Lewis: Acid-Base and Fluid and Electrolytes

Question 1

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?

Answer 1

Blood pressure is 90/40 mm Hg.

Question 2

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?

Answer 2

Serum sodium level of 120 mg/dL

Question 3

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?

Answer 3

Daily weight

Daily weight is the most easily obtained and accurate means of assessing volume status.

Question 4

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake?

Answer 4

Increase fluids if your mouth feels dry.

Question 5

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action?

Answer 5

Ask the health care provider to order a basic metabolic panel.

Question 6

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the
patient indicates that the teaching about this medication has been effective?

Answer 6

I will drink apple juice instead of orange juice for breakfast

Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits).

Question 7

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action?

Answer 7

Assign the patient to a room near the nurses station.

Question 8

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia.
Which action should the nurse take?

Answer 8

Infuse the KCl at a rate of 10 mEq/hour.

Question 9

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction
for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy
should the nurse question?

Answer 9

Infuse 5% dextrose in water at 125 mL/hr.

Question 10

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued
mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2
85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?

Answer 10

Respiratory alkalosis

Question 11

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations.
Which action should the nurse take?

Answer 11

Administer the prescribed normal saline bolus and insulin.

The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the
acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells

Question 12

An older adult patient who is malnourished presents to the emergency department with a serum protein
level of 5.2 g/dL. The nurse would expect which clinical manifestation?

Answer 12

Edema

The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues

Question 13

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion?

Answer 13

Lung sounds

Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid
excess

Question 14

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who
has a low serum total protein level. Which assessment finding indicates that the patients condition has
improved?

Answer 14

Decreased peripheral edema

Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema
indicates an improvement in the patients protein status

Question 15

15. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial
    blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the
    nurse interpret
    these results?

Answer 15

Metabolic acidosis

Question 16

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum
potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is
on which medication?

Answer 16

Oral digoxin (Lanoxin) 0.25 mg daily

Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias

Question 17

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the
nurse include on the care plan?

Answer 17

Encourage fluid intake up to 4000 mL every day.

To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily.

Question 18

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed
assistive personnel (UAP) to remove which food from the patients food tray?

Answer 18

Milk carton

Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets.

Question 19

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which
assessment would be most important for the nurse to make?

Answer 19

Daily alcohol intake

Hypomagnesemia is associated with alcoholism

Question 20

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a
peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?

Answer 20

The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.

Question 21

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate?

Answer 21

Use the push-pause method to flush the CVAD after giving medications

Question 22

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and
weakness. Which laboratory result should the nurse report to the health care provider immediately?

Answer 22

Na+ 154 mEq/L (154 mmol/L)

The elevated serum sodium level is consistent with the patients neurologic symptoms and indicates a need for
immediate action to prevent further serious complications such as seizures

Question 23

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be apriority for the nurse to report to the health care provider?

Answer 23

Gradually decreasing level of consciousness (LOC)

Question 24

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed
medications and seems confused. The patient complains of just blowing up and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?

Answer 24

Mental status

Question 25

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension
(Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to
questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first?

Answer 25

Notify the patients health care provider

Question 26

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patients respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first?

Answer 26

Give the patient the PRN IV morphine sulfate 4 mg

The patients respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety.

Question 27

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)?

Answer 27

Monitor the IV sites for redness, swelling, or tenderness

An experienced LPN/LVN has the education, experience, and scope of practice to monitor IV sites for signs of
infection.

Question 28

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider?

Answer 28

The patient is experiencing laryngeal stridor

Remember: 4.5 – 5.5 mEq/L

Question 29

Following a thyroidectomy, a patient complains of a tingling feeling around my mouth. Which assessment
should the nurse complete immediately?

Answer 29

Presence of the Chvosteks sign

The patients symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid
injury/removal during thyroidectomy.

Question 30

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse?

Answer 30

Serum calcium is 18 mg/dL.

The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The
nurse should initiate cardiac monitoring and notify the health care provider

Remember range 8.5-10.5mg/dL

Question 31

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding
should the nurse report to the health care provider immediately

Answer 31

The patellar and triceps reflexes are absent

The loss of the deep tendon reflexes indicates that the patients magnesium level may be reaching toxic level

Question 32

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will
require the most rapid response by the nurse?

Answer 32

There are crackles audible throughout both lung fields

Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a lifethreatening
adverse effect of hypertonic solutions..

Question 33

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which
action should the nurse take next?

Answer 33

Monitor ionized calcium level

Question 34

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action
should the nurse take first?

Answer 34

Check the patients blood pressure

Question 35

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter?

Answer 35

Auscultate the patients breath sounds

The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax

Question 36

After receiving change-of-shift report, which patient should the nurse assess first?

Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping
Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of
water
Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon
reflexes
Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate
precipitates

Answer 36

Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon
reflexes

The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures.

Question 37

During the admission process, the nurse obtains information about a patient through the physical
assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing
diagnosis is appropriate?

Answer 37

Risk for injury: Seizures

The patients muscle cramps and low serum calcium level indicate that the patient is at risk for seizures and/or
tetany