# MSII: Fluid & Electrolyte AND Acid Base Questions

Term
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The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment
data will be of most concern to the nurse?
a. Blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
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Terms in this set (21)
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment
data will be of most concern to the nurse?
a. Blood pressure is 90/40 mm Hg.
b. Urine output is 30 mL over the last hour.
c. Oral fluid intake is 100 mL for the last 8 hours.
d. There is prolonged skin tenting over the sternum.
A

The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular
fluid loss due to the burn injury. This finding will require immediate intervention to prevent the complications
associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all
indicate the need for increasing the patients fluid intake but not as urgently as the hypotension.
A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic
hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
a. Reported weight gain
b. Serum hematocrit of 42%
c. Serum sodium level of 120 mg/dL
d. Total urinary output of 280 mL during past 8 hours
C

Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum
sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low
value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The
hematocrit level is normal. Weight gain is expected with SIADH because of water retention.
B

Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies
considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial
space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or
of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?
a. Increase fluids if your mouth feels dry.
b. More fluids are needed if you feel thirsty.
c. Drink more fluids in the late evening hours.
d. If you feel lethargic or confused, you need more to drink.
A

An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry- appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume
depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The
patient will not be likely to notice and act appropriately when changes in level of consciousness occur.
A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized
weakness. It is most appropriate for the nurse to take which action?
a. Assess for facial muscle spasms.
c. Suggest that the patient avoid orange juice with meals.
d. Ask the health care provider to order a basic metabolic panel.
D

Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic
panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools
are associated with hyperkalemia.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
a. I will try to drink at least 8 glasses of water every day.
b. I will use a salt substitute to decrease my sodium intake.
c. I will increase my intake of potassium-containing foods.
d. I will drink apple juice instead of orange juice for breakfast.
A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge
nurse should take which action?
a. Assign the patient to a room near the nurses station.
b. Place the patient in a room nearest to the water fountain.
c. Place the patient on telemetry to monitor for peaked T waves.
d. Assign the patient to a semi-private room and place an order for a low-salt diet.
A

The patient should be placed near the nurses station if confused in order for the staff to closely monitor the
patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should
not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused
patient could be distracting and disruptive for another patient in a semiprivate room. This patient needs sodium
replacement, not restriction. DIF: Cognitive Level: Apply
IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take?
a. Administer the KCl as a rapid IV bolus.
b. Infuse the KCl at a rate of 10 mEq/hour.
c. Only give the KCl through a central venous line.
d. Discontinue cardiac monitoring during the infusion.
B

IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this
route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for
dysrhythmias.
A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction
for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy
should the nurse question?
a. Infuse 5% dextrose in water at 125 mL/hr.
b. Administer IV morphine sulfate 4 mg every 2 hours PRN.
c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea.
d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.
10. A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued
mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2
85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis