Fluids, Electrolytes, & Acid-Base Balance

Identify the choice that best completes the statement or answers the question.

____ 1. Which body fluid lies in the spaces between the body cells?

1)
Interstitial
2)
Intracellular
3)
Intravascular
4)
Transcellular

____ 2. Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles?

1)
Cations, because they carry a positive charge
2)
Cations, because they carry a negative charge
3)
Anions, because they carry a positive charge
4)
Anions, because they carry a negative charge

____ 3. A patient is brought to the emergency department (ED) by paramedics after a person standing on the sidewalk saw him fall on a crowded street. He has a history of alcoholism and is frequently brought to the ED. The nurse finds the patient to be disoriented; he has periods of being calm mixed with episodes of being disruptive and loud. His vital signs are the following: BP 138/84; pulse 135, regular and strong; respiratory rate 22; temperature 37.1°C (98.1°F). What electrolyte imbalance might the nurse suspect?

1)
Hypomagnesemia
2)
Hypocalcemia
3)
Hyperkalemia
4)
Hypernatremia

____ 4. The passive process by which molecules of a solute move through a cell membrane from an area of higher concentration to an area of lower concentration is called which of the following?

1)
Osmosis
2)
Filtration
3)
Hydrostatic pressure
4)
Diffusion

____ 5. A client is admitted to the emergency department (ED) in respiratory distress. The results of his arterial blood gases are the following: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/l; PO2 = 80. The nurse interprets the findings as which of the following?

1)
Respiratory acidosis with normal oxygen levels
2)
Respiratory alkalosis with hypoxia
3)
Metabolic acidosis with normal oxygen levels
4)
Metabolic alkalosis with hypoxia

____ 6. A patient is admitted to the emergency department (ED) in respiratory distress. The results of his first arterial blood gases were: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/l; PO2 = 80. The nurse evaluates the patient’s treatment plan by examining repeat arterial blood gases (ABGs). The results are: pH = 7.38; PCO2 = 32; HCO3 = 19 mEq/l. The nurse concludes which of the following?

1)
Respiratory acidosis; the treatment plan is ineffective
2)
Metabolic alkalosis; the treatment plan is effective
3)
Partial compensation; the treatment plan is ineffective
4)
Complete compensation; the treatment plan is effective

____ 7. When a patient has metabolic acidosis, which body system influences the acid–base imbalance to produce the compensatory changes in the arterial blood gases?

1)
Respiratory system
2)
Renal system
3)
Vascular system
4)
Neurological system

____ 8. A patient’s arterial blood gas results are as follows: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/l; PO2 = 80. An appropriate nursing diagnosis for the patient is which of the following?

1)
Impaired Gas Exchange
2)
Metabolic Acidosis
3)
Risk for Impaired Gas Exchange
4)
Risk for Acid–Base Imbalance

____ 9. The nurse is caring for a patient with a medical diagnosis of hypernatremia. The following prescriptions are written in the client’s electronic health record. Which one should the nurse question?

1)
Administer an IV of D5W at 125 ml/hr.
2)
Strict I&O monitoring.
3)
Restrict oral intake to 900 ml every 24 hr.
4)
Monitor serum electrolytes every 4 hr.

____ 10. Which process requires energy to maintain the unique composition of extracellular and intracellular compartments?

1)
Diffusion
2)
Osmosis
3)
Filtration
4)
Active Transport

____ 11. The nurse records a patient’s hourly urine output from an indwelling catheter as follows:

0700: 36 ml

0800: 45 ml

0900: 85 ml

1000: 62 ml

1100: 50 ml

1200: 48 ml

1300: 94 ml

1400: 78 ml

1500: 60 ml

The nurse can conclude that the patient’s urine output should be described as which of the following?

1)
Very low
2)
Within normal limits
3)
Very high
4)
Inconclusive

____ 12. Which of the following is the principle site for regulation of fluid and electrolyte balance?

1)
The heart
2)
The vascular system
3)
The pulmonary system
4)
The kidneys

____ 13. Which electrolyte is the primary regulator of fluid volume?

1)
Potassium
2)
Calcium
3)
Sodium
4)
Magnesium

____ 14. An 82-year-old woman was brought to the emergency department by her granddaughter. She is a widow and lives alone, although her granddaughter checks on her daily. She has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 weak and thready; BP = 80/52. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results:

Sodium
138 mEq/l
Potassium
3.7 mEq/l
Calcium
9.2 mg/dl
Magnesium
1.8 mg/dl
Chloride
99 mEq/l
BUN
29 mg/dl

The nurse recognizes that the patient is displaying symptoms associated with which of the following?

1)
Hypovolemia
2)
Hypervolemia
3)
Hypernatremia
4)
Hyponatremia

____ 15. A patient has been vomiting for 2 days and has not been able to eat or drink anything during this time. She has not urinated for 12 hours. Physical examination reveals the following: T = 99.6°F (37.6°C) orally; P = 110 weak and thready; BP = 80/52. Her skin and mucous membranes are dry, and there is decreased skin turgor. The patient states that she feels very weak. The following are her laboratory results:

Sodium
138 mEq/l
Potassium
3.7 mEq/l
Calcium
9.2 mg/dl
Magnesium
1.8 mg/dl
Chloride
99 mEq/l
BUN
29 mg/dl

Which of the following is an appropriate nursing diagnosis for this patient?

1)
Impaired Gas Exchange related to ineffective breathing
2)
Excess Fluid Volume related to limited fluid output
3)
Deficient Fluid Volume related to abnormal fluid loss
4)
Electrolyte Imbalance related to decreased oral intake

____ 16. Which of the following the most appropriate goal for a patient with the nursing diagnosis of Deficient Fluid Volume?

1)
Electrolyte balance restored, as evidenced by improved levels of alertness and cognitive orientation
2)
Electrolyte balance restored, as evidenced by sodium returning to normal range
3)
Patient demonstrates effective coughing and deep breathing techniques
4)
Maintains fluid balance, as evidenced by moist mucous membranes and urinating every 4 hours

____ 17. Which laboratory results on a client’s health record should alert the nurse to a potential problem?

1)
Na+ = 137 mEq/l
2)
K+ = 5.2 mEq/l
3)
Ca2+ = 9.2 mg/dl
4)
Mg2+ = 1.8 mg/dl

____ 18. A patient’s vital signs prior to a blood transfusion were: T = 97.6°F (36.4°C); P = 72; R = 22; and BP = 132/76. Twenty minutes after the transfusion was begun, the patient began complaining of feeling “itchy and hot.” The nurse discovered a rash on the patient’s trunk. Vital signs were: T = 100.8°F (38.2°C); P = 82; R = 24; BP = 146/88. Based on these findings, what is the priority intervention?

1)
Administer an antihistamine (antiallergenic) medication.
2)
Flush the blood tubing with D5W immediately.
3)
Prepare for emergency resuscitation.
4)
Stop the blood transfusion immediately.

____ 19. A patient is receiving an IV infusion of lactated Ringer’s solution and 40 mEq of KCl at 100 ml/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following?

1)
Infiltration
2)
Extravasation
3)
Hematoma
4)
Phlebitis

____ 20. The nurse assesses that her patient’s intravenous solution has infiltrated into the tissues. What action should she take first?

1)
Aspirate, then inject 0.5 mL normal saline.
2)
Restart the IV line in a different vein.
3)
Stop the infusion immediately.
4)
Notify the primary care provider.

____ 21. The physician has ordered a complete blood count for a 6-year-old child. When the nurse enters the room, she finds the child sobbing uncontrollably. His mother tells him to “shut up and act your age.” How should the nurse proceed?

1)
Request that the mother leave the room immediately
2)
Request the help of a coworker to hold the child down
3)
Inform the child that “this won’t hurt a bit”
4)
Calmly approach the child and tell him what is going to happen

____ 22. A physician has ordered 250 ml of 0.9% sodium chloride to be infused over 2 hours. A microdrip infusion set is being used. What is the drip rate that the nurse should monitor?

1)
60 drops per minute
2)
75 drops per minute
3)
125 drops per minute
4)
250 drops per minute

____ 23. The nurse examines the electrocardiogram (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect?

1)
Hypokalemia
2)
Hypophosphotemia
3)
Hyperkalemia
4)
Hypercalcemia

____ 24. The nurse gathers the following data: BP = 150/94; neck veins distended; P = 104; pulse bounding; respiratory rate = 20; T = 37°C (98.6°F). What disorder should the nurse suspect?

1)
Hypovolemia
2)
Hypercalcemia
3)
Hyperkalemia
4)
Hypervolemia

____ 25. A patient has a continuous IV infusion at 60 ml/hr. The right hand IV has infiltrated and the nurse has started a new IV on the left forearm. Which of the following interventions should the nurse also perform?

1)
elevate the patient’s left forearm.
2)
schedule daily dressing changes to the new IV site.
3)
change the administration set.
4)
place the patient in Fowler’s position.

____ 26. When performing a central venous catheter dressing change, which of the following steps is/are correct? Choose all that apply.

1)
Wear sterile gloves while removing and discarding the soiled dressing.
2)
Apply pressure on the catheter-hub junction when removing the soiled dressing.
3)
Place a sterile transparent dressing over the site and the catheter-hub junction.
4)
Have the patient wear a mask or turn his head away from the site.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. In a healthy adult, which of the following regulate(s) body fluids? Choose all that apply.

1)
Hormone levels
2)
Fluid intake
3)
Oxygen saturation
4)
Kidney function

____ 2. A patient has been admitted to the nursing unit with a diagnosis of chronic renal failure. She will be dialyzed for the first time the following morning. Which of the following are appropriate nursing interventions for the patient? Choose all that apply.

1)
Encourage oral fluid intake of 2,500 ml per day.
2)
Place the patient on strict I&O.
3)
Weigh the patient before and after dialysis.
4)
Maintain a fluid restriction of 1,000 ml as prescribed.

____ 3. Identify the mechanism(s) involved in acid–base balance. Choose all that apply.

1)
Respiratory mechanisms
2)
Active transport mechanisms
3)
Renal mechanisms
4)
Buffer systems

____ 4. Identify the appropriate intervention(s) for a patient with hypovolemia. Choose all that apply.

1)
Teach deep-breathing techniques.
2)
Monitor I&O daily.
3)
Encourage fluid intake.
4)
Monitor electrolyte balance.

____ 5. A patient’s blood group is B. The nurse knows the patient can receive blood only from donors with what group(s) of blood? Choose all that apply.

1)
A
2)
B
3)
O
4)
AB

____ 6. A nurse is caring for a patient with a peripheral IV line located in the right forearm. The patient informs the nurse that the IV site is burning. Upon assessment the nurse determines that the IV solution has infiltrated. What site(s) is/are appropriate to consider when restarting the IV line? Choose all that apply.

1)
Left hand
2)
Right wrist
3)
Right antecubital area
4)
Right saphenous vein

____ 7. A patient has been diagnosed with hypovolemia. Which order(s) for hydration should the nurse question? Choose all orders that should be questioned.

1)
0.9% (normal) saline at 100 ml/hr
2)
Lactated Ringer’s solution at 100 ml/hr
3)
Total parenteral nutrition solution at 100 ml/hr
4)
D5W solution at 100 ml/hr

____ 8. When assisting with bedside central venous catheter (CVC) placement, which nursing intervention is appropriate? Choose all that apply.

1)
Don sterile gloves and mask (and possibly gown).
2)
Scrub the insertion site with antibacterial soap for 1 min.
3)
Verify that informed consent has been obtained.
4)
Place the patient in low Fowler’s position.

Completion

Complete each statement.

1. ____________________ are substances that develop an electrical charge when dissolved in water.

2. A(n) ____________________ is any compound that contains hydrogen ions that can be released.

3. A(n) ____________________ is a compound that combines with (accepts) hydrogen ions in a solution.

Chapter 36. Fluids, Electrolytes, & Acid-Base Balance

Answer Section

MULTIPLE CHOICE

1. ANS: 1

Extracellular fluid lies outside the cells. It is composed of three types of fluid: interstitial, intravascular, and transcellular. Interstitial fluid lies in the spaces between the body cells. Intravascular fluid is the plasma within the blood. Transcellular fluid includes specialized fluids, such as cerebrospinal, pleural, peritoneal, and synovial; and digestive juices. Intracellular fluid is contained within the cells.

PTS: 1 DIF: Easy REF: V1, p. 914

KEY: Client need: HPM | Cognitive level: Recall

2. ANS: 4

Anions are electrolytes that carry a negative charge; they include chloride, bicarbonate, phosphate, and sulfate. Electrolytes that carry a positive charge are called cations. Cations include sodium, potassium, calcium, and magnesium.

PTS: 1 DIF: Moderate REF: V1, p. 914

KEY: Client need: PHSI | Cognitive level: Comprehension

3. ANS: 1

Hypomagnesemia is a frequent consequence of alcoholism. Signs and symptoms include disorientation, mood changes, and tachycardia. Hypocalcemia, a low calcium level, is associated with muscle spasms and tetany. Hyperkalemia, a high potassium level, manifests as weakness, fatigue, and cardiac dysrhythmias. Hypernatremia, a high sodium level, produces extreme thirst and agitation.

PTS: 1 DIF: Difficult REF: V1, p. 925

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

4. ANS: 4

Diffusion is a passive process by which molecules move from an area of higher concentration to an area of lower concentration. Osmosis is the movement of water across a membrane from an area of a less concentrated solution to an area of more concentrated solution. Filtration is the movement of water and smaller particles from an area of high pressure to low pressure. Hydrostatic pressure is the force created by fluid within a closed system.

PTS: 1 DIF: Moderate REF: V1, p. 916 | V2, p. 951

KEY: Client need: HPM | Cognitive level: Recall

5. ANS: 3

The pH is acidotic. The HCO3 of 19 mEq/l is low and has moved in the same direction as the pH, indicating a metabolic disorder. The PCO2 is within normal range with no signs of compensation. The PO2 level is normal.

PTS: 1 DIF: Difficult REF: V1, p. 927 | V2, p. 936

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

6. ANS: 4

Complete compensation has occurred as the PCO2 has returned the pH to the normal range. This change indicates that the treatment plan is effective. Partial compensation would be indicated by changes in the PCO2 but the pH would still be outside the normal range. The ABG is now complete compensation metabolic acidosis.

PTS: 1 DIF: Difficult REF: V1, pp. 926-927 | V2, p. 936

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis

7. ANS: 1

In a metabolic problem, the respiratory system compensates. In a respiratory problem, the renal system must compensate. The respiratory system compensates early in the disorder, but it may take up to 3 days for the renal system to compensate fully.

PTS: 1 DIF: Moderate REF: V1, p. 926

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Analysis

8. ANS: 1

An appropriate diagnosis is Impaired Gas Exchange. The arterial blood gas (ABG) results provide the defining characteristics for Impaired Gas Exchange. The ABG results demonstrate metabolic acidosis; however, this is not a nursing diagnosis. The patient has an actual problem; therefore, the “risk for” nursing diagnoses are incorrect. Additionally, there is no nursing diagnosis of Acid–Base Imbalance or Risk for Acid–Base Imbalance.

PTS: 1 DIF: Moderate REF: V1, p. 930

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

9. ANS: 3

Restricting the oral intake of a patient with hypernatremia (Na+ greater than 145 mEq/l) would lead to further elevation in the serum sodium level. Infusing D5W IV fluid is appropriate, as this solution does not contain sodium. Hydrating the patient with D5W would reduce the serum sodium level. Strict I&O monitoring and laboratory evaluation of electrolytes every 4 hr would ensure that the patient is safely rehydrated.

PTS: 1 DIF: Difficult REF: V1, p. 924

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

10. ANS: 4

Active transport occurs when molecules move across cell membranes from an area of low concentration to an area of high concentration. Active transport requires energy expenditure for the movement to occur against a concentration gradient. In the presence of ATP, the sodium–potassium pump actively moves sodium from the cell into the extracellular fluid. Active transport is vital for maintaining the unique composition of both the extracellular and intracellular compartments. Diffusion, osmosis, and filtration are passive processes.

PTS: 1 DIF: Difficult REF: V1, p. 916 | V2, p. 951

KEY: Client need: PHSI

11. ANS: 2

Urine accounts for the greatest amount of fluid loss. Normal urine output for an average sized adult is approximately 1,500 ml in 24 hr. Urine output varies according to intake and activity but should remain at least 30 to 50 ml per hour. The patient’s urine output is within the normal range. This patient has an indwelling catheter, which will result in continual flow of urine.

PTS: 1 DIF: Moderate REF: V1, p. 917

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

12. ANS: 4

A balance of fluid and electrolytes is essential to maintain homeostasis. Excesses or deficits can lead to severe disorders. The kidneys are the principle regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the body’s fluid and electrolyte balance. The heart and vascular system are involved in fluid balance but not in electrolyte balance and not as dramatically in fluid balance as are the kidneys—that is, they do not actually regulate electrolytes. The pulmonary system plays a major role in regulation of acid–base balance.

PTS: 1 DIF: Easy REF: V1, p. 918

KEY: Client need: PHSI | Cognitive level: Comprehension

13. ANS: 3

Sodium is the major cation in the extracellular fluid (ECF). Its primary function is to regulate fluid volume. When sodium is reabsorbed in the kidney, water and potassium are also reabsorbed, thereby maintaining ECF volume. Potassium is a key electrolyte in cellular metabolism. Calcium is responsible for bone health and neuromuscular and cardiac functions. It is also an essential factor in blood clotting. Magnesium is a mineral used in more than 300 biochemical reactions in the body.

PTS: 1 DIF: Easy REF: V1, p. 918

KEY: Client need: PHSI | Cognitive level: Recall

14. ANS: 1

Hypovolemia may occur as a result of insufficient intake of fluid; bleeding; excessive loss through urine, skin, or the gastrointestinal tract; insensible losses; or loss of fluid into a third space. The first symptom of hypovolemia is thirst. Other symptoms are a rapid weak pulse, a low blood pressure (although initially the blood pressure may rise), dry skin and mucous membranes, decreased skin turgor, and decreased urine output. Temperature increases because the body is less able to cool itself through perspiration. The person with fluid volume deficit usually has elevated BUN (blood urea nitrogen) and hematocrit levels. Hypervolemia involves excessive retention of sodium and water in the extracellular fluid, and the vital sign changes are opposite those of a patient with hypovolemia. Hypernatremia and hyponatremia are not applicable because the patient’s sodium level is within normal range.

PTS: 1 DIF: Difficult REF: V1, pp. 922-923

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Analysis

15. ANS: 3

Vomiting has made this patient hypovolemic; therefore, she has deficient fluid volume. There is no information to indicate that she has respiratory problems or Impaired Gas Exchange. Her symptoms are not consistent with Excess Fluid Volume. Electrolyte Imbalance is not a nursing diagnosis.

PTS: 1 DIF: Difficult REF: V1, pp. 922-923

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

16. ANS: 4

Moist mucous membranes and urinating every 4 hours would demonstrate restoration of fluid balance. Electrolyte imbalance does not necessarily occur with Deficient Fluid Volume; if electrolyte imbalance were present, the nursing diagnosis would be different. There is no evidence that this has a respiratory problem, so coughing and deep breathing are irrelevant.

PTS: 1 DIF: Moderate REF: V1, pp. 922-923

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

17. ANS: 2

A potassium level of 5.2 mEq/l indicates hyperkalemia. The other results are all within normal ranges.

PTS: 1 DIF: Moderate REF: V1, p. 924

KEY: Client need: PHSI | Cognitive level: Comprehension

18. ANS: 4

The nurse should suspect a transfusion reaction. When a transfusion reaction is suspected, the infusion should be stopped immediately. The blood bag and tubing must be sent to the laboratory for analysis. A new IV line of normal saline should be hung. Diphenhydramine (an antihistamine) may be ordered once the physician has been notified of the patient’s condition. There is no information indicating that the patient is in danger of cardiovascular collapse or requires resuscitation.

PTS: 1 DIF: Moderate REF: V1, p. 946 | V2, pp. 931-932

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

19. ANS: 4

Phlebitis is an inflammation of the vein. It may be caused by the infusion of solutions that are irritating to the vein. Patients receiving IV solutions with potassium chloride are at a higher risk for phlebitis, as it is irritating to the vein. The symptom of a palpable cord along the vein distinguishes this as phlebitis. Infiltration presents as erythema, pain, and swelling. However, there is no palpable cord with inflammation. Extravasation is infiltration of a vesicant substance into the tissues. Differentiating symptoms include blanching and coolness of the surrounding skin; the formation of blisters and subsequent tissue sloughing and necrosis are later signs. A hematoma is a localized mass of blood outside the blood vessel. This is generally seen when a vein is nicked during an unsuccessful insertion of an IV line or when an IV line is discontinued without pressure applied over the site.

PTS: 1 DIF: Difficult REF: V1, p. 941

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

20. ANS: 3

The nurse should first stop the infusion to avoid further tissue trauma. Because the IV has infiltrated, you must assume that the nurse has already checked the patency of the line by aspirating. There is no point in injecting saline because doing so puts even more fluid in the tissues. Injecting fluid to try to clear a clot from the catheter is not recommended because of the possibility of causing an embolism. Once the infusion is stopped, the nurse must assess whether the patient needs additional IV therapy. If so, a new IV line must be restarted above the site of infiltration or in the opposite arm. The nurse may need to inform the primary care provider if she is unable to find a new IV site or if she believes the patient no longer needs an IV.

PTS: 1 DIF: Moderate REF: V1, p. 941

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

21. ANS: 4

Having blood drawn may be uncomfortable and frightening for a 6-year-old child. A calm approach can alleviate some of the fear. Explain to the child’s mother that the boy’s behavior is normal. Informing the child that the blood draw will not hurt is wrong and will make him distrustful of future interventions. The nurse may need the help of a coworker, but she should first try a calm approach.

PTS: 1 DIF: Moderate REF: V1, p. 929; critical thinking required

KEY: Nursing process: Interventions | Client need: PSI | Cognitive level: Application

22. ANS: 3

Calculate the drip rate by multiplying the number of milliliters to be infused per hour (hourly rate) by the drop factor in drops/ml, divided by 60 minutes. An infusion of 250 ml in 2 hours results in an hourly rate of 125 ml/hr.

125 (ml/hr) ´ 60 (drops/ml) = 125 drops/min

60 min

PTS: 1 DIF: Moderate REF: V1, p. 940

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

23. ANS: 3

Potassium levels affect the heart. A tall, peaked T wave on an ECG is associated with hyperkalemia. A flat T wave is associated with hypokalemia. Phosphorous levels do not trigger ECG changes.

PTS: 1 DIF: Moderate REF: V1, p. 924

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension

24. ANS: 4

Hypervolemia results from retention of sodium and water. Blood pressure rises, the pulse is bounding, and neck veins become distended due to increased intravascular volume.

PTS: 1 DIF: Easy REF: V1, p. 923

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

25. ANS: 3

Reusing an IV set from a previous site increases the risk of contamination. IV dressings are usually changed every 72 to 96 hours when the IV site is rotated. There is no reason to elevate the patient’s left forearm, nor to place him in Fowler’s position.

PTS: 1 DIF: Easy REF: V1, p. 940

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

26. ANS: 4

Aseptic technique should be used with approaching the insertion site. Therefore, both nurse and patient should wear a mask. If the patient cannot wear a mask, have him turn his head away from the insertion site during the procedure. Sterile gloves should be worn when placing the new sterile dressing; however, procedure gloves are used to remove the soiled dressing. The nurse should stabilize the catheter while removing the soiled dressing, but not apply pressure to the catheter-hub junction. The transparent dressing should cover the hub of the catheter, but not the catheter-hub junction; this makes it too difficult to remove without disturbing the integrity of the IV line or the site.

PTS: 1 DIF: Difficult REF: V1, p. 932 | V1, p. 940

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application

MULTIPLE RESPONSE

1. ANS: 1, 2, 4

A balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. The kidneys are the principle regulator of fluid and electrolyte balance and are the primary source of fluid output. Specific hormones (e.g., ADH, aldosterone) cause the kidneys to regulate the body’s fluid and electrolyte balance. Oxygen saturation does not regulate fluids. It measures the saturation of oxygen on hemoglobin and is influenced by the partial pressure of oxygen, alveolar–arterial gradient lung disease, and the amount and type of hemoglobin (such as sickle cell anemia).

PTS: 1 DIF: Moderate REF: V1, pp. 917-918

KEY: Client need: PHSI | Cognitive level: Comprehension

2. ANS: 2, 3, 4

Fluids are restricted in patients with chronic renal failure because of decreased renal function. Therefore, encouraging oral fluids would not be appropriate. Appropriate nursing interventions for this patient include monitoring the intake and output, weighing the patient before and after dialysis, following a strict renal diet, and monitoring laboratory values.

PTS: 1 DIF: Moderate REF: V1, p. 923

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

3. ANS: 1, 3, 4

Acid–base balance is regulated by respiratory mechanisms, renal mechanisms, and buffer systems. Acid–base regulation can be monitored by examining arterial blood gases, especially blood pH. Buffer systems prevent wide swings in pH by absorbing or releasing free hydrogen ions. The lungs (respiratory mechanisms) control the carbonic acid supply via carbon dioxide. Conditions that cause retention of carbon dioxide, such as chronic obstruction pulmonary disease, lower the pH, whereas tachypneic conditions, such as hyperventilation syndrome, “blow off” carbon dioxide and increase the pH. The kidneys (renal mechanisms) regulate the concentration of plasma bicarbonate. By reabsorbing or excreting bicarbonate, the kidneys affect acid–base balance. Active transport involves the movement of fluids and electrolytes in the body.

PTS: 1 DIF: Moderate REF: V1, pp. 921-922

KEY: Client need: PHSI | Cognitive level: Comprehension

4. ANS: 2, 3, 4

Hypovolemia occurs when more fluid is lost than is taken into the body. Monitoring I&O provides information to evaluate the status of the problem. Encouraging fluid intake helps to correct the problem. It is good to monitor electrolytes because electrolyte imbalance can occur with hypovolemia (although it may not occur at first). Deep-breathing techniques do not address fluid balance; there is no evidence that the patient has a respiratory disorder.

PTS: 1 DIF: Easy REF: V1, pp. 922-923

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

5. ANS: 2, 3

Persons with blood group B can receive blood only from the blood groups B and O. Those with blood group AB may receive AB, A, B, and O blood. Blood group A persons may receive blood from A and O donors. Persons with blood group O may receive blood only from O donors. Blood group AB persons are considered universal recipients, and blood group O persons are considered universal donors.

PTS: 1 DIF: Moderate REF: V1, p. 947

KEY: Client need: SECE | Cognitive level: Comprehension

6. ANS: 1, 3

When restarting an IV line after an infiltration, you must restart above the site of infiltration. As a result, the right antecubital area is correct. The opposite extremity may also be used. The right saphenous vein is incorrect because that vein is located in the leg. The leg should be used as a last resort for an IV site. The primary care provider should be notified if a leg is being considered as an IV site.

PTS: 1 DIF: Difficult REF: V1, p. 938

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application

7. ANS: 3, 4

Hypovolemia occurs when there is a proportional loss of water and electrolytes from the ECF. Lactated Ringer’s and 0.9% (normal) saline are isotonic fluids that remain inside the intravascular space, thus increasing volume. The D5W is a hypotonic solution that would pull body water from the intravascular compartment into the interstitial fluid compartment. Total parenteral nutrition is a hypertonic fluid used to provide nutrition for the patient who cannot meet caloric needs by eating or enteral nutrition.

PTS: 1 DIF: Difficult REF: V1, pp. 922-923 | V1, p. 933

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Analysis

8. ANS: 1, 3

Maximum barrier sterile technique is used for CVC insertion (sterile gloves, mask, and gown), although some agency policies do not include sterile gown for the nurse. This is an invasive procedure, so informed consent is required. The nurse should confirm that this has been obtained. The scrub is not done with antibacterial soap. The scrub is done with chlorhexidine–alcohol solution or, alternatively, first with 70% alcohol and then with povidone detergent. The patient is placed in Trendelenburg position with a rolled towel between the shoulders for best site access.

PTS: 1 DIF: Difficult REF: V1, p. 946; Procedure 36-9

KEY: Nursing process: Implementation | Client need: SECE | Cognitive level: Application

COMPLETION

1. ANS: Electrolytes

PTS: 1 DIF: Easy REF: V1, p. 914

KEY: Client need: PHSI | Cognitive level: Recall

2. ANS: acid

PTS: 1 DIF: Easy REF: V1, p. 921

KEY: Client need: PHSI | Cognitive level: Recall

3. ANS:

base

alkali

PTS: 1 DIF: Moderate REF: V1, p. 921

KEY: Client need: PHSI | Cognitive level: Recall