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Chapter 41: Fluid, Electrolyte, and Acid-Base Balance
Test Bank
MULTIPLE CHOICE
1. Approximately two thirds of the body’s total water volume exists in the _____ fluid.
a.
Intracellular
b.
Interstitial
c.
Intravascular
d.
Transcellular
ANS: A
Intracellular fluid accounts for approximately two thirds of the fluids in the body—about 42% of
total body weight. Interstitial fluid, intravascular fluid, and transcellular fluid constitute extracellular fluid, which is the fluid outside a cell.
DIF: Remember
REF: 883
OBJ: Describe the processes involved in regulating extracellular fluid volume, body fluid osmolality,
and fluid distribution.
TOP: Assessment MSC: Physiological Integrity
2. The process of passively moving water from an area of lower particle concentration to an area of
higher particle concentration is known as
a.
b.
c.
d.
Hydrolysis.
Osmosis.
Filtration.
Active transport.
ANS: B
The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Hydrolysis is not a term related to fluid and electrolyte
balance. Filtration is mediated by fluid pressure from an area of higher pressure to an area of
lower pressure. Active transport requires metabolic activity and is not passive.
DIF: Remember
REF: 884
OBJ: Describe the processes involved in regulating extracellular fluid volume, body fluid osmolality,
and fluid distribution.
TOP: Assessment MSC: Physiological Integrity
3. The nurse knows that edema in a patient who has venous congestion from right heart failure is
facilitated by an imbalance with regard to _____ pressure.
a.
Hydrostatic
b.
Osmotic
c.
Oncotic
d.
Concentration
ANS: A
Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic
pressures involve the concentrations of solutes and can contribute to edema in other situations.
Concentration pressure is not a nursing term.
DIF: Remember
REF: 884-886
OBJ: Describe common fluid, electrolyte, and acid-base imbalances.
TOP: Assessment MSC: Physiological Integrity
4. The nurse understands that administering a hypertonic solution to a patient will shift water from
the _____ to the _____ space.
a.
b.
c.
d.
Intracellular; extracellular
Extracellular; intracellular
Intravascular; intracellular
Intravascular; interstitial
ANS: A
A hypertonic solution has a concentration greater than normal body fluids, so water will shift out
of cells because of the osmotic pull of the extra particles. Movement of water into cells occurs
when hypotonic fluids are administered. Distribution of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.
DIF: Understand REF: 884
OBJ: Describe the processes involved in regulating extracellular fluid volume, body fluid osmolality,
and fluid distribution.
TOP: Assessment MSC: Physiological Integrity
5. Which patient is most at risk for sensible water loss?
a.
A 7-year-old child with asthma
b.
A 24-year-old adult with constipation
c.
A 56-year-old patient with gastroenteritis
d.
An 80-year-old patient with pneumonia
ANS: D
Sensible water loss consists of fluids lost from the skin through visible perspiration, such as with
a resolving fever related to pneumonia. Asthma would be insensible water loss through respiration. Gastroenteritis causes diarrhea with its large volume loss. Constipation does not affect fluid
loss.
DIF: Apply
REF: 896-897
OBJ: Describe common fluid, electrolyte, and acid-base imbalances.
TOP: Assessment MSC: Physiological Integrity
6. The nurse knows that the most abundant cation in the blood is
a.
Sodium.
b.
Potassium.
c.
Chloride.
d.
Magnesium.
ANS: A
Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cat-
ion. Chloride is an anion (negatively charged) rather then a cation (positively charged). Magnesium is found predominantly inside cells and in bone.
DIF: Remember
REF: 883
OBJ: Describe the processes involved in regulating plasma concentrations of potassium, calcium, magnesium, and phosphate ions. TOP:
Assessment
MSC: Physiological Integrity
7. The nurse receives the patient’s most recent blood work results. Which laboratory value is of
greatest concern?
a.
b.
c.
d.
Sodium of 145 mEq/L
Calcium of 17.5 mg/dL
Potassium of 3.5 mEq/L
Chloride of 100 mEq/L
ANS: B
Normal calcium range is 8.5 mg/dL to 10.5 mg/dL; therefore, a value of 17.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L; chloride 98 to 106 mEq/L.
DIF: Remember
REF: 883
OBJ: Interpret basic fluid, electrolyte, and acid-base laboratory values.
TOP: Assessment MSC: Physiological Integrity
8. The nurse would expect a patient with increased levels of serum calcium to also have _____
levels.
a.
b.
c.
d.
Increased potassium
Decreased phosphate
Decreased sodium
Increased magnesium
ANS: B
Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease. Increased serum calcium would not
necessarily cause changes in levels of potassium, sodium, or magnesium.
DIF: Remember
REF: 889
OBJ: Describe the processes involved in regulating plasma concentrations of potassium, calcium, magnesium, and phosphate ions. TOP:
Assessment
MSC: Physiological Integrity
9. The nurse knows that an imbalance of which ion causes acid-base impairment?
a.
Hydrogen
b.
Calcium
c.
Magnesium
d.
Sodium
ANS: A
The concentration of hydrogen ions determines pH. Low pH designates an acidic environment.
High pH designates an alkaline environment. Calcium, magnesium, and sodium are ions, but
their imbalances are not direct acid-base impairments.
DIF: Remember
REF: 891-893
OBJ: Describe the processes involved in regulating acid-base balance.
TOP: Assessment MSC: Physiological Integrity
10. The nurse would expect a patient with respiratory acidosis to have an excessive amount of
a.
Carbon dioxide.
b.
Bicarbonate.
c.
Oxygen.
d.
Phosphate.
ANS: A
Respiratory acidosis occurs when the lungs are not able to excrete enough carbon dioxide. Carbon dioxide and water create carbonic acid. A buildup of carbonic acid causes the ECF to become more acidic, decreasing the pH. Bicarbonate is normal with uncompensated respiratory
acidosis or elevated with compensated respiratory acidosis. Excessive oxygen and phosphate are
not characteristic of respiratory acidosis.
DIF: Remember
REF: 891-895
OBJ: Describe common fluid, electrolyte, and acid-base imbalances.
TOP: Assessment MSC: Physiological Integrity
11. A 2-year-old child was brought into the emergency department after ingesting several morphine
tablets from a bottle in his mother’s purse. The nurse knows that the child is at greatest risk for
which acid-base imbalance?
a.
Respiratory acidosis
b.
Respiratory alkalosis
c.
Metabolic acidosis
d.
Metabolic alkalosis
ANS: A
Morphine overdose can cause respiratory depression and hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.
DIF: Apply
REF: 891-895
OBJ: Identify risk factors for fluid, electrolyte, and acid-base imbalances.
TOP: Assessment MSC: Physiological Integrity
12. A patient was admitted for a bowel obstruction and has had a nasogastric tube set to low
intermittent suction for the past 3 days. The patient’s respiratory rate has decreased to 12 breaths
per minute. The nurse would expect the patient to have which of the following arterial blood gas
values?
a.
pH 7.78, PaCO2 40 mm Hg, HCO3– 30
mEq/L
b.
pH 7.52, PaCO2 48 mm Hg, HCO3– 28
c.
d.
mEq/L
pH 7.35, PaCO2 35 mm Hg, HCO3– 26
mEq/L
pH 7.25, PaCO2 47 mm Hg, HCO3– 29
mEq/L
ANS: B
Compensated metabolic alkalosis should show alkalosis pH and HCO3– (metabolic) values, with
a slightly acidic CO2 (compensatory respiratory acidosis). In this case, pH 7.52 is alkaline (normal = 7.35 to 7.45), PaCO2 is acidic (normal 35 to 45 mm Hg), and HCO3– is elevated (normal =
22 to 26 mEq/L). A result of pH 7.78, PaCO2 40 mm Hg, HCO3– 30 mEq/L is uncompensated
metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3– 26 mEq/L is within normal limits. pH
7.25, PaCO2 47 mm Hg, HCO3– 29 mEq/L is compensated respiratory acidosis.
DIF: Analyze
REF: 891-895
OBJ: Interpret basic fluid, electrolyte, and acid-base laboratory values.
TOP: Assessment MSC: Physiological Integrity
13. The nurse would not expect full compensation to occur for which acid-base imbalance?
a.
Respiratory acidosis
b.
Respiratory alkalosis
c.
Metabolic acidosis
d.
Metabolic alkalosis
ANS: B
Usually the cause of respiratory alkalosis is a temporary event (e.g., an asthma or anxiety attack).
The kidneys take about 24 hours to compensate for an event, so it is unlikely to see much if any
compensation for respiratory alkalosis. Respiratory acidosis usually results from longer-term
conditions such as chronic lung disease, narcotic overdose, or another event that causes respiratory depression. The kidneys still do not respond for about 24 hours, but usually the event is still
occurring. For both metabolic imbalances, the respiratory system is quick to attempt to compensate: however, it may have difficulty sustaining that compensation.
DIF: Understand REF: 891-895
OBJ: Describe the processes involved in regulating acid-base balance.
TOP: Assessment MSC: Physiological Integrity
14. A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia.
Which assessment finding would the nurse expect?
a.
Thready peripheral pulses
b.
Abdominal distention
c.
Dry mucous membranes
d.
Flushed skin
ANS: B
Signs and symptoms of hypokalemia are muscle weakness and fatigue, abdominal distention,
decreased bowel sounds, and cardiac dysrhythmias. Thready peripheral pulses indicate
hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hyper-
natremia.
DIF: Apply
REF: 888-890
OBJ: Choose appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.
TOP:
Assessment
MSC: Physiological Integrity
15. In which patient would the nurse expect to see a positive Chvostek sign?
a.
A 7-year-old child admitted for severe
b.
c.
d.
burns
A 24-year-old adult admitted for chronic
alcohol abuse
A 50-year-old patient admitted for an
acute exacerbation of hyperparathyroidism
A 75-year-old patient admitted for a broken hip related to osteoporosis
ANS: B
A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and
pancreatitis (which also can be affected by alcohol consumption). Burn patients frequently experience ECV deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with
hypercalcemia.
DIF: Apply
REF: 888-890
OBJ: Choose appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.
TOP:
Assessment
MSC: Physiological Integrity
16. Which organ system is responsible for compensation of respiratory acidosis?
a.
Respiratory
b.
Renal
c.
Gastrointestinal
d.
Endocrine
ANS: B
The kidneys are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate.
Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but
these systems cannot compensate for an existing imbalance.
DIF: Understand REF: 891-895
OBJ: Describe the processes involved in regulating acid-base balance.
TOP: Assessment MSC: Physiological Integrity
17. Which laboratory value should the nurse examine when evaluating uncompensated respiratory
alkalosis?
a.
b.
PaO2
Anion gap
c.
d.
PaCO2
HCO3–
ANS: C
Uncompensated respiratory imbalances are seen in the PaCO2 levels. PaO2 indicates oxygen status. Anion gap is used for metabolic acidosis. HCO3– is used to evaluate compensation for respiratory imbalances or uncompensated metabolic imbalances.
DIF: Remember
REF: 891-895
OBJ: Interpret basic fluid, electrolyte, and acid-base laboratory values.
TOP: Assessment MSC: Physiological Integrity
18. The nurse is caring for a diabetic patient in renal failure. Which laboratory findings would the
nurse expect?
a.
b.
c.
d.
pH 7.3, PaCO2 36 mm Hg, HCO3– 19
mEq/L
pH 7.5, PaCO2 35 mm Hg, HCO3– 35
mEq/L
pH 7.3, PaCO2 47 mm Hg, HCO3– 23
mEq/L
pH 7.35, PaCO2 40 mm Hg, HCO3– 25
mEq/L
ANS: A
Patients in renal failure develop metabolic acidosis. The laboratory values that reflect this are pH
7.3, PaCO2 36 mm Hg, HCO3– 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg,
HCO3– 35 mEq/L is metabolic alkalosis. pH 7.3, PaCO2 47 mm Hg, HCO3– 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3– 25 mEq/L values are within normal range.
DIF: Analyze
REF: 891-895
OBJ: Interpret basic fluid, electrolyte, and acid-base laboratory values.
TOP: Assessment MSC: Physiological Integrity
19. The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. The
nurse gives the patient a diuretic. What electrolyte imbalance is the nurse most concerned about?
a.
Potassium imbalance
b.
Sodium imbalance
c.
Calcium imbalance
d.
Phosphate imbalance
ANS: A
Using a diuretic can cause excess excretion of potassium, unless it is a potassium-sparing diuretic. The other electrolytes are not excreted in the same way with diuretics.
DIF: Understand REF: 889-890
OBJ: Identify risk factors for fluid, electrolyte, and acid-base imbalances.
TOP: Assessment MSC: Physiological Integrity
20. A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse
is most appropriate?
a.
b.
c.
d.
“Are you having difficulty sleeping at
night?”
“How many calories a day do you consume?”
“Do you have dry mouth or feel thirsty?”
“How many times a day do you urinate?”
ANS: D
A rapid gain in weight usually indicates ECV excess if the person began with normal ECV.
Asking the patient about urination habits will illuminate whether the body is trying to excrete the
excess fluid, or if renal dysfunction is contributing to ECV excess. Difficulty sleeping at night
can occur if the body builds up excessive fluid in the lungs; however, it could also mean that the
patient is getting up frequently to urinate, so the question is not specific enough. Caloric intake
does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which
would be associated with rapid weight loss.
DIF: Apply
REF: 898-900
OBJ: Choose appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.
TOP:
Implementation
MSC:
Physiological Integrity
21. Which fluid order should the nurse question for a patient with a traumatic brain injury?
a.
0.45% sodium chloride
b.
0.9% sodium chloride
c.
Lactated Ringer’s
d.
Dextrose 5% in 0.9% sodium chloride
ANS: A
0.45% sodium chloride is a hypotonic solution, and hypotonic solutions cause cells to swell,
which can cause increased intracranial pressure. This can be life threatening for a patient with a
traumatic brain injury. The other solutions are physiologically isotonic sodium-containing solutions that will expand ECV but will not cause cell swelling. In the fluid container, dextrose 5% in
0.9% sodium chloride is hypertonic, but the dextrose enters cells rapidly, leaving isotonic 0.9%
sodium chloride.
DIF: Evaluate
REF: 904-905
OBJ: Discuss purpose and procedure for initiation and maintenance of intravenous therapy.
TOP: Implementation
MSC: Physiological Integrity
22. The physician asks the nurse to monitor the fluid volume status of a congestive heart failure
patient and a patient at risk for clinical dehydration. What is the most effective nursing intervention for monitoring both of these patients?
a.
Weigh the patients every morning before
breakfast.
b.
Ask the patients to record their intake and
output.
c.
d.
Measure the patients’ blood pressure every 4 hours.
Assess the patients for edema in extremities.
ANS: A
An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds)
change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at
the same time every day using the same scale and the same amount of clothing. Although intake
and output records are important assessment measures, some patients are not able to keep their
own records themselves. Blood pressure can decrease with ECV deficit but will not necessarily
increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not
with clinical dehydration.
DIF: Evaluate
REF: 898-899
OBJ: Apply the nursing process when caring for patients with fluid, electrolyte, and acid-base imbalances. TOP:
Implementation
MSC:
Physiological Integrity
23. A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60,
elevated white blood cell count, and oral candidiasis. The nurse knows that the purpose of starting total parenteral nutrition (TPN) is to
a.
Replace fluid, electrolytes, and nutrients
in the patient.
b.
Stimulate the patient’s appetite to eat.
c.
Provide medication to raise the patient’s
blood pressure.
d.
Deliver antibiotics to fight off infection.
ANS: A
Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to
replace the ones the patient is not eating. TPN does not stimulate the appetite. TPN does not
contain blood pressure medication or antibiotics.
DIF: Apply
REF: 904
OBJ: Discuss purpose and procedure for initiation and maintenance of intravenous therapy.
TOP: Implementation
MSC: Physiological Integrity
24. A patient presents to the emergency department with the complaint of vomiting and diarrhea for
the past 48 hours. The nurse anticipates which fluid therapy initially?
a.
0.9% sodium chloride
b.
Dextrose 10% in water
c.
Dextrose 5% in water
d.
0.45% sodium chloride
ANS: A
Patients with prolonged vomiting and diarrhea become hypovolemic. The best solution to replace
extracellular volume is 0.9% sodium chloride, which is an isotonic solution. Dextrose 10% in
water, dextrose 5% in water, and 0.45% sodium chloride act as hypotonic solutions in the body.
The first consideration is replacing extracellular volume to oxygenate tissues.
DIF: Apply
REF: 905
OBJ: Discuss purpose and procedure for initiation and maintenance of intravenous therapy.
TOP: Implementation
MSC: Physiological Integrity
25. A patient with a lower respiratory infection has pH of 7.25, PaCO2 of 55 mm Hg, and HCO3– of
20 mEq/L. The physician has been notified. Which is the priority nursing intervention for this
patient?
a.
Check the color of the patient’s urine
output.
b.
Place the patient in Trendelenburg position.
c.
Encourage the patient to increase respirations.
d.
Place the patient in high Fowler’s position.
ANS: C
The patient has respiratory acidosis from CO2 retention. Increasing rate and depth of respiration
will allow the patient to blow off excess carbon dioxide, and this will begin to correct the imbalance. Checking the urine color is not a necessary assessment. The Trendelenburg position likely
would make it more difficult for the patient to breathe and should be avoided. Placing the patient
in high Fowler’s position may make the patient more comfortable, but it is not necessary.
DIF: Apply
REF: 891-895
OBJ: Apply the nursing process when caring for patients with fluid, electrolyte, and acid-base imbalances. TOP:
Implementation
MSC:
Physiological Integrity
26. The nurse knows that intravenous fluid therapy has been effective for a patient with hyper-
natremia when
a.
b.
c.
d.
Serum sodium concentration returns to
normal.
Systolic and diastolic blood pressure decrease.
Large amounts of emesis and diarrhea decrease.
Urine output increases to 150 mL/hr.
ANS: A
Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an
accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous
therapy. Urine output is influenced by many factors, including extracellular fluid volume. A
large dilute urine output can cause further hypernatremia.
DIF: Apply
REF: 886-888
OBJ: Apply the nursing process when caring for patients with fluid, electrolyte, and acid-base imbalances. TOP:
Implementation
MSC:
Physiological Integrity
27. The nurse would select the dorsal venous plexus of the foot as an IV site for which patient?
a.
A 2-year-old child
b.
A 22-year-old adult
c.
A 50-year-old patient
d.
An 80-year-old patient
ANS: A
Use of the foot as an IV site is common in children but is avoided in adults because of the risk
for thrombophlebitis.
DIF: Understand REF: 906
OBJ: Discuss purpose and procedure for initiation and maintenance of intravenous therapy.
TOP: Implementation
MSC: Physiological Integrity
28. Which assessment finding should cause a nurse to question administering a sodium-containing
isotonic intravenous fluid?
a.
b.
c.
d.
Blood pressure 102/58
Dry mucous membranes
Poor skin turgor
Pitting edema
ANS: D
Pitting edema indicates that the patient may be retaining excess extracellular fluid, and the nurse
should question the type of solution meant to rehydrate the patient. All other options are consistent with ECV deficit, and the patient would benefit from a sodium-containing isotonic solution that expands extracellular volume.
DIF: Understand REF: 905-906
OBJ: Discuss purpose and procedure for initiation and maintenance of intravenous therapy.
TOP: Implementation
MSC: Physiological Integrity
29. A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr.
The nurse is using microdrip gravity drip tubing. What is the minute flow rate (drops per minute)?
a.
12 gtt/min
b.
24 gtt/min
c.
125 gtt/min
d.
150 gtt/min
ANS: C
Microdrip tubing delivers 60 gtt/mL. Calculation for a rate of 125 mL/hr using microdrip tubing:
(125 mL/1 hr)(60 gtt/1 mL)(1 hr/60 min) = 125 gtt/min.
DIF: Apply
REF: 926
TOP: Implementation
OBJ: Calculate an intravenous flow rate.
MSC: Physiological Integrity
30. A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to
infuse at 20 mL/hr. At what time should the infusion be completed?
a.
0645 Tuesday
b.
0675 Tuesday
c.
0715 Tuesday
d.
0735 Tuesday
ANS: C
250 mL divided by 20 mL/hr = 12.5 hr
0.5 hr  60 min = 30 min
1845 + 12 hr 30 min = 3115, which would be 0715 on Tuesday, the following day.
DIF: Apply
REF: 924-927
TOP: Implementation
OBJ: Calculate an intravenous flow rate.
MSC: Physiological Integrity
31. A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the
volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with
0.9% sodium chloride through a 22-gauge catheter infusing at 4 mL/hr and has eaten 200 mL of
ice chips. The patient also has an NG suction tube set to low continuous suction that had 300 mL
output. The patient has voided 400 mL of urine. After reporting these values to the physician,
what orders does the nurse anticipate?
a.
Add a potassium supplement to replace
loss from output.
b.
Decrease the rate of intravenous fluids to
100 mL/hr.
c.
Discontinue the nasogastric suctioning.
d.
Administer a diuretic to prevent fluid
volume excess.
ANS: A
The total fluid intake and output equals 700 mL, which meets the provider goals. Record half the
volume of ice chips when calculating intake. Patients with nasogastric suctioning are at risk for
potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition.
The other measures would be unnecessary because the net fluid volume is equal.
DIF: Apply
REF: 896-898
OBJ: Describe how to measure and record fluid intake and output.
TOP: Implementation
MSC: Physiological Integrity
32. A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the
patient’s peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red
streak that is warm to the touch. What is the nurse’s initial action?
a.
Notify the physician.
b.
Administer pain medication.
c.
Discontinue the IV.
d.
Start a new IV line.
ANS: D
The IV site has phlebitis. The nurse should start a new IV before discontinuing the old one be-
cause it is important to always have an IV access site in a patient who is in hypertensive crisis.
Then the physician can be notified. Pain medication may or may not need to be administered.
DIF: Understand REF: 910| 935
OBJ: Describe potential complications of intravenous therapy and what to do if they occur.
TOP: Implementation
MSC: Physiological Integrity
33. A patient was admitted for hypovolemia and has intravenous fluid running at 250 mL/hr. The
patient complains of burning at the IV insertion site. Upon assessment, the nurse does not find
redness, swelling, heat, or coolness. The nurse suspects that the
a.
IV has infiltrated.
b.
IV has caused phlebitis.
c.
Fluid is infusing too quickly.
d.
Patient is allergic to the fluid.
ANS: C
The infusion may be flowing faster than the vein can handle, causing discomfort. The nurse
should slow down the infusion. Infiltration results in skin that is blanched, cool, and edematous
around the IV insertion site. Pain, warmth, erythema, and a palpable venous cord are all symptoms of phlebitis. Allergic response to the fluid could involve a combination of itching, flushing,
hypotension, and dyspnea, depending on the severity.
DIF: Apply
REF: 910
OBJ: Describe potential complications of intravenous therapy and what to do if they occur.
TOP: Assessment MSC: Physiological Integrity
34. The nurse is caring for a patient with sepsis. The plan of care for the patient is to administer
antibiotics 3 times a day for 4 weeks. What device will be used to administer these antibiotics?
a.
A continuous infusion
b.
A heparin locked peripheral catheter
c.
A PICC line
d.
An implanted port catheter
ANS: C
A PICC line is a type of central venous device that can be introduced into a peripheral vein for
administration of IV antibiotics for an extended period, over the course of several weeks. A continuous infusion would not take place if the patient received antibiotics only 3 times daily. A peripheral catheter would not be necessary or heparin locked. An implanted port catheter is intended for long-term use of venous access over months, or even years.
DIF: Apply
REF: 906-907
OBJ: Discuss purpose and procedure for initiation and maintenance of intravenous therapy.
TOP: Implementation
MSC: Physiological Integrity
35. A nurse is preparing to administer a blood transfusion. Which assessment finding would the
nurse report immediately?
a.
b.
Blood pressure 120/60
Temperature 101.3° F
c.
d.
Poor skin turgor and pallor
Heart rate of 100 beats per minute
ANS: B
A fever should be reported immediately, and the blood transfusion may be postponed. All other
assessment findings are acceptable before starting a blood transfusion.
DIF: Understand REF: 909-913
OBJ: Discuss the procedure for initiating a blood transfusion and interventions to manage a transfusion
reaction.
TOP: Implementation
MSC: Physiological Integrity
36. A nurse has just received a bag of packed red blood cells. The nurse knows that the blood must
not remain at room temperature for longer than
a.
30 minutes.
b.
1 hour.
c.
2 hours.
d.
4 hours.
ANS: D
Blood should be allowed to sit at room temperature for a maximum of 4 hours. After 4 hours,
risk of bacterial contamination of the blood is increased.
DIF: Understand REF: 912-913
OBJ: Discuss the procedure for initiating a blood transfusion and interventions to manage a transfusion
reaction.
TOP: Implementation
MSC: Physiological Integrity
37. A patient had an acute intravascular hemolytic reaction to a blood transfusion. After discontinu-
ing the blood transfusion, what is the nurse’s next action?
a.
Run normal saline through the existing
tubing.
b.
Start normal saline at TKO rate using new
tubing.
c.
Discontinue the IV catheter.
d.
Return the blood to the blood bank.
ANS: B
The nurse should first attach new tubing and begin running in normal saline at a rate to keep the
vein open, in case any sorts of medications need to be delivered through that IV site. The existing tubing should not be used because that would infuse the blood in the tubing into the patient.
It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the patient has been assessed and stabilized, the blood can be returned to the blood bank.
DIF: Understand REF: 912-913
OBJ: Discuss the procedure for initiating a blood transfusion and interventions to manage a transfusion
reaction.
TOP: Implementation
MSC: Physiological Integrity
38. A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is
anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in
both lung bases and sees jugular vein distention. The nurse recognizes that the patient is experiencing which transfusion complication?
a.
Anaphylactic shock
b.
Septicemia
c.
Fluid volume overload
d.
Hemolytic reaction
ANS: C
The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would
have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A
hemolytic reaction would consist of flank pain, chills, and fever.
DIF: Understand REF: 909-913
OBJ: Discuss the procedure for initiating a blood transfusion and interventions to manage a transfusion
reaction.
TOP: Implementation
MSC: Physiological Integrity
39. The nurse selects appropriate tubing for a blood transfusion by ensuring that the tubing has
a.
Two-way valves to allow the patient’s
b.
c.
d.
blood to mix and warm the blood transfusing.
An injection port to mix additional electrolytes into the blood.
An air vent to let bubbles in the blood escape.
A filter to ensure that clots do not enter
the patient.
ANS: D
All blood transfusions must have a filter to prevent microemboli from being administered to the
patient. The patient’s blood should not be aspirated to mix with the infusion blood. The blood
should not have air bubbles to vent; if a bag of blood does have bubbles, the nurse should
promptly return the blood to the blood bank. The only substance compatible with blood is normal
saline; no additives should be mixed with the infusing blood.
DIF: Understand REF: 909-913
OBJ: Discuss the procedure for initiating a blood transfusion and interventions to manage a transfusion
reaction.
TOP: Implementation
MSC: Physiological Integrity
40. The nurse is caring for a patient with hyperkalemia. Which body system would be most
important for the nurse plan to monitor closely?
a.
Gastrointestinal
b.
Neurological
c.
Cardiac
d.
Respiratory
ANS: C
Potassium balance is necessary for cardiac function. Hyperkalemia places the patient at risk for
potentially serious dysrhythmias. Monitoring of gastrointestinal, neurological, and respiratory
systems would be indicated for other electrolyte imbalances.
DIF: Apply
REF: 889-890| 915
OBJ: Apply the nursing process when caring for patients with fluid, electrolyte, and acid-base imbalances. TOP:
Assessment
MSC: Physiological Integrity
41. Which assessment finding would the nurse expect for a patient with the following laboratory
values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?
a.
Lightheadedness when standing up
b.
Weak quadriceps muscles
c.
Tingling of the extremities and tetany
d.
Decreased deep tendon reflexes
ANS: C
This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Sodium
and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to
5.0 mEq/L. Hypocalcemia causes muscle tetany, positive Trousseau’s sign, and tingling of the
extremities. Lightheadedness when standing up is a manifestation of ECV deficit or sometimes
hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased
deep tendon reflexes are related to hypercalcemia or hypermagnesemia.
DIF: Apply
REF: 883| 899
OBJ: Choose appropriate clinical assessments for specific fluid, electrolyte, and acid-base imbalances.
TOP:
Assessment
MSC: Physiological Integrity
42. A patient informs the nurse that he has the type of diabetes that does not require insulin. The
nurse advises the patient to make which dietary change?
a.
Drink plenty of fluids throughout the day
to stay hydrated.
b.
Avoid food high in acid to avoid metabolic acidosis.
c.
Reduce the quantity of carbohydrates ingested to lower blood sugar.
d.
Include a serving of dairy in each meal to
elevate calcium levels.
ANS: A
The patient is indicating that he has diabetes insipidus, which places him at risk for dehydration
and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the
extra water excreted in the urine. Foods high in acid should be avoided in a patient with GERD.
A reduction in carbohydrates applies to type 2 diabetes mellitus patients. Calcium-rich dairy
products would be recommended for a hypocalcemic patient.
DIF: Apply
REF: 898
OBJ: Apply the nursing process when caring for patients with fluid, electrolyte, and acid-base imbalances. TOP:
Planning
MSC: Physiological Integrity
MULTIPLE RESPONSE
1. When selecting a site to insert an intravenous catheter on an adult, the nurse should (Select all
that apply.)
a.
b.
c.
d.
e.
f.
Start proximally and move distally on the
arm.
Choose a vein with minimal curvature.
Choose the patient’s dominant arm.
Check for contraindications to the extremity.
Select a vein that is rigid.
Avoid areas of flexion.
ANS: B, D, F
The nurse should start distally and move proximally, choosing the nondominant arm if possible.
The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an
IV catheter are conditions such mastectomy, AV fistula, and central line in the extremity. The
nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be
avoided because it might have had previous trauma or damage.
DIF: Apply
REF: 906-910
OBJ: Discuss purpose and procedure for initiation and maintenance of intravenous therapy.
TOP: Implementation
MSC: Physiological Integrity
2. Which of the following assessments would indicate that a patient’s IV has infiltrated? (Select all
that apply.)
a.
b.
c.
d.
e.
f.
g.
Edema of the extremity near the insertion
site
Skin discolored or bruised in appearance
Pain and warmth at the insertion site
Skin cool to the touch
Reddish streak proximal to the insertion
site
Numbness or loss of sensation
Palpable venous cord
ANS: A, B, D, F
Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch
and may be bruised or discolored, and the patient may experience some numbness. Pain, warmth,
erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis.
DIF: Remember
REF: 910-911
OBJ: Describe potential complications of intravenous therapy and what to do if they occur.
TOP: Assessment
MSC: Physiological Integrity
3. When discontinuing a peripheral IV access, the nurse should (Select all that apply.)
a.
Use scissors to remove the IV site dressb.
c.
d.
e.
f.
ing and tape.
Keep the catheter parallel to the skin
while removing it.
Apply firm pressure with sterile gauze
during removal.
Stop the infusion before removing the IV
catheter.
Wear sterile gloves and a mask.
Apply pressure to the site for 2 to 3
minutes after removal.
ANS: B, D, F
The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on
the patient’s skin; keep the catheter parallel to the skin while removing it to reduce trauma to the
vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the
site. Scissors should not be used because they may accidentally cut the catheter or tubing or may
injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicated to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because
gloved hands will handle the external dressing, tubing, and tape, which are not sterile.
DIF: Remember
REF: 933
OBJ: Explain how to change intravenous solutions and tubing and discontinue an infusion.
TOP: Implementation
MSC: Physiological Integrity