disease has been having 16 or more stools per day.Which symptom should the nurse expect to find during the assessment?

Accepted Answer

D.A patient having 16 stools a day is at risk for dehydration; furrowed tongue and sticky mucous membranes are signs of dehydration.A,B,and C are signs of fluid excess.

Question 11

A patient with hypertension is placed on a low-sodium diet.The nurse recognizes that further teaching is necessary if the patient chooses which menu?

Accepted Answer

C.Processed cheeses and canned soups are high in sodium.A.B.D.Poultry,fish,fruits,and fresh vegetables have small amounts of sodium.

Question 12

The nurse is testing a patient for the presence of Trousseau's sign.Which patient response should the nurse recognize as a positive result?

Accepted Answer

C.Spasticity indicates impending tetany.A.B.D.Weakness,redness,or pain may be signs of circulatory impairment but not tetany.

Question 13

The nurse is concerned that an older patient is at risk for dehydration.What reduced function did the nurse assess in this patient?

Accepted Answer

C.Reduced sensation of thirst causes patients to take in less water,which can be dangerous in an older patient who has reduced body water.A,B,and D can potentially increase water retention.

Question 14

A patient develops an irregular heart rate,abdominal cramping,and diarrhea after a thyroidectomy.Which emergency medication should the nurse anticipate being prescribed for this patient?

Accepted Answer

B.These are initial signs of hypocalcemia,which can occur with accidental removal of the parathyroid glands during thyroidectomy.A,C,and D will not raise serum calcium levels.

Question 15

The nurse is preparing diet teaching for a female patient who is postmenopausal,weighs 100 lbs.and is 5 feet 1 inch tall.Which food should the nurse encourage the patient consume?

Accepted Answer

D.The patient is at risk for osteoporosis.Dairy products should be encouraged.A.B.C.Red meat,fresh fruits,and whole grains do not help prevent the development of osteoporosis.

Question 16

An older patient is admitted for treatment of fluid volume excess.For which serious respiratory complication of fluid volume excess should the nurse assess this patient?

Accepted Answer

A.Acute fluid excess typically results in congestive heart failure.As the fluid builds up in the heart,the heart is not able to properly function as a pump.The fluid then backs up into the lungs,causing a condition known as pulmonary edema.B,C,and D are not related to fluid volume.

Question 17

A patient is diagnosed with an abnormal potassium level.Which complication should the nurse assess for in this patient?

Accepted Answer

A.Both hypokalemia and hyperkalemia can cause cardiac dysrhythmias and arrest.B.C.Fluid overload and internal bleeding are not associated with potassium abnormalities.D.Tetany is associated with hypocalcemia.

Question 18

A patient is prescribed an electrolyte replacement.How should the nurse explain the purpose of an electrolyte to the patient?

Accepted Answer

B.Electrolytes are chemicals that can conduct electricity when dissolved in water.Examples of electrolytes are sodium,potassium,calcium,magnesium,acids,and bases.A.A substance that enhances a chemical reaction is a catalyst.C.A substance that uses electrical current to attach to receptor sites does not define any substance having to do with an electrolyte.D.A substance secreted by a gland that carries messages to target tissues is a hormone.

Question 19

The nurse is preparing to provide a patient with an IV fluid that has a lower osmolarity than blood.Which type of fluid should the nurse document that the patient is going to receive?

Accepted Answer

B.A solution that has a lower osmolarity than blood is called hypotonic.A.A fluid that has the same osmolarity as the blood is called isotonic.C.Hypertonic solutions exert greater osmotic pressure than blood.D.A substance that is hydrophobic does not dissolve in water.

Question 20

An older adult patient has an IV infusion of 0.45% normal saline infusing at 150 mL/hr.Which assessment finding should cause the nurse to be most concerned?

Accepted Answer

D.This patient is at risk for fluid volume overload; newly noted crackles are indicative of fluid volume overload.A.Tenderness at the IV site is concerning,but is not the highest priority listed.B.C.The values listed for urine specific gravity and capillary refill are normal.

Quiz 6: Nursing Care of Patients With Fluid,Electrolyte,and Acid–Base Imbalances