Fluid, Electrolyte, and Acid-Base Balance

1. When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except:

1.
Rales
2.
A bounding pulse
3.
Engorged peripheral veins
4.
An elevated hematocrit level

ANS: 4

An elevated hematocrit level would be expected with a deficit of body fluid in the intravascular compartment. When an excess of body fluid exists in the intravascular compartment, a decreased hematocrit would be expected. Crackles (in lungs) are consistent findings with fluid volume excess. An assessment finding associated with fluid volume excess is a bounding pulse. Engorged peripheral veins may be seen with fluid volume excess.

DIF: A REF: 975 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

2. A homeless client is brought into the emergency department with indications of extremely poor nutrition. Arterial blood gas levels are assessed, and the nurse anticipates that this client will demonstrate which of the following results?

1.
pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L
2.
pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L
3.
pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L
4.
pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L

ANS: 1

Metabolic acidosis may be found in cases of starvation. The client’s pH is below the normal of 7.35 (at 7.3), the PaCO2 is in the normal range of 35 to 45 mm Hg (at 38 mm Hg), and the HCO3is below the normal of 22 mEq/L (at 19 mEq/L). These findings demonstrate metabolic acidosis. Values of pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L are consistent with respiratory alkalosis, compensated, which would not be typical of malnutrition. Values of pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L are consistent with metabolic alkalosis, compensated, which would not be an expected finding with extremely poor nutrition.

DIF: C REF: 977 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

3. When a client’s serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system?

1.
Neurological
2.
Gastrointestinal
3.
Pulmonary
4.
Hepatic

ANS: 1

Because sodium is necessary for nerve impulse transmission, the priority nursing assessment with hyponatremia is the neurological system.

DIF: A REF: 973 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

4. An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse determines that the child is suffering from:

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

ANS: 2

These assessment findings (i.e., warm and flushed skin, lethargy, and medical diagnosis of pneumonia) are indicative of respiratory acidosis. Lethargy and flushed skin may be seen with metabolic acidosis, but this child has a respiratory problem with difficulty breathing, which is consistent with respiratory acidosis.

DIF: A REF: 977 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

5. Arterial blood gas levels are obtained for the client. If the client’s results are pH 7.48, CO2 42 mm Hg, and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances?

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

ANS: 4

The client’s pH is elevated at 7.48 (normal 7.35 to 7.45), the CO2 is normal at 42 mm Hg (normal 35 to 45 mm Hg), and the bicarbonate is elevated at 32 mEq/L (normal 22 to 26 mEq/L). The client is experiencing metabolic alkalosis. In metabolic acidosis the client’s pH would be below 7.35, and the bicarbonate would be below 22 mEq/L. In respiratory acidosis the client’s pH would be below 7.35, and the CO2 would be elevated above 45 mm Hg. In respiratory alkalosis the client’s pH would be above 7.45, and the CO2 would be below 35 mm Hg.

DIF: C REF: 976 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

6. The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is:

1.
Hyperventilation to decrease the CO2 levels
2.
Hypoventilation to increase the CO2 levels
3.
Retention of HCO3 by the kidneys to increase the pH level
4.
Excretion of HCO3 by the kidneys to decrease the pH level

ANS: 3

The compensating mechanism in the presence of respiratory acidosis is retention of bicarbonate by the kidneys to increase the pH level. Hyperventilation would be the compensating mechanism in metabolic acidosis to decrease CO2 levels. Hypoventilation would be the compensating mechanism in metabolic alkalosis to increase CO2 levels. The compensating mechanism in the presence of metabolic alkalosis is excretion of bicarbonate to decrease the pH level.

DIF: A REF: 977 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

7. Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is:

1.
A 6-month-old learning to drink from a cup
2.
A 12-year-old who is moderately active in 80° F weather
3.
A 42-year-old with severe diarrhea
4.
A 90-year-old with frequent headaches

ANS: 3

The client at greatest risk for a fluid volume deficit is the client who has severe diarrhea. Any condition that results in the loss of gastrointestinal (GI) fluids predisposes the client to dehydration and a variety of electrolyte disturbances. The very young are at risk for a fluid volume deficit because their body water loss is proportionately greater per kilogram of weight. A 12-year-old who is moderately active in warm weather will lose body water through sweating. The very old are at increased risk for fluid volume deficit as they have a decreased thirst sensation and a decreased number of filtering nephrons.

DIF: C REF: 980 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

8. A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is:

1.
0.45% normal saline (NS)
2.
10% dextrose
3.
5% dextrose in lactated Ringer’s
4.
Dextrose 5% in NS

ANS: 1

The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid. Dextrose 5% in NS, 10% dextrose, and 5% dextrose in lactated Ringer’s are all hypertonic solutions that will draw fluid into the vascular space by osmosis. The client needs a hypotonic solution to rehydrate the cells.

DIF: A REF: 968 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

9. The client has been experiencing right flank and lower back pain. Which of the following laboratory values would be most desirable for the nurse to obtain based on the client’s assessment?

1.
Serum potassium
2.
Serum sodium
3.
Serum magnesium
4.
Serum calcium

ANS: 4

Flank pain and lower back pain may be indicative of kidney stones from excess calcium. The laboratory value for the nurse to obtain would be a serum calcium level.

DIF: A REF: 974 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

10. The health care provider orders 1000 mL of D5LR with 20 mEq KCl to run for 8 hours. Using an infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be:

1.
12 gtt/min
2.
22 gtt/min
3.
32 gtt/min
4.
42 gtt/min

ANS: 3

1000 mL ÷ 8 hr = 125 mL/hr; (15 gtt/mL ÷ 60 min) x 124 mL = 32 gtt/min.

DIF: A REF: 1007 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

11. The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should:

1.
Start with the most proximal site
2.
Look for hard, cordlike veins
3.
Use the dominant arm
4.
Avoid sites on the extremity away from a dialysis graft

ANS: 4

The nurse should avoid veins in an extremity with compromised circulation, such as a dialysis graft. The nurse should use the most distal site in the nondominant arm, if possible, and should avoid hardened cordlike veins.

DIF: A REF: 998 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

12. A client has intravenous therapy for the administration of antibiotics and is stating that the “IV site hurts and is swollen.” Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration?

1.
Intensity of the pain
2.
Warmth of integument surrounding the IV site
3.
Amount of subcutaneous edema
4.
Skin discoloration of a bruised nature

ANS: 2

Signs of phlebitis may include increased temperature over the vein, erythema, pain, and edema. With phlebitis, the area is warm to the touch; with infiltration, the area is cool to the touch. The intensity of pain is not a differentiating factor between phlebitis and infiltration. Pain may occur with both. The amount of subcutaneous edema is not a differentiating factor between phlebitis and infiltration. Edema may occur with both. Skin discoloration of a bruised nature is not the best way to differentiate phlebitis from infiltration. With phlebitis, the area is typically reddened. With infiltration, the area is typically pale.

DIF: A REF: 1012 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

13. A client complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the following actions should the nurse take immediately?

1.
Check the vital signs.
2.
Stop the blood transfusion.
3.
Slow down the rate of blood flow.
4.
Notify the health care provider and blood bank personnel.

ANS: 2

If a blood reaction is suspected, the nurse stops the blood transfusion immediately. The nurse should take the client’s vital signs, but the initial action should be to stop the blood transfusion. Once the transfusion is stopped, the nurse could notify the health care provider and blood bank personnel.

DIF: C REF: 1023 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

14. For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms?

1.
Weak, thready pulse
2.
Hypertension
3.
Dry mucous membranes
4.
Flushed skin

ANS: 2

Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess.

DIF: A REF: 1012 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

15. A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert to the presence of:

1.
Cardiac dysrhythmias
2.
Severe diarrhea
3.
Hyperactive reflexes
4.
Peripheral cyanosis

ANS: 1

Lasix is a non–potassium-sparing diuretic. Without a potassium supplement the client may become hypokalemic. Hypokalemia increases the risk for digoxin toxicity. Both hypokalemia and digoxin toxicity can cause cardiac dysrhythmias. Clients with hypokalemia from diuretic use may experience intestinal distention and decreased bowel sounds. Severe diarrhea may be a cause of hypokalemia, not a result of hypokalemia. Clients with hyperactive reflexes may have hypocalcemia. Lasix and digoxin do not predispose a client to hypocalcemia. Peripheral cyanosis is not a potential problem related to the client’s medication regimen.

DIF: A REF: 973 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

16. A rapid infusion of citrated blood has been given to the client. The nurse observes for:

1.
Diaphoresis
2.
Anxiety
3.
Chvostek’s sign
4.
Nausea and vomiting

ANS: 3

Chvostek’s sign is seen with hypocalcemia. Rapid administration of blood transfusions containing citrate may cause hypocalcemia. Citrate solution is used to prevent clotting of the blood so that it can be stored in the refrigerator until it is needed for transfusion. Also, if blood that is cold is administered too rapidly, it may cause cardiac dysrhythmias. If a client receives a rapid blood transfusion, the kidneys may not be able to excrete phosphorus quickly enough and the phosphorus level increases while the calcium level decreases. Sepsis may also increase the risk for developing hypocalcemia. The client who has a rapid blood transfusion of citrated blood would not be expected to experience excessive sweating. The client who experiences an anaphylactic reaction or sepsis typically has cool, clammy skin. Anxiety may be related to an anaphylactic or febrile, nonhemolytic reaction to a blood transfusion. However, it is not the best indication of a possible reaction because the client may be anxious because of receiving a blood transfusion, having nothing to do with a physiological reaction to the transfusion. Nausea and vomiting may or may not indicate a reaction to a blood transfusion.

DIF: A REF: 973 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

17. For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and symptoms consistent with:

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

ANS: 4

A salicylate overdose may cause respiratory alkalosis because of hyperventilation. Aspirin overdose is not associated with metabolic acidosis, metabolic alkalosis or respiratory acidosis.

DIF: A REF: 983 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

18. The single best indicator of fluid status is the nurse’s assessment of the client’s:

1.
Skin turgor
2.
Intake and output
3.
Serum electrolyte levels
4.
Daily weight

ANS: 4

Daily weights are the single most important indicator of fluid status. Skin turgor is a measure of hydration, as are intake and output. Serum electrolyte levels help monitor fluid status; however, daily weights are the single best indicator of a client’s fluid status.

DIF: A REF: 983 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

19. An IV solution of 125 mL is to be infused over a 1-hour period. A microdrip infusion set will be used. The nurse calculates the infusion rate as:

1.
32 gtt/min
2.
60 gtt/min
3.
125 gtt/min
4.
250 gtt/min

ANS: 3

(60 gtt/mL ÷ 60 min) x 125 mL = 125 gtt/min.

DIF: A REF: 1007 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

20. A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete the admission history, the nurse anticipates that the client will have experienced:

1.
Decreased muscle tone
2.
Hypertension
3.
Diarrhea
4.
Fever

ANS: 3

A cause of hyponatremia is adrenal insufficiency. The client with hyponatremia may experience diarrhea, abdominal cramping, and nausea and vomiting. Decreased muscle tone is a symptom of hypokalemia. A client with adrenal insufficiency is not likely to experience hypertension. Resultant hyponatremia with adrenal insufficiency may be exhibited as postural hypotension. Fever is a symptom of hypernatremia, not hyponatremia. Hypernatremia is not caused by adrenal insufficiency.

DIF: A REF: 973 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

21. In reviewing the results of the client’s blood work, the nurse recognizes that the unexpected value that should be reported to the health care provider is:

1.
Calcium 3.9 mEq/L
2.
Sodium 140 mEq/L
3.
Potassium 3.5 mEq/L
4.
Magnesium 2.1 mEq/L

ANS: 1

A calcium level of 3.9 mEq/L should be reported to the health care provider. A normal calcium level is 4.5 to 5.5 mEq/L. A sodium level of 140 mEq/L is within the normal range of 135 to 145 mEq/L. A potassium level of 3.5 mEq/L is within the normal range of 3.5 to 5.0 mEq/L. A magnesium level of 2.1 mEq/L is within the normal range of 1.5 to 2.5 mEq/L.

DIF: A REF: 971 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

22. The nurse anticipates that the client with a fluid volume excess will manifest a(n):

1.
Increased urine specific gravity
2.
Decreased body weight
3.
Increased blood pressure
4.
Decreased pulse strength

ANS: 3

Hypertension is manifested with fluid volume excess. The urine specific gravity would be decreased with fluid volume excess. The nurse would anticipate an increased urine specific gravity with fluid volume deficit, as well as an increase in body weight and an increase in pulse strength.

DIF: A REF: 1021 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

23. The nurse recognizes that the client, based on the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the health care provider is:

1.
0.45% saline
2.
Lactated Ringer’s
3.
5% dextrose in normal saline
4.
5% dextrose in lactated Ringer’s

ANS: 2

Lactated Ringer’s is an isotonic solution. 0.45% saline is a hypotonic solution. 5% dextrose in normal saline and 5% dextrose in lactated Ringer’s are both hypertonic solutions.

DIF: A REF: 968 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

24. A client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain. After stopping the transfusion, the nurse should:

1.
Administer an antipyretic
2.
Begin an infusion of epinephrine
3.
Run normal saline through the blood tubing
4.
Obtain and send a urine specimen to the laboratory

ANS: 4

After stopping the blood transfusion, the nurse should obtain and send a urine specimen to the laboratory to determine the presence of hemoglobin as a result of red blood cell (RBC) hemolysis. In an acute hemolytic reaction, management of the reaction does not include the administration of an antipyretic. The nurse should be prepared to administer emergency drugs, such as diuretics, per the health care provider’s order. The nurse should not turn off the blood and simply turn on the normal saline that is connected to the Y-tubing set. This would cause blood remaining in the Y-tubing to infuse into the client. Even a small amount of mismatched blood can cause a major reaction. The nurse should run normal saline directly into the IV line (not through the blood tubing).

DIF: C REF: 1022-1023 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

25. A client is prescribed 0.9% sodium chloride (normal saline), which is an isotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:

1.
Expand the volume of fluid in the vascular system
2.
Pull fluid from the cells
3.
Keep protein levels normal
4.
Move fluid into the cells

ANS: 1

Isotonic solutions such as normal saline, 0.9% sodium chloride, expand the body’s fluid volume without causing a fluid shift from one compartment to another. The remaining options describe the function of other types of fluids.

DIF: A REF: 968 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

26. A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:

1.
Expand the volume of fluid in the vascular system
2.
Pull fluid from the cells
3.
Keep protein levels normal
4.
Move fluid into the cells

ANS: 2

A hypertonic solution (a solution of higher osmotic pressure), such as 3% sodium chloride, pulls fluid from cells, causing them to shrink. The remaining options describe the function of other types of fluids.

DIF: A REF: 968 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

27. A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to:

1.
Expand the volume of fluid in the vascular system
2.
Pull fluid from the cells
3.
Keep protein levels normal
4.
Move fluid into the cells

ANS: 4

Hypotonic solutions (a solution of lower osmotic pressure), such as 0.45% sodium chloride, move fluid into the cells, causing them to enlarge. The remaining options describe the function of other types of fluids.

DIF: A REF: 968 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

28. The nurse recognizes which of the following clients is at the greatest risk for dehydration?

1.
A 35-year-old client diagnosed with Crohn’s disease
2.
A 15-year-old client who is following a low-carbohydrate diet
3.
A 2-year-old client diagnosed with an allergy to milk proteins
4.
A 79-year-old client who has been diagnosed with advanced Alzheimer’s disease

ANS: 4

Infants, clients with neurological or psychological problems, and some older adults who are unable to perceive or respond to the thirst mechanism are at risk for dehydration.

DIF: C REF: 978-979 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

29. Which of the following clients is at greatest risk for insensible water loss?

1.
A 37-year-old with a superficial burn to the left hand
2.
A 15-year-old experiencing an asthmatic attack
3.
A 50-year-old with type 2 diabetes
4.
A 73-year-old with a history of pneumonia

ANS: 2

Insensible water loss is continuous and occurs through the skin and lungs. A person does not perceive the loss, but it can significantly increase with fever or burns. This insensible water loss increases in response to changes in respiratory rate and depth. In addition, devices for administering oxygen increase insensible water loss from the lungs. The teenager experiencing the asthmatic attack is at greatest risk because of the increased respiratory involvement and possible fever. Type 2 diabetes does not necessarily increase insensible water loss, and the remaining clients may have a small risk.

DIF: C REF: 970 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

30. Which of the following foods will have the greatest impact on the water balance of the person consuming it?

1.
A pickle
2.
A banana
3.
A milkshake
4.
A spinach salad

ANS: 1

Sodium ions are the major contributors to maintaining water balance through their effect on serum osmolality, nerve impulse transmission, regulation of acid-base balance, and participation in cellular chemical reactions. Pickles are a high-sodium food. The remaining options are good sources of potassium, calcium, and magnesium.

DIF: C REF: 970 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

31. Which of the following foods will have the greatest impact on the heart’s conductivity of the person consuming it?

1.
A pickle
2.
A banana
3.
A milkshake
4.
A spinach salad

ANS: 2

Potassium is the major electrolyte and principal cation in the intracellular compartment. It regulates many metabolic activities and is necessary for glycogen deposits in the liver and skeletal muscle, transmission and conduction of nerve impulses, normal cardiac conduction, and skeletal and smooth muscle contraction. Bananas are a high-potassium food. The remaining options are good sources of sodium, calcium, and magnesium.

DIF: C REF: 972 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

32. Which of the following foods will have the greatest impact on the blood-clotting mechanism of the person consuming it?

1.
A pickle
2.
A banana
3.
A milkshake
4.
A spinach salad

ANS: 3

Calcium is necessary for bone and teeth formation, blood clotting, hormone secretion, cell membrane integrity, cardiac conduction, transmission of nerve impulses, and muscle contraction. Milk is a high-calcium food. The remaining options are good sources of sodium, potassium, and magnesium.

DIF: C REF: 973-975 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

33. Which of the following foods will have the greatest impact on the neurochemical activity of the person consuming it?

1.
A pickle
2.
A banana
3.
A milkshake
4.
A spinach salad

ANS: 4

Magnesium is essential for enzyme activities, neurochemical activities, and cardiac and skeletal muscle excitability. Spinach is a high-magnesium food. The remaining options are good sources of sodium, potassium, and calcium.

DIF: C REF: 974 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

34. Which of the following clinical assessment findings is most likely seen in a client experiencing partial-thickness burns over 35% of the body as a result of hyponatremia?

1.
Dry, sticky tongue
2.
Increased anxiety
3.
Nausea and vomiting
4.
Decreased bowel sounds

ANS: 3

Physical examination of a hyponatremic client may reveal apprehension, personality change, postural hypotension, postural dizziness, abdominal cramping, nausea and vomiting, diarrhea, tachycardia, dry mucous membranes, convulsions, and coma. The remaining options are examples of hypernatremia, hypokalemia, and hyperkalemia.

DIF: C REF: 973 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

35. Which of the following clinical assessment findings is most likely seen in a client experiencing hypernatremia as a result of diabetes insipidus?

1.
Dry, sticky tongue
2.
Increased anxiety
3.
Nausea and vomiting
4.
Decreased bowel sounds

ANS: 1

Physical examination of a hypernatremic client may reveal extreme thirst, dry and flushed skin, dry and sticky tongue and mucous membranes, postural hypotension, fever, agitation, convulsions, restlessness, and irritability. The remaining options are examples of hyponatremia, hypokalemia, and hyperkalemia.

DIF: C REF: 973 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

36. Which of the following clinical assessment findings is most likely seen in a client experiencing hypokalemia as a result of the misuse of potassium-wasting diuretics?

1.
Dry, sticky tongue
2.
Increased anxiety
3.
Nausea and vomiting
4.
Decreased bowel sounds

ANS: 4

Physical examination of a hypokalemic client may reveal weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. The remaining options are examples of hypernatremia, hyponatremia, and hyperkalemia.

DIF: C REF: 973 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

37. Which of the following clinical assessment findings is most likely seen in a client experiencing hyperkalemia as a result of adrenal insufficiency?

1.
Dry, sticky tongue
2.
Increased anxiety
3.
Nausea and vomiting
4.
Decreased bowel sounds

ANS: 2

Physical examination of a hyperkalemic client may reveal anxiety, dysrhythmias, paresthesia, weakness, abdominal cramps, and diarrhea. The remaining options are examples of hypernatremia, hyponatremia, and hypokalemia.

DIF: C REF: 973 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

38. A client who takes furosemide presents at the emergency department with weakness and fatigue and complains of nausea and vomiting for 3 days. Upon assessment, the nurse finds that the client has decreased bowel sounds and ECG abnormalities including a flattened T wave and flattened ST segment. The nurse knows that these are signs of:

1.
Hypokalemia
2.
Hyperkalemia
3.
Hyponatremia
4.
Hypocalcemia

ANS: 1

Signs of hypokalemia include weakness and fatigue, muscle weakness, nausea and vomiting, intestinal distention, decreased bowel sounds, decreased deep tendon reflexes, ventricular dysrhythmias, paresthesias, and weak, irregular pulse. ECG abnormalities: flattened T wave, ST segment depression, U wave, potentiated digoxin effects (e.g., ventricular dysrhythmias). The most common cause of hypokalemia is vomiting and the use of potassium-wasting diuretics. Signs of hyperkalemia include anxiety, dysrhythmias, paresthesia, weakness, abdominal cramps, and diarrhea. ECG abnormalities: peaked T wave and widened QRS complex (bradycardia, heart block, dysrhythmias); eventually QRS pattern widens and cardiac arrest occurs. Signs of hyponatremia include extreme thirst, dry and flushed skin, dry and sticky tongue and mucous membranes, postural hypotension, fever, agitation, convulsions, restlessness, and irritability, whereas signs of hypocalcemia include numbness and tingling of fingers and circumoral (around mouth) region, hyperactive reflexes, positive Trousseau’s sign (carpopedal spasm with hypoxia), positive Chvostek’s sign (contraction of facial muscles when facial nerve is tapped), tetany, muscle cramps, pathological fractures (chronic hypocalcemia), and ECG abnormalities: ventricular tachycardia.

DIF: A REF: 979 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

39. A mother brings her 2-year-old daughter to the clinic with a 2-day history of a fever of unknown origin. The mother explains to the nurse that the air conditioning in her apartment is not working and it has been very hot; her daughter has been vomiting for 2 days and has had a fever, and the child is lethargic. The child’s rectal temperature is 101.1° F. The nurse knows the child is probably dehydrated and should do which of the following first?

1.
Give the child some juice to drink.
2.
Prepare to start an IV.
3.
Get an order for an antipyretic.
4.
Sponge the child to bring down the fever.

ANS: 2

Children ages 2 through 12 have less stable regulatory responses to imbalance, and in childhood illnesses they tend to operate within a more narrow range with less tolerance for severe fluid and electrolyte imbalance. Clients who have been exposed to temperature extremes may have clinical signs of fluid and electrolyte alterations. Exposure to environmental temperatures exceeding 28° to 30° C (82.4° to 86° F) results in excessive sweating with weight loss. A body weight loss over 7% decreases the ability of the cooling mechanism to conserve water. The nurse’s first priority is fluid volume replacement, then an antipyretic (because the fever is not dangerously high). If the child has been vomiting, she is likely to vomit the juice.

DIF: A REF: 976 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

40. The nurse is caring for a 73-year-old female client who is 3 days postoperative for a bowel obstruction. The nurse knows that the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and antidiuretic hormone (ADH) are increasingly secreted, causing sodium and chloride retention and potassium excretion. Because of this, it is important for the nurse to closely monitor:

1.
Urine output
2.
Intake of sodium
3.
Activity level
4.
Oxygen level

ANS: 1

Recent surgery is a condition that places clients at high risk for fluid, electrolyte, and acid-base alterations. Clients continue to be at risk during the acute phase until the underlying process is resolved. For example, the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and ADH are increasingly secreted, causing sodium and chloride retention, potassium excretion, and decreased urinary output. The client’s diet most likely has not advanced enough to be concerned about excess sodium intake. The client’s activity level is important, and the nurse should encourage her to increase her activity level. The client’s oxygen level is also important to monitor, but has no direct effect on the fluid, electrolyte, and acid-base alterations

DIF: A REF: 976 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

41. Which of the following clients is most at risk for fluid volume deficit?

1.
25-year-old male near-drowning victim
2.
56-year-old woman with salicylate poisoning
3.
45-year-old woman with second-degree burns over 20% of her body
4.
13-year-old boy with an oral temperature of 103.4° F

ANS: 3

The greater the body surface burned, the greater the fluid loss. The burned client loses body fluids by one of five routes. First, plasma leaves the intravascular space and becomes trapped edema. This is also called the plasma-to-interstitial fluid shift. It is accompanied by a loss of serum proteins. Second, plasma and interstitial fluids are lost as burn exudate. Third, water vapor and heat are lost in proportion to the amount of skin that is burned. Fourth, blood leaks from damaged capillaries, adding to the intravascular fluid volume loss. Finally, sodium and water shift into the cells, further compromising extracellular fluid volume. A near-drowning victim may suffer from hypoxia and respiratory acidosis but would not be as likely to be at risk for fluid volume deficit as the burn victim. Salicylate poisoning may cause some insensible fluid loss through the body’s hyperventilation to compensate for the increased PaCO2. Adolescents have increased metabolic processes and increased water production because of the rapid changes that occur in the anatomical and physiological process.

DIF: A REF: 976 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

42. A 66-year-old female client is admitted to the hospital with diabetic ketoacidosis. The client has a running IV line through which she receives her medications and fluid maintenance. Which of the following would not be counted on the daily intake and output (I&O)?

1.
IV fluids
2.
Cream of mushroom soup
3.
Gelatin
4.
Mashed potatoes

ANS: 4

Mashed potatoes do not contain enough liquid to be counted in the fluid intake of the client, whereas IV fluids are part of the liquid intake of the client and should be counted. Soups are high in the percentage of water that they contain, as is gelatin, and both should be counted in the daily fluid intake.

DIF: A REF: 979 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

43. A client with transient atrial fibrillation has been taking 83 mg of aspirin daily for the past 3 years. When preparing the client for discharge from the hospital, the nurse discontinues his IV line. In order to prevent a hematoma, the nurse needs to hold pressure on the IV site for:

1.
1 to 2 minutes
2.
2 to 3 minutes
3.
3 to 5 minutes
4.
5 to 10 minutes

ANS: 4

Because the client is on a low-dose aspirin, it takes longer for his blood to form a clot, so the nurse needs to hold pressure for 5 to 10 minutes. Holding pressure for 2 to 3 minutes would be appropriate for a client who is not on anticoagulant therapy.

DIF: B REF: 972 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

44. The nurse is preparing to replace a bag of IV fluids for a client receiving fluid therapy. When assessing the client, the nurse notes that the IV solution is not dripping. Which of the following should the nurse do to assess the patency of the site?

1.
Lower IV container below level of IV site for presence of blood return.
2.
Use a large-volume syringe to apply negative pressure to achieve a blood return.
3.
Carefully adjust the roller clamp to see an increase in flow rate.
4.
Massage the client’s arm proximal to where the catheter is inserted.

ANS: 3

The catheter may be lodged against the vein wall; allowing additional pressure from the bag of fluid to flow into the vein may float the catheter into the vein, allowing the instillation of fluids. Using a large-volume syringe could cause the vein to collapse, and massaging the client’s arm could dislodge a clot, causing an embolus.

DIF: B REF: 973 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

45. A client has been hospitalized following a myocardial infarction. The client has an IV line running with multiple drips. The nurse assesses the client’s medical record to determine the last time the IV tubing was changed, because the nurse knows that the Centers for Disease Control and Prevention (CDC) recommends that IV tubing be changed:

1.
Every shift
2.
Daily
3.
Every 48 hours
4.
Every 72 hours

ANS: 4

CDC and INS recommend tubing change no more often than 72-hour intervals or whenever tubing has been compromised. The more frequently a closed sterile system is opened, the more opportunities there are for microorganisms to be introduced into the system.

DIF: B REF: 978 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

46. The nurse is assessing the client with an IV line. The nurse notes that the IV insertion site is red, edematous, and painful. The nurse’s first action should be to:

1.
Immediately discontinue the IV line and remove the cannula
2.
Put cool compresses on the IV site to decrease the edema
3.
Notify the health care provider of the situation
4.
Put warm compresses on the IV site to decrease the pain

ANS: 3

The nurse should notify the health care provider to determine if the health care provider would like to culture the IV cannula. (Confirm before removal of IV line.) Wrapping the extremity in a warm, moist towel for 20 minutes promotes venous return, increases circulation, and reduces pain and edema. Heat therapy can be repeated three to four times during the day.

DIF: B REF: 969-970 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

47. Blood replacement or transfusion is the IV administration of whole blood or a component such as plasma, packed red blood cells (RBCs), or platelets. The minimum gauge IV cannula necessary for administering a blood transfusion is:

1.
24 gauge
2.
22 gauge
3.
20 gauge
4.
18 gauge

ANS: 3

A large cannula such as an 18 gauge or 19 gauge is preferred because blood is more viscous than IV fluids, although smaller gauge sizes will accommodate transfusions. However, a catheter no smaller than a 20 gauge should be used to transfuse blood; 22- and 24-gauge cannulas are not recommended because they are too small to allow the viscous blood to flow freely through them. An 18 gauge is considered ideal, but the minimum-size cannula that should be used is a 20 gauge.

DIF: B REF: 979 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

48. The nurse is discontinuing a client’s IV line in preparation for the client’s discharge home. Upon withdrawing the cannula from the peripheral site, the nurse notes that the tip of the cannula is missing. The first thing that the nurse should do is:

1.
Notify the health care provider immediately
2.
Apply pressure to the IV site
3.
Apply a tourniquet high on the extremity
4.
Ask another nurse to double-check the cannula

ANS: 3

The first priority of the nurse is to apply a tourniquet high on the extremity to restrict mobility of catheter embolus. The health care provider needs to be notified after the tourniquet is applied.

DIF: B REF: 990-991 OBJ: Application

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

MULTIPLE RESPONSE

1. A client with partial-thickness burns over 40% of the body is likely to lose body fluid via: (Select all that apply.)

1.
Water vapor that is lost through the skin that is burned
2.
Plasma and interstitial fluids that are lost as burn exudate
3.
Blood leakage via damaged capillaries in the dermis
4.
Respiratory acidosis resulting from altered respiratory function
5.
Plasma that leaves the intravascular space and becomes trapped in blisters
6.
Sodium and water shift that out of the vessels because of increased permeability

ANS: 1, 2, 3, 5, 6

DIF: C REF: 1017 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

2. A client experiencing respiratory alkalosis as a result of asthma is likely to present with which of the following clinical signs? (Select all that apply.)

1.
A respiratory rate of 36 breaths per minute
2.
Complaints of numbness in fingers and toes
3.
Dizziness when attempting to sit upright
4.
Difficulty holding a cup because of tremors
5.
An irregular heartbeat on an electrocardiogram (ECG)
6.
Warm, flushed skin

ANS: 1, 2, 3, 4

Physical examination of a client experiencing respiratory alkalosis may reveal dizziness, confusion, dysrhythmias, tachypnea, numbness and tingling of extremities, convulsions, and coma.

DIF: C REF: 1013 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

3. A client experiencing respiratory acidosis as a result of pneumonitis is likely to present with which of the following clinical signs? (Select all that apply.)

1.
Tingling fingers
2.
Difficult to arouse
3.
Warm, flushed skin
4.
Tremors in the hands
5.
Reporting a “terrible headache”
6.
Repeatedly asking “Where am I?”

ANS: 2, 3, 4, 5, 6

Physical examination of a client experiencing respiratory acidosis may reveal confusion, dizziness, lethargy, headache, ventricular dysrhythmias, warm and flushed skin, muscular twitching, convulsions, and coma. The remaining option is not reflective of respiratory acidosis.

DIF: C REF: 1012 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

4. A client experiencing diabetic ketoacidosis is likely to present with which of the following clinical signs? (Select all that apply.)

1.
Red, flushed skin
2.
Verbally aggressive
3.
Complaints of dry mouth
4.
Crackles in both lung fields
5.
Oral temperature of 102.8° F
6.
Requiring frequent linen changes

ANS: 1, 2, 3, 5, 6

Physical examination of a client experiencing diabetic ketoacidosis may reveal dry and sticky mucous membranes, flushed and dry skin, thirst, elevated body temperature, irritability, convulsions, and coma. The remaining option is not reflective of diabetic ketoacidosis.

DIF: C REF: 1021 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

5. A client experiencing acute congestive heart failure (CHF) is likely to present with which of the following clinical signs? (Select all that apply.)

1.
Flat neck veins
2.
Bilateral crackles
3.
+2 ankle edema bilaterally
4.
Urine output of 790 mL in 24 hours
5.
History of a 5-pound weight gain in 3 days
6.
Systemic blood pressure 15 mm Hg above usual baseline

ANS: 2, 3, 5, 6

Physical examination of a client experiencing CHF may reveal rapid weight gain, edema (especially in dependent areas), hypertension, polyuria (if renal mechanisms are normal), neck vein distention, increased blood and venous pressure, crackles in lungs, and confusion. The remaining options are not reflective of CHF.

DIF: C REF: 1022 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances

6. Which of the following clients is at risk for fluid, electrolyte, and acid-base imbalances? (Select all that apply.)

1.
50-year-old with hypertension
2.
36-year-old with schizophrenia
3.
40-year-old with a fractured femur
4.
15-month-old with diarrhea for 2 days
5.
76-year-old with advanced Alzheimer’s disease
6.
25-year-old with partial-thickness burns over 40% of the body

ANS: 1, 3, 4, 5, 6

When there is a loss of body fluids because of burns, illnesses, or trauma, the client is also at risk for electrolyte imbalance. In addition, electrolyte imbalance may occur from vomiting, diarrhea, or a client’s inability to communicate fluid needs, resulting in acid-base disturbances. Trauma, disease, and medications (e.g., diuretics) all contribute to alterations in fluid, electrolyte, and acid-base balance. Schizophrenia itself is not a risk for fluid, electrolyte, or acid-base imbalances.

DIF: C REF: 1017 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX® test plan designation: Physiological Adaptation/Fluid and Electrolyte Imbalances