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.
A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would
be the most accurate way for the nurse to evaluate fluid balance?
a. Skin turgor
b. Daily weight
c. Presence of edema
d. Hourly urine output
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.
b. Ask the patient about loose stools.
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.
D

Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium
foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the
patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake.
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.
A

Because the patients gastric suction has been depleting electrolytes, the IV solution should include electrolyte
replacement. Solutions such as lactated Ringers solution would usually be ordered for this patient. The other
orders are appropriate for a postoperative patient with gastric suction.
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
D

The pH indicates that the patient has alkalosis and the low PaCO2
indicates a respiratory cause. The other
responses are incorrect based on the pH and the normal HCO3
11. The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided imagery.C The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema c. Confusion d. RestlessnessB The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edemaA Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation.The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patients condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm HgC Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patients protein status. Good skin turgor is an indicator of fluid balance, not protein status. A low hematocrit could be caused by poor protein intake. Blood pressure does not provide a useful clinical tool for monitoring protein status.15. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosisA The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every eveningA Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level.The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseaus and Chvosteks signs. d. Encourage fluid intake up to 4000 mL every day.D To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseaus and Chvosteks signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patients food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breastB Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets.19. A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxativesA Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels.20. A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a. There is a decreased risk for infection when 25% dextrose is infused through a central line. b. The prescribed infusion can be given much more rapidly when the patient has a central line. c. The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line. d. The required blood glucose monitoring is more accurate when samples are obtained from a central line.C The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Position the patients face toward the CVAD during injection cap changes.B