Fluid Electrolyte and Acid Base Balance EOCHQ

Question 1

An older nursing home resident has refused to eat or drink for several days and is admitted to the hospital. The nurse should expect which assessment finding?

Answer 1

Weak, rapid pulse

(caused by fluid volume deficit)

Question 2

A man brings his elderly wife to the emergency department. He states that she has been vomiting and has had diarrhea for the past 2 days. She appears lethargic and is complaining of leg cramps. What should the nurse do first?

Answer 2

Review the results of serum electrolytes

(further assessment is needed to determine appropriate action)

Question 3

The nurse administers and IV solution of d5//1.5 NS to a postoperative pt. This is classified as what type of IV solution?

Answer 3

Hypertonic

Question 4

An older pt comes to the ED experiencing chest pain and SOB. An ABG is ordered. Which ABG result indicates respiratory acidosis?

Answer 4

pH: 7.32
PaCO2: 46 mmHg
HCO3: 24

Question 5

The I&O record of a pt with an NG tube who has been attached to suction for 2 days shows greater output than input. Which nursing dx are most applicable?

Answer 5

Decreased fluid volume
Dry oral mucous membranes
Inadequate cardiac output

Question 6

Which statement indicates a need for further teaching regarding tx for hypokalemia?

Answer 6

I will stop using my salt substitute
(salt substitutes contain potassium)

Question 7

An older man is admitted to the medical unit with a dx of dehydration. Which sign of sx is most indicative of sodium imbalance?

Answer 7

Mental confusion
(sodium contributes to the function of neural tissue. potassium and calcium are related to cardiac function - irregular pulse is ore likely to be associated with those alterations)

Question 8

The pts ABG results are:
pH: 7.32
PaCO2: 58
HCO3: 32
The nurse knows that the pt is experiencing which acid-base imbalance?

Answer 8

Respiratory acidosis

Question 9

A pt is admitted to the hospital for hypocalcemia. Nursing interventions relating to which system would have the highest priority?

Answer 9

Neuromuscular
(hypocalcemia s/s are due to increased neuromuscular activity)

Question 10

The nurse would assess for signs for hypomagnesemia in which of the following pts

Answer 10

A pt with pancreatitis
A pt with excessive nasogastric drainage
A pt with chronic alcoholism

Question 11

What are the s/s of hypoxia?

Answer 11

Rapid pulse
Rapid and shallow respirations/ dyspnea
Flaring of the nares
Cyanosis
Substernal/ intercostal retractions
Restlessness and light headedness
(cerebral cortex can only tolerate hypoxia for 3-5 min before permanent brain damage occurs)

Question 12

Gas exchange occurs where?

Answer 12

Between the air on the alveolar side and the blood on the capillary side