Fluid and Electrolytes Chapter 36

Question 1

Body Fluid

Answer 1

 Water is the primary body fluid

	Water content varies with age, sex, adipose tissue

	Water contains solutes
•	Electrolytes
•	Nonelectrolytes

Question 2

Intracellular

Answer 2

Within the cells

Question 3

Extracellular

Answer 3

Interstitial
Intravascular
Transcellular

Question 4

Movement of Fluids and Electrolytes

Answer 4

 Osmosis

	Diffusion

	Filtration

	Active transport

Question 5

Fluid Intake

Answer 5

	Primarily through drinking fluids
		IOM recommendation: 2700 mL/day women, 3500 mL/day men
		20% from food / metabolism of food
		Fluid intake regulated by thirst
	•	Change in plasma osmolality
	•	Hypothalamus

Question 6

Fluid Output

Answer 6

 Urine: 1500 mL/day

	Skin: perspiration

	Lungs: exhalation

	Feces: 100–200 mL/day

Question 7

Hormonal Regulation

Answer 7

 Antidiuretic hormone (ADH)

	Renin-angiotensin system		

	Aldosterone

	Thyroid hormone
	Brain naturetic factor

Question 8

Fluid Imbalances

Answer 8

Fluid volume deficit
		Hypovolemia
		Dehydration
		Dry skin, mucous membranes
		Nonelastic skin turgor
		Decreased urine output and blood pressure (hypotension); increased heart rate (tachycardia); rise in temperature
		Weight loss

Question 9

Fluid volume excess

Answer 9

Hypervolemia
Overhydration
Elevated blood pressure, bounding pulse
Pale, cool skin
Edema/ascites
Crackles

Question 10

Sodium

Answer 10

Extracellular fluid (ECF): regulates fluid volume
Kidney reabsorbs

Question 11

Potassium

Answer 11

Intracellular fluid (ICF): muscle contraction; cardiac conduction
Kidneys eliminate

Question 12

K+ Deficit (potassium)

ASIC WALT

Answer 12

alkalosis
shallow respirations
irritability
confusion/ drowsiness
weakness / fatigue
arrhythmias- irregular rate, tachycardia
Lethargy
Thready Pulse

Question 13

K+ Hyperkalemia

Answer 13

Muscle twitches -> Cramps -> Paresthesia
Irritability & Anxiety
Decreased BP
EKG Changes'
Dysrhythmias- Irregular rhythm
Abdominal Cramping
Diarrhea

Question 14

Calcium

Answer 14

Calcium
Bone health; neuromuscular function; cardiac function
Insufficiency leads to osteoporosis

Question 15

Magnesium

Answer 15

ICF; bone; many cellular functions

Alcoholism leads to low levels

Question 16

Chloride

Answer 16

ECF; bound to other ions

Question 17

Phosphate

Answer 17

(Phosphorus)
ICF anion
Bound with calcium in teeth and bones; inverse relationship

Question 18

Bicarbonate

Answer 18

ICF and ECF; acid-base balance
Regulated by kidneys
Produced by body to act as buffer

Question 19

Increase in Calcium causes a _____ in phosphorus

Answer 19

decrease ; calcium 10.5 mg/dl , phosphorus 2.5 mg.dl

Question 20

Acid

Answer 20

compound that contains hydrogen (H+) ions

Question 21

Base

Answer 21

compound that accepts hydrogen ions

Question 22

Acid-Base Balance

Answer 22

Amounts in solution reflected by pH

Acceptable range for serum: 7.35–7.45

Measured by arterial blood gases (ABGs)

Question 23

Acid-Base Regulation

Answer 23

 Buffer systems

	Respiratory mechanisms

	Renal mechanisms

Question 24

Acid-Base Imbalances

Acidosis

Answer 24

Serum pH below 7.35
Respiratory cause: retention of CO2
Metabolic cause: loss of bicarbonate

Question 25

Respiratory Acidosis

Answer 25

Hypoventilation
rapid shallow respirations
dyspena
headache
hyperkalcemia
disorientation
increased cardiac output
muscle weakness
hypoxemia

PH down 7.35 and pCO2 up 45 mm/Hg

Question 26

Metabolic Acidosis

Answer 26

Headache
Changes in LOC
Disorientation
hyperkalemia 
muscle twitching
kusmal breathing

PH down 7.35 and HCO3 down 22mEq

Question 27

Alkalosis

Answer 27

Serum pH above 7.45
Respiratory cause: blowing off CO2
Metabolic cause: increase in bicarbonate

Question 28

Respiratory Alkalosis

Answer 28

seizures
deep rapid breathing
hyperventilation
confusion
hypokalemia
lightheadedness
tingling in extremeties

PH up 7.45, Pco2 down 35mmhg

Question 29

Metabolic Alkalosis

Answer 29

Restless
dysrhythmias
hypoventilation
confusion
nausea vomiting
diarrhea
slow respirations
hypokalemia

ph up 7.45, hco3 up 26

Question 30

Nursing Assessment: Fluid, Electrolyte, Acid-Base Imbalances

Answer 30

	Head-to-toe physical assessment
		Vital signs: temperature, pulse, respirations, blood pressure
		Daily weights
		Fluid intake/output
		Laboratory studies

Question 31

Nursing Interventions

Answer 31

 Dietary teaching

	Oral electrolyte supplements

	Limiting or facilitating oral 
fluid intake

	Parenteral replacement of fluids and/or electrolytes

Question 32

solute

Answer 32

A solute is a solid substance dissolved in body fluids.

Question 33

electrolyte

Answer 33

An electrolyte is a substance that develops an electrical charge when dissolved in water.

Question 34

Intracellular fluid (ICF)

Answer 34

Intracellular fluid (ICF) is fluid contained within the cells.

Question 35

Extracellular fluid (ECF)

Answer 35

Extracellular fluid (ECF) is fluid outside the cells. ECF consists of three types of fluid: interstitial, intravascular, and transcellular fluid.

Question 36

cation

Answer 36

A cation is an electrolyte that carries a positive charge. They include sodium (Na+), potassium (K+), calcium (Ca2+), and magnesium (Mg2+).

Question 37

anion

Answer 37

An anion is an electrolyte that carries a negative charge. Examples are chloride (Cl−), bicarbonate (HCO3−), phosphate (HPO42−), and sulfate (SO42−).

Question 38

Identify the major electrolytes in the ICF and ECF.

Answer 38

Answer:
These cellular fluids contain the following major electrolytes:
● In intracellular fluid (ICF), the major cations are potassium (K+) and magnesium (Mg2+), and the major anion is phosphate (HPO42−) .
● In extracellular fluid (ECF), the major cation is sodium (Na+), and the major anions are chloride (Cl−) and bicarbonate (HCO3−)

Question 39

Molecules move across a membrane to equalize concentration.

Answer 39

Answer:

Diffusion

Question 40

Fluid moves across a membrane to equalize concentration.

Answer 40

Answer:

Osmosis

Question 41

Molecules move against a concentration gradient.

Answer 41

Answer:

Active transport

Question 42

Molecules move to equalize pressure.

Answer 42

Answer:

Filtration

Question 43

Identify the major functions of sodium

Answer 43

Sodium
● Regulates fluid volume
● Helps maintain blood volume
● Interacts with calcium to maintain muscle contraction
● Stimulates conduction of nerve impulses

Question 44

Identify the major functions of potassium

Answer 44

Potassium
● Maintains osmolality of intracellular fluid
● Regulates conduction of cardiac rhythm
● Transmits electrical impulses in multiple body systems
● Assists with acid–base balance

Question 45

Identify the major functions of calcium

Answer 45

Calcium
● Promotes transmission of nerve impulses
● Regulates muscle contractions
● Maintains cardiac automaticity
● Serves as an essential factor in the formation of blood clots
● Catalyzes many cellular activities
● Major component of bones and teeth

Question 46

Identify the major functions of magnesium,

Answer 46

Magnesium
● Involved in protein and carbohydrate metabolism
● Necessary for protein and DNA synthesis within the cell
● Maintains normal intracellular levels of potassium
● Involved in electrical activity in nerve, cardiac, and muscle membranes

Question 47

Identify the major functions of chloride,

Answer 47

Chloride
● Works with sodium to maintain osmotic pressure of blood
● Essential for production of hydrochloric acid (HCl) for gastric secretions
● Functions as a buffer for the gas exchange (oxygen and carbon dioxide) in RBCs
● Assists with acid–base balance

Question 48

Identify the major functions of phosphate

Answer 48

Phosphate (Phosphorous)
● Serves as a catalyst for many intracellular activities
● Promotes muscle and nerve action
● Bound with calcium, as calcium phosphate, in bones and teeth
● Assists with acid–base balance
● Important for cell division and transmission of hereditary traits

Question 49

Identify the major functions of bicarbonate.

Answer 49

Bicarbonate

● Maintains acid–base balance by functioning as the primary buffer in the body

Question 50

What are the major concerns associated with sodium and potassium intake?

Answer 50

Answer:
The major concerns are excessive sodium intake and inadequate potassium intake, which could lead to:
● Sodium: weight gain (edema), hypertension (high blood pressure)
● Potassium: cardiac dysrhythmias (bradycardias, heart block, asystole), potential for acid–base imbalance (metabolic acidosis)

Question 51

Identify at least five potassium-rich foods.

Answer 51

Answer:
Answers may include any five of these common food sources:
●   Bananas
●   Oranges
●   Apricots
●   Figs
●   Dates
●   Carrots
●   Tomatoes
●   Spinach
●   Dairy products
●   Meats

Question 52

Briefly describe the three mechanisms used to maintain pH.

Answer 52

Answer:
The three mechanisms that maintain pH (acid–base balance) are buffers, respiratory mechanisms, and renal mechanisms:
● Buffers. Buffer systems respond to electrolyte imbalances to prevent wide swings in pH. A buffer system consists of a weak acid and a weak base. These molecules react with strong acids or bases to keep them from altering the pH by either absorbing free hydrogen ions or releasing free hydrogen ions (H+).
● Respiratory. When the serum pH is too acidic (pH is low), the lungs remove carbon dioxide (CO2) through rapid, deep breathing. This reduces the amount of carbon dioxide available to make carbonic acid (H2CO3)in the body. If the serum pH is too alkaline (pH is high), the lungs try to conserve carbon dioxide through shallow respirations.
● Renal. The kidneys affect pH by regulating the amount of bicarbonate (a base, HCO3−) that is kept in the body. If the serum pH is too acidic, the kidneys reabsorb additional bicarbonate to neutralize the acid. If the serum pH is too alkaline, the kidneys excrete additional bicarbonate to lower the amount of base and thereby decrease the pH. The kidneys also buffer pH by forming acids and ammonium (a base).

Question 53

Rank order the acid–base balance mechanisms from most rapidly acting to the most slowly acting.

Answer 53

Answer:
The three acid–base balance mechanisms are ranked as follows:
● Buffers act the most rapidly.
● Respiratory mechanisms are intermediate.
● Renal mechanisms act the slowest.

Question 54

Deficient fluid volume

Answer 54

Deficient fluid volume occurs when there is a proportional loss of water and electrolytes from the ECF. It may occur as a result of insufficient intake of isotonic fluid; bleeding; excessive loss through urine, skin, insensible losses, or the gastrointestinal tract; or loss of fluid into a third space.

Question 55

Excess fluid volume

Answer 55

Excess fluid volume involves excessive retention of sodium and water in the ECF. A synonym is hypervolemia. Fluid volume excess occurs as a result of excessive salt intake, disease affecting kidney or liver function, or poor pumping action of the heart.

Question 56

Describe dehydration and hypervolemia.

Answer 56

Answer:
● Dehydration implies the loss of water only.
● Hypervolemia implies excess water.
Neither involves changes in electrolyte levels.

Question 57

Interpret the following ABG results.

pH = 7.53 PCO2 = 26 mm Hg HCO3− = 22 mEq/L

Answer 57

Answer:

Respiratory alkalosis uncompensated

Question 58

pH = 7.40 PCO2 = 39 mm Hg HCO3− = 25 mEq/L

Answer 58

Answer:

Normal ABG results

Question 59

pH = 7.25 PCO2 = 70 mm Hg HCO3− = 30 mEq/L

Answer 59

Answer:

Respiratory acidosis, partially compensated

Question 60

pH = 7.48 PCO2 = 46 mm Hg HCO3− = 30 mEq/L

Answer 60

Answer:

Metabolic alkalosis, partially compensated

Question 61

dentify ten physical assessment components that can be used to monitor fluid, electrolyte, and acid–base balance.

Answer 61

Answer:
The following physical assessment components can be used to monitor fluid, electrolyte, and acid–base balance:
● Skin is evaluated for six components: color, temperature, moisture content, continuity, turgor, and edema.
● The status of the mucous membranes provides information about fluid and electrolyte balance.
● All of the vital signs reflect information about fluid, electrolyte, and acid–base balance.
● If you suspect fluid volume deficit, be sure to assess the patient for orthostatic hypotension.
● Capillary refill and venous filling also offer information about fluid status.
● Respiratory rate and pattern, as well as breath sounds, offer clues about fluid, electrolyte, and acid–base status.
● Assess orientation, level of consciousness, reflexes, and fatigue.
● Monitoring daily change in weight is an accurate method of assessing fluid status.
● Measure all fluids consumed or excreted in a 24-hour period.

Question 62

What aspects should be evaluated in a nursing history focused on fluid, electrolyte, and acid–base balance?

Answer 62

Answer:
The nursing history related to fluids, electrolytes, and acid–base balance includes questions about intake and output, underlying medical conditions, and current health problems. The following topics need to be assessed:
●   Demographic data
●   Past medical history
●   Current health concerns
●   Food and fluid intakes
●   Fluid elimination
●   Medications
●   Lifestyle

Question 63

identify laboratory tests that monitor fluid, electrolyte, and acid–base balance.

Answer 63

Answer:
The following lab tests monitor fluid, electrolyte, and acid–base balance:
● Serum electrolytes measures sodium, potassium, chloride, and bicarbonate levels. Test often includes blood urea nitrogen (BUN), creatinine, and glucose.
● Serum osmolality is a measure of the solute concentration of the blood.
● Urine osmolality is the solute concentration of urine.
● Hematocrit is a measure of the percent of RBCs in whole blood.
● Specific gravity measures the kidney’s ability to concentrate or dilute urine in relation to the plasma.
● ABGs measure acid–base balance and oxygen status.

Question 64

Give at least five strategies to prevent fluid and electrolyte imbalance.

Answer 64

Answer:
Answers may include any five of the following strategies to prevent fluid and electrolyte imbalance:
● Drink at least eight to ten 8-ounce glasses of water per day. Educate the client about usual fluid needs and circumstances that increase fluid needs, such as high environmental temperature, fever, gastrointestinal fluid loss, or draining wounds. Base your teaching on the client’s current intake and the changes required to meet fluid goals.
● Instruct clients to use thirst as guide. When the client is physically able to access liquid, this is a useful tool.
● Limit consumption of fluids high in salt, sugar, caffeine, or alcohol.
● Teach the client to contact a healthcare provider if he experiences prolonged vomiting, diarrhea, or inability to tolerate liquids or food.
● Encourage clients to drink water before, during, and after strenuous exercise.
● Identify medications or conditions that place the client at risk for imbalances. For example, if the client is receiving a potassium-wasting diuretic, she will need to increase her potassium intake, either by taking a supplement or by altering her diet.
● Caution clients to avoid routine use of laxatives, antacids, weight-loss products, or enemas. All of these products may cause imbalances.
● Instruct the client to weigh himself daily if fluid balance is critical or if the client is experiencing excessive loss.
● Instruct the client to contact a health professional if there is a sudden change of weight, decreased urine output, swelling in dependent areas, shortness of breath, or dizziness.
● Encourage clients to eat a well-balanced diet, including dairy products rich in calcium.

Question 65

What is the purpose of IV fluids?

Answer 65

Answer:
IV fluids are used for the following reasons:
● To expand intravascular volume
● To correct an underlying imbalance in fluids or electrolytes
● To compensate for an ongoing problem that is affecting either fluids or electrolytes

Question 66

Isotonic fluids

Answer 66

(examples are lactated Ringer’s and 0.9% sodium chloride (normal saline). The osmolality of isotonic fluids is similar to that of blood serum. When infused, isotonic solutions remain inside the intravascular compartment. As a result, they are useful for clients with hypotension or hypovolemia. Monitor them carefully if the client is at risk for fluid volume excess due to congestive heart failure (CHF) or hypertension.

Question 67

Hypotonic solutions

Answer 67

(examples are 5% dextrose [D5W] and 0.45% sodium chloride [D5½NS]). Hypotonic solution osmolality is less than serum. Infusion of these solutions pulls body water from the intravascular compartment into the interstitial fluid compartment. As the interstitial fluid is diluted, its osmolarity decreases, drawing water into the adjacent cells. Hypotonic fluid is used for hyperglycemic conditions, such as diabetic ketoacidosis, in which high serum glucose draws fluid out of the cells and into the vascular and interstitial compartments. Hypotonic fluids must be administered carefully to prevent a sudden fluid shift from the intravascular space to the cells.

Question 68

Hypertonic fluids (

Answer 68

(volume expanders, such as dextran and serum albumin). Hypertonic fluids have a higher osmolality than serum. When administered, they pull fluids and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Hypertonic fluids can help stabilize blood pressure, increase urine output, and reduce edema. Volume expanders are used to increase blood volume following severe loss of blood or plasma, such as in severe burns or hemorrhage.

Question 69

Mrs. Katz has been admitted to the intermediate care unit with a diagnosis of acute gastrointestinal bleeding. Her blood pressure is 88/50 mm Hg, and her pulse is 120 beats/min. The nurse would expect Mrs. Katz’s IV therapy to be:
A. a blood transfusion.
B. an isotonic fluid, such as normal saline.
C. a peripheral IV lock.
D. a hypotonic fluid, such as 5% dextrose.

Answer 69

Answer:
B. an isotonic fluid, such as normal saline.

Rationale:
Although Mrs. Katz may need a blood transfusion, there are no data related to her hematocrit and hemoglobin levels. With a blood pressure of 88/50 mm Hg, she would need IV therapy to replace volume and correct her hypotension, and neither an IV lock nor hypotonic fluid would accomplish this goal.

Question 70

Mr. Shoen has congestive heart failure. In obtaining a dietary history from Mr. Shoen, the nurse notes that his meals consist of many high-sodium foods. The nurse should teach the patient which of the following?
A. A diet high in sodium will cause him to lose too much fluid volume and his blood pressure to fluctuate.
B. A diet high in sodium will cause him to retain fluid, increasing the workload of his heart.
C. A diet high in sodium will cause him to lose potassium, putting him at risk for cardiac arrhythmias.
D. A diet high in sodium will cause him to lose calcium, putting him at risk for osteoporosis.

Answer 70

Answer:
B. A diet high in sodium will cause him to retain fluid, increasing the workload of his heart.

Rationale:
A high-sodium diet would not cause fluid loss, potassium loss, or calcium loss. Sodium contributes to fluid retention.

Question 71

The nurse notes that a patient on her unit has had a very high temperature for the past 2 days. Today, the patient’s skin turgor is poor, and she tells the nurse her mouth feels very dry. Which of the following is the nurse’s best response?
A. Call the physician to request an IV fluid bolus.
B. Place the patient on intake and output measurements.
C. Restrict the patient’s fluid intake to 600 mL for the rest of the shift.
D. Encourage the patient to increase oral fluid intake

Answer 71

Answer:
D. Encourage the patient to increase oral fluid intake .

Rationale:
The patient is slightly dehydrated, and an IV fluid bolus would only be necessary if the patient exhibited serious signs of hypovolemia or could not tolerate oral liquids. You would not restrict the fluid intake. Merely measuring the patient’s intake and output will not address the dehydration.

Question 72

Cammy Smith is brought to the emergency room following an attempted robbery. She is extremely distraught and hyperventilating. If an arterial blood gas sample were to be obtained, the nurse would expect to find:
A.  a falling pH and a rising PCO2.
B.  a rising pH and a rising PCO2.
C.  a rising pH and a falling PCO2.
D.  a falling pH and a falling PCO2.

Answer 72

Answer:
C. a rising pH and a falling PCO2.

Rationale:
The patient would be developing respiratory alkalosis, which would be identified by a rise in pH and a decrease in the PCO2 due to the hyperventilation.

Question 73

The tip of all central venous access devices infuses IV fluids into the:
A.  jugular vein.
B.  superior vena cava.
C.  subclavian vein.
D.  brachial vein.

Answer 73

Answer:
B. superior vena cava.

Rationale:
Although central venous access device catheters may be inserted into the jugular, subclavian, or brachial vein, the end of the catheter is threaded into the superior vena cava.

Question 74

Patients who are placed on a fluid restriction may still have as much crushed ice as they desire.

Answer 74

Answer:
False

Rationale:
Crushed ice must be counted as fluid intake, as is everything that becomes liquid at room temperature.

Question 75

A goal of administering albumin intravenously is to increase oncotic pressure in the vascular space.

Answer 75

Answer:
True

Rationale:
Albumin is a large serum protein that draws fluid into the vascular space.

Question 76

If the nurse is unsuccessful in his attempt to perform venipuncture for IV therapy, he should keep trying until the catheter is placed successfully in the vein.

Answer 76

Answer:
False

Rationale:
Many institutions have policies regarding the number of attempts that may be made at venipuncture by the nurse. These policies often direct the nurse to enlist the assistance of a CRNA or IV nurse if unable to establish venous access after a number of attempts. We recommend, as do several guidelines, making only two attempts before seeking help.

Question 77

A person who has the blood type B+ could receive a transfusion from an O+ donor.

Answer 77

Answer:

True

Question 78

The best overall measurement of total body fluid loss or gain is the measurement of intake and output.

Answer 78

Answer:
False

Rationale:
Intake and output only measures the fluid that enters and exits the vascular system. It will not measure the fluid contained interstitially or fluid that is in a third space.

Question 79

A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dl; Mg2+ = 1.4 mg/dL; and Cl– = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient’s prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. The nurse recognizes that these symptoms and diagnostic information are consistent with which of the following?

1) Hypocalcemia
2) Hypernatremia
3) Hypokalemia
4) Hypermagnesemia

Answer 79

Answer:
3) Hypokalemia

Rationale:
The serum potassium level is low (norm = 3.5 to 5.0 mEq/L). PVCs related to cardiac irritability and a flat T wave on an ECG are also indicative of hypokalemia. The patient takes furosemide (Lasix), a diuretic that can induce hypokalemia.

Question 80

A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dL; Mg2+ = 1.4 mg/dL; and Cl– = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient’s prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. Why might the nurse question the order for digoxin 0.25 mg orally daily?

1) Based on the digoxin level, the dose may need to be increased.
2) The patient is at risk for an elevated digoxin level at this time.
3) Digoxin and furosemide should never be taken together.
4) The nurse should not be concerned about the order as written.

Answer 80

Answer:
2) The patient is at risk for an elevated digoxin level at this time.

Rationale:
The hypokalemic patient on digoxin is at high risk for digoxin toxicity. The patient’s serum digoxin level will need to be assessed as she receives potassium supplementation. Digoxin and furosemide can be taken together.

Question 81

Which of the following is considered a first-line intravenous solution for a patient with hypovolemia?

1) 0.9% NaCl (normal saline)
2) 0.45% NaCl (1/2 normal saline)
3) Dextran (a plasma expander)
4) D5W (5% dextrose in water)

Answer 81

Answer:
1) 0.9% NaCl (normal saline)

Rationale:
Hypovolemia occurs when there is a proportional loss of water and electrolytes from the extracellular fluid. Normal saline is an isotonic fluid that remains inside the intravascular space, thus increasing volume. Solutions of 0.45% NaCl and D5W are hypotonic fluids and therefore would pull body water from the intravascular compartment into the interstitial fluid compartment, leading to cellular death. Dextran is a hypertonic fluid that pulls fluid and electrolytes from the intercellular and interstitial compartments into the intravascular compartment and can be used in cases of hypovolemia but is not considered as a first choice.

Question 82

A physician has prescribed 1,000 ml of 0.9% NaCl (normal saline) over 4 hours for a hypovolemic patient. The drop (gtt) factor is 60. What would the nurse set the drip rate at?

1) 75 gtt/min
2) 100 gtt/min
3) 250 gtt/min
4) 500 gtt/min

Answer 82

Answer:
3) 250 gtt/min

Rationale:
Calculate the drip rate by multiplying the hourly rate by the drop factor in drops/mL divided by 60 min. An infusion of 1,000 mL over 4 hours yields an hourly rate of 250 mL.

Question 83

A patient is to receive two units of packed red blood cells. Her blood group is O+. The nurse knows that the patient may receive blood from which of the following donors?

1) AB+, A–, B+, and O–
2) A+ and O+
3) AB– and O+
4) O+ and O–

Answer 83

nswer:
4) O+ and O–

Rationale:
Persons with O+ blood may receive O+ or O-. Blood group O persons are considered “universal donors.” Rh+ persons may receive Rh+ and Rh– blood. Persons who are Rh– may receive only Rh– blood.

Question 84

A patient has been admitted to the hospital with medical diagnoses of hypervolemia, acute renal failure, and cardiac dysrhythmias. The patient’s vital signs are the following: T = 98.4°F (36.9°C); P = 110; R = 32; BP = 162/102. On physical examination the nurse notes distended neck veins and 3+ pitting edema in both lower extremities. The patient reports he has been drinking and eating as usual but has been unable to urinate. Which is the most appropriate nursing diagnosis for this patient?

1) Excess Fluid Volume related to excessive food and fluid intake
2) Deficient Fluid Volume related to increased metabolic demands
3) Imbalanced Electrolytes secondary to fluid shifts
4) Excess Fluid Volume secondary to acute renal failure

Answer 84

Answer:
4) Excess Fluid Volume secondary to acute renal failure

Rationale:
This patient is experiencing Excess Fluid Volume secondary to acute renal failure. There is no indication that he has engaged in excessive food or fluid intake. There is no laboratory result to indicate an electrolyte imbalance, although his test results will most likely demonstrate abnormalities because of the acute renal failure.

Question 85

A patient is in respiratory distress. The physician has ordered arterial blood gases (ABGs). The results are the following: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. How should the nurse interpret the ABGs?

1) Respiratory acidosis
2) Respiratory alkalosis
3) Metabolic acidosis
4) Metabolic alkalosis

Answer 85

Answer:
2) Respiratory alkalosis

Rationale:
The ABGs are consistent with respiratory alkalosis. The pH is elevated, indicating alkalosis. The PCO2 is decreased, which is also consistent with alkalosis. The HCO3 is within normal range.

Question 86

For a patient in respiratory distress, the first arterial blood gases (ABGs) were the following: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. The ABGs were repeated the next morning. The new results are the following: pH = 7.47; PCO2 = 26 mmol/L; HCO3 = 28 mEq/L. The nurse recognizes that the values have changed and that the patient is now experiencing

1) respiratory acidosis.
2) metabolic alkalosis.
3) partial compensation.
4) complete compensation.

Answer 86

Answer:
3) partial compensation.

Rationale:
Although the pH remains alkalotic, the bicarbonate level has begun to rise to compensate for the low PCO2. Complete compensation occurs when the pH returns to normal.

Question 87

The nurse is discontinuing a central venous access device. When she removes the catheter, she notes that a portion of the tip is missing. What action must she take?

1) Apply a tourniquet above the site.
2) Start a new peripheral IV.
3) Apply warm compresses to the site.
4) Notify the physician and radiologist.

Answer 87

Answer:
4) Notify the physician and radiologist.

Rationale:
Loss of the catheter tip places the patient at risk for an embolus. Because the catheter was in a central vein, it is not possible to place a tourniquet above the site. Warm compresses are appropriate follow-up care for IV extravasation or infiltration. A new peripheral IV may be needed, but this is not the priority. The nurse must notify the physician and radiologist.

Question 88

The student nurse is reviewing a patient’s laboratory reports. Which of the following results should be reported to the primary care provider?

1) Na+ = 126 mEq/L
2) K+ = 3.8 mEq/L
3) Ca2+ = 9.2 mg/dL
4) Mg2+ = 1.8 mg/dL

Answer 88

Answer:
1) Na+ = 126 mEq/L

Rationale:
Serum sodium of 126 mEq/L indicates significant hyponatremia. The student nurse should report the findings to the nurse with whom she is working (or the primary care provider, depending on agency policy) who will report the findings to the primary care provider. The other laboratory results are all within normal limits.