Fluid And Electrolyte Disorders

Question 1

Which of the following conditions is the result of too much fluid in the vascular compartment?

(A) Edema
(B) Hypervolemia
(C) Hypovolemia
(D) Hypernatremia

Answer 1

B.

Too much fluid in the vascular compartment is known as hypervolemia. Hypovolemia is associated with too little fluid in the vascular compartment. Hypernatremia is too much sodium and a probable cause of hypervolemia.

Question 2

Loss of body water along with a loss of sodium contributes to

(A) Hypernatremia
(B) Intracellular fluid overload
(C) Fluid volume deficit
(D) An increase in electrolytes

Answer 2

C.

When sodium is lost from the body, water follows, causing a deficit in fluid volume. Hypernatremia is a condition of too much sodium, not a loss.

Question 3

Trousseau’s and Chvostek’s signs are tests reflective of

(A) Hypercalcemia
(B) Hypocalcemia
(C) Carpal spasm
(D) Decreased muscle excitability

Answer 3

B.

Hypocalcemia generates neuromuscular irritability manifested by a Chvostek’s or Trousseau’s sign. Hypercalcemia causes a decrease in neuromuscular excitability. Carpal spasm elicited by occluding the arterial blood flow to the hand ~3 minutes, is the positive indicator for Trousseau’s sign. A facial twitch when the facial nerve is tapped is indicative of a positive Chvostek’s sign. Also, these signs are also positive with patients experiencing hypomagnesemia.

Question 4

It is especially important for the nurse to assess for
which of the following in a patient who has just
undergone a total thyroidectomy?

A. weight gain
B. depressed reflexes
C. positive Chvostek’s sign
D. confusion and personality changes

Answer 4

C.

Question 5

The typical fluid replacement for the patient with an ICF fluid volume deficit is

A. isotonic.
B. hypotonic.
C. hypertonic.
D. a plasma expander.

Answer 5

B. Hypotonic

Question 6

Dry mucous membranes are a clinical sign of
dehydration. Weight loss can be associat y with
dehydration but is not a confirming sign. Engorged
neck vessels and bounding pulse are signs of fluid
overload.
The nurse anticipates that the physician will order
which intravenous (IV) fluid for a client who is
dehydrated?

A. Ringer’s lactate
B. 3% Sodium chloride
C. 0.9% Sodium chloride
D. 0.45% Sodium chloride

Answer 6

D. 0.45% Sodium Chloride

Question 7

A client with hypoparathyroidism complains of
numbness and tingling in his fingers and around the
mouth. The nurse would assess for what electrolyte
imbalance?

A. Hyponatremia
B. Hypocalcemia
C. Hyperkalemia
D. Hypermagnesemia

Answer 7

B. Hypocalcemia

Question 8

The nurse evaluates which of the following clients to be at risk for developing hypernatremia?

A. 50-year-old with pneumonia, diaphoresis, and high fevers
B. 62-year-old with congestive heart failure taking loop diuretics
C. 39-year-old with diarrhea and vomiting
D. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

Answer 8

A. 50-year-old with pneumonia, diaphoresis, and high fevers

Diaphoresis and a high feper can lead to free water loss through the skin, resulting in hypernatremia.

Question 9

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse?

1. “The fluid is an adverse reaction ot the chemotherapy.”
2. “A decrease in activity has allowed extra fluid to accumulate in the tissues.”
3. “Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues.”
4. “Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues.”

Answer 9

3. “Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues.”

Rationale: generalized edema, or anasarca, is often seen in clients with low albumin levels secondary to poor nutrition. Decreased oncotic pressure within the blood vessels allows fluid to move from the intravascular space to the interstitial space

Question 10

13. A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action?

A.Encourage the client to increase fluid intake
B.Administer the dose as ordered
C.Draw a potassium level and administer the dose if the level is low or normal
D.Notify the physician of the urine output and hold the dose

Answer 10

D.Notify the physician of the urine output and hold the dose

Question 11

A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for deficient fluid volume?

A. A client with a colostomy
B. A client with congestive heart failure
C. A client with decreased kidney function
D. A client receiving frequent wound irrigations

Answer 11

A.

Question 12

A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume?

A. The client taking diuretics
B. The client with renal failure
C. The client with an ileostomy
D. The client who requires gastrointestinal suctioning

Answer 12

B.

Question 13

A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present?

A. Dry skin 
B. Decreased urinary output
C. Hyperactive bowel sounds 
D. Increased
specific gravity of the urine

Answer 13

C.

Question 14

A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

A. Twitching
B. Negative Trousseau’s sign
C. Hypoactive bowel sounds
D. Hypoactive deep tendon reflexes

Answer 14

A.

Question 15

A nurse reviews a client’s laboratory report and notes that the client’s serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?

A. Alcoholism
B. Renal insufficiency
C. Hypoparathyroidism
D. Tumor lysis syndrome

Answer 15

A.

Question 16

The nurse writes the nursing
problem of "fluid volume
excess" (FVE). Which
intervention should be
included in the plan of care?

1. Change the IV fluid from 0.9% NS to D5W.
2. Restrict the clients sodium in the diet.
3. Monitor blood glucose levels.
4. Prepare the client for hemodialysis.

Answer 16

2. Restrict the clients sodium in the diet.

• option 1 is not a right or prerogative in nursing (Nursing plan of care does not include changing the health care providers orders)
• option 2 refers to fluid volume excess which refers to an isotonic expansion of the extracellular fluid by an abnormal expansion of water and sodium. Therefore sodium is restricted to allow the body to excrete the extra volume.

Question 17

The client is admitted with a
serum sodium level of 110
mEg/L. Which nursing
intervention should be
implemented?

A.Encourage fluids orally.
B.Administer 10% saline solution IVPB.
C.Administer antidiuretic hormone intranasally.
D.Place on seizure precautions.

Answer 17

D. Place on seizure precautions

Question 18

The client post-thyroidectomy
complains of numbness and
tingling around the mouth
and the tips of the fingers.
Which intervention should the
implement first?

1. Notify the health-care
provider immediately.
2. Tap the cheek about two (2)
cm anterior to the ear lobe.
3. Check the serum calcium
and magnesium levels.
4. Prepare to administer
calcium gluconate IVP

Answer 18

2. These are signs and symptoms of hypocalcemia,
   and the nurse can confirm this by tapping the
   cheek to elicit the Chvostek’s sign. If tie muscles of
   the cheek begin to twitch, then the HCP should be
   notified immediately because hypocalcemia is a
   medical emergency.

• The HCP may need to be notified, but the nurse
  should perform assessment first.
• A positive Chvostek’s sign can indicate a low
• If the client does have hypocalcemia, this may be
  ordered, but it is not implemented prior to
  assessment.
  TEST-TAKING HINT: Assessment is the first step in
  the nursing process and is an appropriate option to
  select if the test taker has difficulty when trying to
  decide between two options.

Question 19

The nurse is caring for a client
with congestive heart failure.
On assessment, the nurse notes
that the client is dyspneic and
that crackles are audible on
auscultation. The nurse
suspects excess fluid volume.
What additional signs would
the nurse expect to note in this
client if excess fluid volume is
present?

1) Weight loss
2) Flat neck and hand veins
3) An increase in blood
pressure
4) a decreased central venous
pressure (CVP)

Answer 19

Answer: 3

Rational: A fluid volume excess is also known as
overhydration or fluid overload and occurs when
fluid intake or fluid retention exceeds the fluid
needs of the body. Assessment findings associated
with fluid colume excess include cough, dyspnea,
crackles, tachypnea, tachycardia, elevated blood
pressure, bounding pulse, elevated CVP, weight
gain, edema, neck and hand vein distention, altened
level of consciousness, and decreased hematocrit.
Options 1, 2, and 4 identify signs noted in fluid
volume deficit.

Question 20

The nurse is creating a plan of care for the client
with multiple myeloma and includes which
priority intervention in the plan?

1 Encouraging fluids
2 Providing frequent oral care
3 Coughing and deep breathing
4 Monitoring the red blood cell count

Answer 20

1 encouraging fluids

Rationale: Hypercalcemia caused by bone destruction is a
priority concern in the client with multiple
myeloma. The nurse should administer fluids in
adequate amounts to maintain a urine output of
1.5 to 2 L/day; this requires about 3 L of fluid
intake per day. The fluid is needed not only to
dilute the calcium overload but also to prevent
protein from precipitating in the renal tubules.
Options 2, 3, and 4 may be components of the
plan of care but are not the priority in this client.

Question 21

The nurse is caring for a client with lung cancer
and bone metastasis. What signs and symptoms
would the nurse recognize as indications of a
possible oncological emergency? Select all that
apply.

1Facial edema in the morning
2Weight less of 20 b (9 kg) in 1 month
3Serum calcium level of 12 mo/dL (3.0 mmol/L)
4Serum sodium level of 136 mg/dL (136 mmol/L)
5Serum potassium level of 3.4 mg/dL. (3.4 mmol/L)
6Numbness and tingling of the lower extremities

Answer 21

1,3,6

Rationale: Oncological emergencies include sepsis,
disseminated intravascular coagulation, syndrome
of inappropriate antidiuretic hormone, spinal cord
compression, hypercalcemia, superior vena cava
syndrome, and tumor lysis syndrome. Blockage of
blood flow to the venous system of the head
resulting in facial edema is a sign of superior
vena cava syndrome. A serum calcium level of 12
mg/dL (3.0 mmol/L) indicates hypercalcemia.
Numbness and tingling of the lower extremities
could be a sign of spinal cord compression. Mild
hypokalemia and weight loss are not oncological
emergencies. A sodium level of 136 mg/dL (136
mmol/L is a normal level.

Question 22

A client with carcinoma of the lung develops
syndrome of inappropriate antidiuretic hormone
(SIADH) as a complication of the cancer. The
nurse anticipates that the primary health care
provider will request which prescriptions? Select
all that apply.

2. Chemotherapy
3. Increased fluid intake
4. Decreased oral sodium intake
5. Serum sodium level determination
6. Medication that is antagonistic to antidiuretic hormone

Answer 22

1,2,5,6

Rationale: Cancer is a common cause of SIADH. In SIADH,
excessive amounts of water are reabsorbed by
the kidney and put into the systemic circulation.
The increased water causes hyponatremia
(decreased serum sodium levels) and some
degree of fluid retention. The syndrome is
managed by treating the condition and cause and
usually includes fluid restriction, increased
sodium intake, and medication with a mechanism
of action that is antagonistic to antidiuretic
hormone. Sodium levels are monitored closely
because hypernatremia can develop suddenly as
a result of treatment. The immediate institution
of appropriate cancer therapy, usually radiation or
chemotherapy, can cause tumor regression so
that antidiuretic hormone synthesis and release
processes return to normal.

Question 23

The nurse in the ambulatory care unit is providing
home care instructions to a client after
cryotherapy for the treatment of malignant skin
lesions. Which statement would be most
appropriate for the nurse to include in the home
care instructions for this client?

1 “Apply ice to the site to prevent swelling.”
2 “Clean the site with alcohol 3 times daily.”
3 “Apply a warm, damp washcloth if discomfort occurs.”
4 “Avoid showering or taking baths until seen by the primary health care provider in 1 week

Answer 23

3

Rationale: Cryotherapy involves the local application of liquid
nitrogen to the lesion; this causes cell death and
tissue destruction. Tissue freezing is followed in 1
to 2 days by hemorrhagic blister formation;
therefore, ice is not applied to the site. The
application of a warm, damp washcloth
intermittently to the site will provide relief of any
discomfort. The nurse instructs the client to clean
the site with the prescribed solution to prevent
secondary infection. A topical antibiotic also may
be prescribed. Alcohol would cause irritation to
the skin. There is no reason for the client to avoid
showering or bathing.