I.V. Therapeutics Evidence Based Practice for Infusion Therapy 6th Edition by Lynn Dianne Phillips, Lisa Gorski – Test Bank
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Sample
Test
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 excess |
|
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 poor skin turgor |
|
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. |
The client with ulcerative
colitis |
|
b. |
The client with Cushing’s
syndrome |
|
c. |
The client who has overused
laxatives |
|
d. |
The 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 gel
(Amphojel) |
____ 6. A nurse is caring for a
client with an ileostomy. 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 infant’s 24-hour
fluid needs. Which three methods for assessment of 24-hour fluid needs in an
infant should the nurse consider?
|
a. |
Meter square, diaper
weight, and urinary output |
|
b. |
Meter square, body weight,
and caloric methods |
|
c. |
Meter square, 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 15 mEq/hr via a peripheral vein. When infusing
potassium at this rate via this route, for which imbalance should the nurse
monitor?
|
a. |
Hypernatremia |
|
b. |
Hypercalcemia |
|
c. |
Hyperkalemia |
|
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 nursing instructor is teaching a
group of nursing students about the intracellular and extracellular fluid
compartments of the cell. Which is the major electrolyte in the intracellular
compartment?
|
a. |
Calcium |
|
b. |
Sodium |
|
c. |
Potassium |
|
d. |
Bicarbonate |
____ 12. A nursing instructor is teaching a
group of nursing students about the intracellular and extracellular fluid
compartments of the cell. Which electrolyte is the second most
plentiful cation in the intracellular fluid compartment?
|
a. |
Calcium |
|
b. |
Sodium |
|
c. |
Chloride |
|
d. |
Magnesium |
____ 13. A nurse educator is conducting an
in-service presentation on electrolytes. Which group of electrolytes should the
educator refer to as being “positively charged”?
|
a. |
Potassium, sodium, calcium |
|
b. |
Potassium, sodium,
bicarbonate |
|
c. |
Bicarbonate, phosphate,
chloride |
|
d. |
Chloride, magnesium,
bicarbonate |
____ 14. A nurse is caring for a client who
has been experiencing prolonged vomiting prior to being admitted to a hospital.
The client has experienced development of metabolic alkalosis. Which of the
following are manifestations of alkalosis (bicarbonate excess)?
|
a. |
Tetany, soft tissue
calcification |
|
b. |
Dizziness, tingling of fingers
and toes, carpopedal spasm |
|
c. |
Kussmaul respirations,
confusion, increased respiratory rate |
|
d. |
Impaired mentation,
tingling of fingers and toes, depressed respirations |
____ 15. 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 3.1 mEq/L, and a serum sodium level of 135 mEq/L.
Which electrolyte imbalance should the nurse suspect?
|
a. |
Hyponatremia |
|
b. |
Hypokalemia |
|
c. |
Hyperchloremia |
|
d. |
Hypernatremia |
____ 16. 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 |
____ 17. 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. |
Nasogastric tubes to
suction |
|
c. |
Use of mechanical
ventilators |
|
d. |
Overzealous administration
of I.V. potassium chloride |
____ 18. A nurse is caring for an elderly,
hospitalized client diagnosed with emphysema. The client’s arterial blood gases
reveal that the blood chemistry is slightly alkaline but is considered
physiologically neutral. To be considered physiologically neutral, or normal,
what is the client’s serum pH?
|
a. |
7.2 |
|
b. |
7.3 |
|
c. |
7.4 |
|
d. |
7.5 |
____ 19. Which nursing action would be most
important after adding 20 mEq potassium chloride to an I.V. bag of 1000 mL of
5% dextrose in water?
|
a. |
Rotate the bag gently. |
|
b. |
Attach the tubing to the
client. |
|
c. |
Check the solution for
particles. |
|
d. |
Place the time-tape on the
I.V. bag. |
____ 20. A 3-year-old child is hospitalized
because of persistent vomiting. For which condition should a nurse carefully
monitor the child?
|
a. |
Diarrhea |
|
b. |
Metabolic acidosis |
|
c. |
Metabolic alkalosis |
|
d. |
Hyperactive bowel |
Multiple Response
Identify one or more choices that best complete the statement or
answer the question.
____ 1. A nurse is caring for
multiple clients on a medical-surgical unit. Which clients should a nurse
identify as being at risk for developing “third spacing?” SELECT ALL THAT
APPLY.
|
a. |
Client with cirrhosis |
|
b. |
Client with diabetes
mellitus |
|
c. |
Client with sepsis |
|
d. |
Client with renal failure |
____ 2. The nurse understands that
insensible fluid loss occurs through which routes? SELECT ALL THAT APPLY.
|
a. |
Skin |
|
b. |
Lungs |
|
c. |
Urinary output |
|
d. |
Gastrointestinal tract |
____ 3. A physician orders that a
client receives 0.9% sodium chloride intravenously at 150 mL/hr. Which are
characteristics of this I.V. solution? SELECT ALL THAT APPLY.
|
a. |
The solution is isotonic
with the plasma. |
|
b. |
The solution is hypotonic
with the plasma. |
|
c. |
The solution does not
affect the plasma’s osmolarity. |
|
d. |
The solution contains only sodium
and chloride ions. |
____ 4. 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. |
Thyroid gland |
____ 5. 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 |
____ 6. A client is admitted with
a diagnosis of hypocalcemia. Which clinical manifestations are indicative of
this diagnosis? SELECT ALL THAT APPLY.
|
a. |
Tingling sensations |
|
b. |
Hyperactive reflexes |
|
c. |
Hypotonicity of the muscles |
|
d. |
Positive Trousseau’s sign |
____ 7. 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. |
Infusion of 0.45% or 0.9%
sodium chloride |
____ 8. A client presents to an
emergency department and is diagnosed with respiratory acidosis. A nurse caring
for the client knows that respiratory acidosis may be caused by which
conditions? SELECT ALL THAT APPLY.
|
a. |
Asthma |
|
b. |
Diabetes |
|
c. |
Pneumonia |
|
d. |
Emphysema |
____ 9. 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 |
Chapter 3: Fundamentals of Fluid and Electrolyte Balance
Answer Section
MULTIPLE CHOICE
1. ANS:
C
The signs and symptoms of fluid volume deficit reflect a
contracted vascular compartment due to either a significant extracellular fluid
(ECF) loss or an accumulation of fluid in the interstitial space.
Gastrointestinal dysfunction is the most common cause of ECF deficit and the
symptoms related to it, and it is most often responsible for general loss of
body fluids.
PTS:
1
KEY: Cognitive Level: Analysis
2. ANS:
C
FVD results when water and electrolytes are lost. An increased
pulse rate, decreased blood pressure, and poor skin turgor are signs of
hypovolemia or FVD.
PTS:
1
KEY: Cognitive Level: Application
3. ANS:
B
Fluid volume excess is the most accurate nursing diagnosis for
this client. Extracellular fluid (ECF) volume excess causes an expansion of the
ECF compartment. The primary cause of ECF excess is cardiovascular dysfunction.
Clinically, ECF volume excess has distinct signs and symptoms; the most
prominent are weight gain, edemas, and alterations in respiratory and
cardiovascular function.
PTS:
1
KEY: Cognitive Level: Analysis
4. ANS:
D
A serum potassium level greater than 5.0 mEq/L is indicative of
hyperkalemia. Clients who experience cellular shifting of potassium that occurs
in the early stages of massive cell destruction, such as in trauma, burns,
sepsis, or with metabolic or respiratory acidosis (with the exception of
diabetic acidosis), are at risk for hyperkalemia. Clients with Cushing’s
syndrome or colitis and the client who has been overusing laxatives are all at
risk for hypokalemia.
PTS:
1
KEY: Cognitive Level: Analysis
5. ANS:
D
The normal serum phosphorus level is 2.5 to 4.5 mg/dL or 1.8 to
2.6 mEq/L. This client is experiencing hyperphosphatemia, and his or her
phosphorus level should be lowered. Certain medications can be given to
increase the fecal excretion of phosphorus by binding phosphorus to the food in
the gastrointestinal tract. Aluminum hydroxide gel is one such medication.
Calcium gluconate and calcium chloride are medications used in the treatment of
tetany that occurs from acute hypocalcemia. Calcitonin decreases the plasma
calcium level.
PTS:
1
KEY: Cognitive Level: Application
6. ANS:
B
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