Fundamentals Of Fluid And Electrolyte | Full Test Bank Ch.3

Chapter 3: Fundamentals of Fluid and Electrolyte Balance

Multiple Choice

Identify the choice that best completes the statement or answers the question.

1. A nurse is assessing an older adult client who is disoriented to time and place. The nurse notes that the client’s eyes are sunken, the mouth is coated, the tongue has an extra longitudinal furrow, and the client’s lips are cracked. The client’s hand vein filling takes more than 5 seconds; tenting is apparent over the sternum; and the vital signs are BP 110/60 mm Hg, pulse 62, and respiratory rate of 12. Based on these assessment findings, which fluid or electrolyte imbalance should the nurse suspect?

A. Sodium deficit

B. Magnesium deficit

C. Fluid volume deficit

D. Fluid volume excess

2. A nurse prepares to assess a client who has been vomiting for several days. For which signs of fluid volume deficit (FVD) should the nurse assess?

A. Bounding pulse, decreased blood pressure, and moist crackles

B. Dyspnea, jugular vein distention, and sternum fingerprinting

C. Increased pulse rate, decreased blood pressure, and weak peripheral pulses

D. Increased respiratory rate; warm, moist skin; and decreased body temperature

3. A nurse assesses a client who has moist crackles (rales) in the lung bases, an increased respiratory rate, dyspnea, and 3+ edema of the ankles. Which is the most accurate nursing diagnosis for this client?

A. Fluid volume deficit

B. Fluid volume excess

C. Impaired tissue integrity

D. Altered tissue perfusion, renal

4. A nurse analyzes a client’s laboratory report that shows a serum potassium level of 5.7 mEq/L. Which client’s laboratory report is the nurse most likely reviewing?

A. A client with ulcerative colitis

B. A client with Cushing’s syndrome

C. A client who has overused laxatives

D. A client who has sustained a traumatic burn

5. A nurse notes that a client admitted with renal failure has a serum phosphorus level of 7.0 mg/dL. Which medication should a nurse expect to be prescribed for this client?

A. Calcium gluconate

B. Calcium chloride

C. Calcitonin (Calcimar)

D. Aluminum hydroxide

6. A nurse is caring for a client with a draining fistula. Which acid-base imbalance will this client most likely experience?

A. Metabolic alkalosis

B. Metabolic acidosis

C. Respiratory acidosis

D. Respiratory alkalosis

7. A nurse assesses a newly admitted client and notes fatigued muscles, reports of nausea and anorexia, irritability, and diminished deep tendon reflexes. The nurse reviews the client’s laboratory reports that reveal a serum chloride level of 92 mEq/L, a serum potassium level of 3.1 mEq/L, and a serum sodium level of 135 mEq/L. Which treatment should the nurse anticipate for this electrolyte imbalance?

A. Treatment with sodium bicarbonate

B. Change of infusion to 5% dextrose in water

C. Replacement therapy with potassium chloride

D. Replacement therapy with sodium and chloride

8. A pediatric nurse is thinking critically to determine the best methods for assessing an ill infant’s 24-hour fluid needs. Which assessments of 24-hour fluid needs in an infant should the nurse consider?

A. I&O, diaper weight, and urinary output

B. Vital signs, skin and mucous membranes, and fontanels

C. Skin elasticity, specific gravity of urine, and urinary output

D. Diaper weight, urinary output, and caloric needs

9. A nurse is administering I.V. potassium at a rate of 10 mEq/hr via a peripheral vein. When infusing potassium via this route, for which signs should the nurse monitor?

A. Decreased urinary output

B. Diarrhea

C. Phlebitis

D. Hyperglycemia

10. A client in a critical-care unit is experiencing drastic fluctuations in serum potassium. Which sentinel event can occur if the client’s serum potassium level is less than 2.5 mEq/L or greater than 7.0 mEq/L?

A. Embolic stroke

B. Cardiac arrest

C. Atrial fibrillation

D. Intracranial hemorrhage

11. A nurse is caring for a client who has been experiencing prolonged vomiting prior to being admitted to a hospital, resulting in a diagnosis of metabolic alkalosis. Which client complaints should the nurse anticipate?

A. Tingling in fingers and toes, tetany, and soft tissue calcification

B. Dizziness, tingling of fingers and toes, and carpopedal spasm

C. Kussmaul respirations, confusion, and increased respiratory rate

D. Impaired mentation, rapid respirations, and vomiting

12. A nurse assesses a newly admitted client and notes fatigued muscles, reports of nausea and anorexia, irritability, and diminished deep tendon reflexes. The nurse reviews the client’s laboratory reports, which reveal a serum chloride level of 92 mEq/L, a serum potassium level of 2.5 mEq/L, and a serum sodium level of 130 mEq/L. Which electrolyte imbalance should the nurse suspect?

A. Hyponatremia

B. Hypokalemia

C. Hyperchloremia

D. Hypernatremia

13. A client presents to an emergency department with confusion, a respiratory rate of 30 breaths per minute, blood pressure 100/70 mm Hg, and a previous admission for renal failure. The client’s arterial blood gases reveal a pH of 7.32, an HCO₃ of 20 mEq/L, and a PaCO₂ of 34 mm Hg. Which acid-base imbalance should a nurse suspect?

A. Metabolic acidosis

B. Metabolic alkalosis

C. Respiratory acidosis

D. Respiratory alkalosis

14. An intensive care nurse is implementing orders for an elderly client diagnosed with hypermagnesemia. What is the most likely cause of hypermagnesemia in this client?

A. Renal failure

B. Use of nasogastric suctioning

C. Use of mechanical ventilators

D. Too much I.V. potassium chloride

15. A nurse is caring for an elderly, hospitalized client diagnosed with emphysema. The client’s arterial blood gases reveal that the blood chemistry includes a 7.5 pH. What does this mean physiologically for the client?

A. This is a normal pH level.

B. This is pH is considered physiologically acidotic.

C. The pH is considered physiologically neutral.

D. The pH level is normal for someone in respiratory acidosis.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

1. A client who has been experiencing vomiting and diarrhea for several days is admitted to a hospital with a fluid volume deficit and numerous electrolyte imbalances. Which organs are involved in the regulation of fluid and electrolyte balance in the client’s body? (Select all that apply.)

A. Kidney

B. Lung

C. Pancreas

D. Hypothalamus

E. Skin

2. A nurse analyzes a client’s laboratory data and notes an increase in serum sodium, a decrease in potassium, an elevated hematocrit, and an increase in blood urea nitrogen. Based on this information, which condition should the nurse anticipate in this client? (Select all that apply.)

A. Fluid volume excess

B. Fluid volume deficit

C. Decreased urinary output

D. Increased urinary output

E. Hypernatremia

3. A multidisciplinary health-care team is caring for a client diagnosed with hypercalcemia. Which treatments would be appropriate when treating this imbalance? (Select all that apply.)

A. Calcitonin

B. Inorganic phosphates

C. Calcium gluconate I.V.

D. IV 0.9% sodium chloride

E. Bisphosphonates

4. A client presents to an emergency department and is diagnosed with respiratory acidosis. A nurse assesses the client to determine that the respiratory acidosis may be caused by which conditions? (Select all that apply.)

A. Asthma

B. Diabetes

C. Pneumonia

D. Emphysema

E. COPD

5. A nurse in a long-term care facility is assessing the fluid volume status of clients. Which are acceptable methods of assessing fluid volume status in an elderly adult client? (Select all that apply.)

A. Skin turgor

B. Presence of bowel sounds

C. Blood pressure

D. Rate and filling of veins of the hand

E. Thirst

Chapter 3: Fundamentals of Fluid and Electrolyte Balance

Multiple Choice

Identify the choice that best completes the statement or answers the question.

1. A nurse is assessing an older adult client who is disoriented to time and place. The nurse notes that the client’s eyes are sunken, the mouth is coated, the tongue has an extra longitudinal furrow, and the client’s lips are cracked. The client’s hand vein filling takes more than 5 seconds; tenting is apparent over the sternum; and the vital signs are BP 110/60 mm Hg, pulse 62, and respiratory rate of 12. Based on these assessment findings, which fluid or electrolyte imbalance should the nurse suspect?

A. Sodium deficit

B. Magnesium deficit

C. Fluid volume deficit

D. Fluid volume excess