Test Bank Chapter 10 Nursing Altered Fluid Electrolyte - Medical Surgical Nursing 7e | Test Bank by LeMone, Burke, Bauldoff by LeMone, Burke, Gerene Bauldoff. DOCX document preview.
LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno)
Chapter 10 Nursing Care of Patients with Altered Fluid, Electrolyte, and Acid-Base Balance
1) The nurse is caring for an older patient who is occasionally confused. What should be the nurse's primary concern regarding fluid and electrolytes when caring for this patient?
1. Risk of dehydration
2. Risk of kidney damage
3. Risk of stroke
4. Risk of bleeding
Page Ref: 232
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.1 Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
2) The nurse is planning care for a patient with severe burns. What health problem should the nurse realize that this patient could develop?
1. Intracellular fluid deficit
2. Intracellular fluid overload
3. Extracellular fluid deficit
4. Interstitial fluid deficit
Page Ref: 235
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
3) A patient experiencing multisystem fluid volume deficit has tachycardia; pale, cool skin; and decreased urine output. Which process should the nurse consider is causing these findings?
1. The body's natural compensatory mechanisms
2. Pharmacological effects of a diuretic
3. Effects of rapidly infused intravenous fluids
4. Cardiac failure
Page Ref: 235
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
4) A pregnant patient is admitted with excessive thirst and increased urination. For which problem should the nurse focus the care of this patient?
1. Imbalanced fluid
2. Fluid overload
3. Nutritional deficiency
4. Insufficient blood flow
Page Ref: 232
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.1 Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
5) A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volume should the nurse notify the patient's healthcare provider?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL
Page Ref: 238
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.
6) A patient is receiving intravenous fluids postoperatively following cardiac surgery. On which potential postoperative complication should the nurse focus the assessment of this patient?
1. Fluid volume excess
2. Fluid volume deficit
3. Seizure activity
4. Liver failure
Page Ref: 240
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
7) A patient is diagnosed with severe hyponatremia. Which type of precautions should be implemented for this patient?
1. Seizure
2. Infection
3. Neutropenia
4. High-risk fall
Page Ref: 246
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Safety and Infection Control
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
8) A patient is diagnosed with hypokalemia. Which medication should the nurse consider that might have contributed to the patient's health problem?
1. Corticosteroid
2. Thiazide diuretic
3. Narcotic
4. Muscle relaxant
Page Ref: 248
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
9) A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. Of which electrolyte imbalance is this patient demonstrating signs?
1. Hyperkalemia
2. Hypokalemia
3. Hypercalcemia
4. Hypocalcemia
Page Ref: 252
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
10) The nurse is planning care for a patient with fluid volume overload and hyponatremia. What should be included in this patient's plan of care?
1. Restrict fluids.
2. Administer intravenous fluids.
3. Provide Kayexalate.
4. Administer intravenous normal saline with furosemide.
Page Ref: 245
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
11) The nurse is caring for a patient diagnosed with hypocalcemia. What additional assessment should the nurse include when caring for this patient?
1. Other electrolyte disturbances
2. Hypertension
3. Visual disturbances
4. Drug toxicity
Page Ref: 257
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
12) A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. What intervention should the nurse include in this patient's plan of care?
1. Request a dietitian consult for selecting foods high in phosphorous.
2. Provide aluminum hydroxide antacids as prescribed.
3. Instruct patient to avoid poultry, peanuts, and seeds.
4. Instruct patient to avoid the intake of sodium phosphate.
Page Ref: 212
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.7 Describe the pathophysiology and manifestations of hypophosphatemia and hyperphosphatemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
13) The nurse is analyzing an arterial blood gas report of a patient with COPD and respiratory acidosis. Through which mechanism should the nurse expect compensation to occur?
1. The kidneys retain bicarbonate.
2. The kidneys excrete bicarbonate.
3. The lungs will retain carbon dioxide.
4. The lungs will excrete carbon dioxide.
Page Ref: 266
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 10.8 Describe the functions and regulatory mechanisms that maintain acid-base balance in the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
14) The nurse is caring for a patient diagnosed with renal failure. What should the nurse recognize as compensation for the acid‒base disturbance found in patients with renal failure?
1. The patient breathes rapidly to eliminate carbon dioxide.
2. The patient will retain bicarbonate in excess of normal.
3. The pH will decrease from the present value.
4. The patient's oxygen saturation level will improve.
Page Ref: 266
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.8 Describe the functions and regulatory mechanisms that maintain acid-base balance in the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
15) The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?
1. Patient with bulimia
2. Patient on dialysis
3. Patient with venous stasis ulcer
4. Patient with COPD
Page Ref: 274
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
16) The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. Which intervention should the nurse expect to be prescribed to correct this problem?
1. Encourage the patient to breathe in and out slowly into a paper bag.
2. Immediately administer oxygen via a mask and monitor oxygen saturation.
3. Prepare to start an intravenous fluid bolus using isotonic fluids.
4. Anticipate the administration of intravenous sodium bicarbonate.
Page Ref: 280
Cognitive Level: Evaluating
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.
17) A patient is prescribed 20 mEq of potassium chloride. For which reason is this patient most likely needing this electrolyte replacement?
1. Sustain respiratory function
2. Help regulate acid‒base balance
3. Keep a vein open
4. Encourage urine output
Page Ref: 248
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.
18) An elderly patient does not complain of thirst. What should the nurse do to assess this patient's hydration status?
1. Ask the physician for an order to begin intravenous fluid replacement.
2. Ask the physician to order a chest x-ray.
3. Monitor serum osmolality level.
4. Ask the physician for an order for a brain scan.
Page Ref: 232
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.1 Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
19) An elderly patient who is being medicated for pain had an episode of incontinence. Which health problem is this patient at risk for developing?
1. Dehydration
2. Over-hydration
3. Fecal incontinence
4. A stroke
Page Ref: 234
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
20) The nurse assesses a patient's weight loss as being 22 lbs. How many liters of fluid did this patient lose? Record your answer rounding to the nearest whole number.
Page Ref: 235
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
21) A postoperative patient with a fluid volume deficit is prescribed progressive ambulation, yet is weak from an inadequate fluid status. What should the nurse do to help this patient?
1. Assist the patient to maintain a standing position for several minutes.
2. Recommend that this patient be on bed rest.
3. Assist the patient to move into different positions in stages.
4. Contact physical therapy to provide a walker.
Page Ref: 239
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
22) A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?
1. Poor skin turgor
2. Decreased urine output
3. Distended neck veins
4. Concentrated hemoglobin and hematocrit levels
Page Ref: 238
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
23) An older patient is at home after being diagnosed with fluid volume overload. What should the nurse instruct this patient to do?
1. Wear support hose.
2. Keep legs in a dependent position.
3. Avoid wearing shoes while in the home.
4. Try to sleep without extra pillows.
Page Ref: 244
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
24) A patient is diagnosed with fluid retention related to kidney disease. Which electrolyte imbalance is this patient most likely experiencing?
1. Hypokalemia
2. Hypernatremia
3. Carbon dioxide
4. Magnesium
Page Ref: 246
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
25) An older patient experiences watery diarrhea for several days with abdominal and muscle cramping. Which imbalance is this patient most likely experiencing?
1. Hypernatremia
2. Hyponatremia
3. Fluid volume excess
4. Hyperkalemia
Page Ref: 245
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
26) A patient is admitted with hypernatremia caused by being stranded on a boat in the Atlantic Ocean for five days without a fresh water source. What is this patient at risk for developing?
1. Pulmonary edema
2. Atrial dysrhythmias
3. Cerebral bleeding
4. Stress fractures
Page Ref: 247
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
27) A patient is diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most affected with this disorder?
1. Calcium
2. Magnesium
3. Phosphorous
4. Potassium
Page Ref: 252
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
28) A patient who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. What should the nurse realize might occur with this patient?
1. Digoxin toxicity may occur.
2. A higher dose of digoxin (Lanoxin) may be needed.
3. A diuretic may be needed.
4. Fluid volume deficit may occur.
Page Ref: 251
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
29) A patient is prescribed 40 mEq potassium as a replacement. How should the nurse plan to administer this medication?
1. Directly into the venous access line
2. Mixed in the prescribed intravenous fluid
3. Via a rectal suppository
4. Via intramuscular injection
Page Ref: 251
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.
30) An older patient with a history of sodium retention experiences "heart skipping beats" and leg tremors. What should the nurse ask this patient regarding these symptoms?
1. "Have you stopped taking your digoxin medication?"
2. "When was the last time you had a bowel movement?"
3. "Were you doing any unusual physical activity?"
4. "Are you using a salt substitute?"
Page Ref: 251
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
31) A patient is recovering from a parathyroidectomy. What should the nurse include when teaching health promotion activities to this patient?
1. Drink one glass of red wine per day.
2. Avoid the sun.
3. Milk and milk-based products will ensure an adequate calcium intake.
4. Red meat is the protein source of choice.
Page Ref: 257
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
32) A patient is admitted for treatment of hypercalcemia. Which type of intravenous fluid should the nurse expect to be prescribed for this patient?
1. Dextrose 5% and water
2. Dextrose 5% and 0.9% normal saline
3. Dextrose 5% and 0.45% normal saline
4. Normal saline
Page Ref: 260
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.
33) A patient is diagnosed with diabetic ketoacidosis. Which electrolyte should the nurse expect to be replaced in this patient?
1. Sodium
2. Potassium
3. Calcium
4. Magnesium
Page Ref: 262
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.6 Describe the pathophysiology and manifestations of hypomagnesemia and hypermagnesemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.
34) An older patient with peripheral neuropathy has been taking magnesium supplements. Which symptoms indicate this patient may have hypermagnesemia?
1. Hypotension, warmth, and sweating
2. Nausea and vomiting
3. Hyperreflexia
4. Excessive urination
Page Ref: 263
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.6 Describe the pathophysiology and manifestations of hypomagnesemia and hypermagnesemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
35) A patient is admitted with burns over 50% total body surface area. Which electrolyte imbalance is this patient at risk for developing?
1. Hypercalcemia
2. Hypophosphatemia
3. Hypernatremia
4. Hypermagnesemia
Page Ref: 264
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.7 Describe the pathophysiology and manifestations of hypophosphatemia and hyperphosphatemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
36) A patient is diagnosed with hyperphosphatemia. Which additional electrolyte imbalance might this patient experience?
1. Calcium
2. Sodium
3. Potassium
4. Chloride
Page Ref: 265
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.7 Describe the pathophysiology and manifestations of hypophosphatemia and hyperphosphatemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
37) The nurse is reviewing a patient's blood pH level. What system in the body does the nurse recognize as contributing to the regulation of blood pH? Select all that apply.
1. Renal
2. Cardiac
3. Buffers
4. Respiratory
5. Integumentary
Page Ref: 266
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.8 Describe the functions and regulatory mechanisms that maintain acid-base balance in the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
38) A patient's respiration rate is 30 per minute and very deep. What disorder should the nurse suspect is occurring in this patient?
1. Hypernatremia
2. Increased carbon dioxide in the blood
3. Hypertension
4. Pain
Page Ref: 266
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.8 Describe the functions and regulatory mechanisms that maintain acid-base balance in the body.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
39) The blood gases of a patient with an acid‒base disorder show a blood pH outside of normal limits. What should the nurse consider is occurring with this patient?
1. Fully compensated
2. Demonstrating anaerobic metabolism
3. Partially compensated
4. In need of intravenous fluids
Page Ref: 271
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
40) A patient's blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. Which acid-base disorder is this patient demonstrating?
1. Respiratory acidosis
2. Metabolic acidosis
3. Respiratory alkalosis
4. Metabolic alkalosis
Page Ref: 274
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
41) An older postoperative patient using patient-controlled anesthesia (PCA) is demonstrating lethargy, confusion, and a respiratory rate of 8 per minute. Which acid‒base disorder might this patient be experiencing?
1. Respiratory acidosis
2. Metabolic acidosis
3. Respiratory alkalosis
4. Metabolic alkalosis
Page Ref: 276
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
42) A patient is prescribed a 1200 mL daily fluid restriction. The patient's IV is infusing at a keep open rate of 10 mL/hr. The patient has no additional IV medications. How much fluid should the patient be permitted from 0700 until 1500? Record your answer rounding to the nearest whole number.
Page Ref: 241
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
43) A patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.
1. Administer the dose IV push over 3 minutes.
2. Monitor the injection site for redness.
3. Add the ordered dose to the IV hanging.
4. Use an infusion pump for the IV.
5. Monitor fluid intake and output.
Page Ref: 250
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
44) The nurse is reviewing care needs for a group of assigned patients. Which patient should the nurse identify as being at risk for the development of hypercalcemia? Select all that apply.
1. The patient with a malignancy
2. The patient taking lithium
3. The patient who uses excessive sunscreen
4. The patient with hyperparathyroidism
5. The patient who overuses antacids
Page Ref: 259
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
45) The patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which food should the nurse suggest for this patient? Select all that apply.
1. Romaine lettuce
2. Seafood
3. White rice
4. Bananas
5. Chocolate
Page Ref: 262
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 10.6 Describe the pathophysiology and manifestations of hypomagnesemia and hypermagnesemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
46) A patient has a serum phosphate level of 4.7 mg/dL. Which treatment should the nurse expect to be prescribed for this patient? Select all that apply.
1. IV normal saline
2. Calcium-containing antacids
3. IV potassium phosphate
4. Additional milk intake
5. Increased vitamin D intake
Page Ref: 265
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.7 Describe the pathophysiology and manifestations of hypophosphatemia and hyperphosphatemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.
47) A patient newly diagnosed with diabetes mellitus has nausea, vomiting, and abdominal pain. ABG results include a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment finding should the nurse anticipate in this patient? Select all that apply.
1. Tachycardia
2. Weakness
3. Dysrhythmias
4. Kussmaul respirations
5. Cold, clammy skin
Page Ref: 272
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
48) A patient has a serum sodium level of 145 mEq/L, serum chloride level of 114 mEq/L, and serum bicarbonate level of 20 mEq/L. What should the nurse calculate as being this patient's anion gap? Record your answer rounding to the nearest whole number.
Page Ref: 271
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Physiological Adaptation
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.
49) A patient weighing 176 lbs. is recovering from mild dehydration. The patient is awake, alert, and can safely take oral fluids. How many mL of fluid should the nurse instruct the patient to consume every day? Record your answer rounding to the nearest whole number.
Page Ref: 237
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
50) A patient with fluid overload is prescribed furosemide (Lasix) 20 mg by mouth each day. What should the nurse include when teaching the patient about this medication? Select all that apply.
1. Expect urination to increase.
2. Expect to feel weak and dizzy.
3. Measure body weight every day.
4. Report swelling of the face or hands.
5. Take the medication before going to sleep.
Page Ref: 241
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning
Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.
51) A patient with chronic renal failure has an occluded arteriovenous fistula, and routine hemodialysis is delayed. However, the patient's serum potassium level is 6.0 mEq/L. What should the nurse expect to be prescribed for this patient? Select all that apply.
1. Insulin
2. Dextrose 10%
3. Furosemide (Lasix)
4. Sodium bicarbonate
5. Sodium polystyrene sulfonate (Kayexalate)
Page Ref: 253
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.
52) The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What finding did the nurse use to come to this conclusion? Select all that apply.
1. Heart rate 88 and regular
2. Complaints of fingers tingling
3. Contraction of the facial muscle
4. Asked when the foot numbness would go away
5. Carpal spasm with blood pressure measurement
Page Ref: 257
Cognitive Level: Analyzing
Client Need & Sub: Physiological Integrity: Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders.
MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.
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