Nursing Care of Patients With Fluid, Electrolyte, and Acid–Base Imbalances

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

____ 1. A patient is prescribed an electrolyte replacement. How should the nurse explain the purpose of an electrolyte to the patient?
a. Any substance that enhances a chemical reaction
b. A chemical that can conduct electricity when dissolved in water
c. A substance that uses electrical current to attach to receptor sites
d. A substance secreted by a gland and carries messages to target tissues
____ 2. A student nurse is reviewing the use of intravenous (IV) fluids for a school paper. Which definition should the student use to explain the process of diffusion?
a. The expenditure of energy to transport a solute
b. The movement of solute and water caused by hydrostatic pressure differences
c. Movement of a solute from an area of higher concentration to an area of lesser concentration
d. Movement of water from an area of lesser concentration to an area of higher concentration
____ 3. The nurse is preparing to provide a patient with an IV fluid that has a lower osmolarity than blood. Which type of fluid should the nurse document that the patient is going to receive?
a. Isotonic
b. Hypotonic
c. Hypertonic
d. Hydrophobic
____ 4. The nurse is concerned that a patient has a high volume of insensible water loss. What is the patient experiencing that is causing the nurse this concern?
a. Diarrhea
b. Vomiting
c. Urination
d. Perspiration
____ 5. An older patient with a colostomy was admitted for weakness, nausea, vomiting, and loose stools. Which action should the nurse take first to determine the effectiveness of this patient’s care?
a. Weigh the patient.
b. Measure urine specific gravity.
c. Check a pulse oximetry reading.
d. Determine the creatinine clearance.
____ 6. An older adult with gastroenteritis is disoriented and weak and has the following laboratory test results:
Hct 56% (normal 40% to 51%)
BUN 32 mg/dL (normal 6 mg/dL to 20 mg/dL)
Which nursing diagnosis should the nurse select for this patient?
a. Risk for injury
b. Excess fluid volume
c. Deficient fluid volume
d. Impaired skin integrity
____ 7. A patient with hypertension is placed on a low-sodium diet. The nurse recognizes that further teaching is necessary if the patient chooses which menu?
a. Pork chop, steamed brown rice, and fruit cocktail
b. Broiled salmon, mashed sweet potato, broccoli, and pumpkin pie
c. Tomato soup, grilled cheese sandwich, salad, and chocolate chip cookie
d. Grilled chicken, boiled potatoes, frozen green beans, and gelatin dessert
____ 8. An older adult patient has an IV infusion of 0.45% normal saline infusing at 150 mL/hr. Which assessment finding should cause the nurse to be most concerned?
a. Tenderness at the IV site
b. Capillary refill is <3 seconds
c. Urine specific gravity is 1.018
d. Newly noted crackles in the lungs
____ 9. A patient with a history of renal failure is admitted to the hospital because of decreasing urine output and a potassium level of 5.9 mEq/L. Which food should the nurse teach the patient to avoid?
a. Gelatin
b. Potatoes
c. Zucchini
d. White bread
____ 10. A patient is diagnosed with an abnormal potassium level. Which complication should the nurse assess for in this patient?
a. Cardiac arrest
b. Fluid overload
c. Internal bleeding
d. Tetany with laryngospasm
____ 11. A 22-year-old patient with inflammatory bowel disease has been having 16 or more stools per day. Which symptom should the nurse expect to find during the assessment?
a. Dyspnea and crackles in the lungs
b. Decreased hemoglobin and hematocrit
c. Bounding pulse and increased blood pressure
d. Furrows of the tongue and sticky mucous membranes
____ 12. A patient with severe diarrhea has a potassium imbalance. Which symptoms should the nurse expect the patient to demonstration because of this imbalance?
a. Shallow respirations, lethargy, nausea
b. Pitting edema, confusion, bounding pulse
c. Apathy, weakness, positive Chvostek’s sign
d. Kussmaul’s breathing, thirst, furrowed tongue
____ 13. A patient with acute abdominal pain has a serum potassium level of 2 mEq/L. What should the nurse do first?
a. Call the physician STAT.
b. Administer a Kayexalate enema.
c. Document the result on the chart.
d. Notify the physician during morning rounds.
____ 14. The nurse is preparing diet teaching for a female patient who is postmenopausal, weighs 100 lbs. and is 5 feet 1 inch tall. Which food should the nurse encourage the patient consume?
a. Red meat
b. Fresh fruits
c. Whole grains
d. Dairy products
____ 15. A patient develops an irregular heart rate, abdominal cramping, and diarrhea after a thyroidectomy. Which emergency medication should the nurse anticipate being prescribed for this patient?
a. Furosemide (Lasix)
b. Calcium gluconate
c. Potassium chloride
d. Diazepam (Valium)
____ 16. The nurse is testing a patient for the presence of Trousseau’s sign. Which patient response should the nurse recognize as a positive result?
a. Weakness of the arm
b. Pain in the arm and hand
c. Spasticity of the arm and fingers
d. Redness of the arm below the cuff
____ 17. The nurse is concerned that an older patient is at risk for dehydration. What reduced function did the nurse assess in this patient?
a. Filtration
b. Kidney function
c. Sensation of thirst
d. Cardiac contractility
____ 18. While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?
a. Provide oxygen at 2 L per nasal cannula.
b. Place the patient in a high Fowler’s position.
c. Provide a urinal and encourage the patient to void.
d. Lay the patient flat in bed to listen to bowel sounds.
____ 19. A patient is prescribed furosemide (Lasix). Which electrolyte should the nurse monitor carefully because of this medication?
a. Calcium
b. Potassium
c. Phosphate
d. Magnesium
____ 20. An older patient is admitted for treatment of fluid volume excess. For which serious respiratory complication of fluid volume excess should the nurse assess this patient?
a. Pulmonary edema
b. Pulmonary infarction
c. Pulmonary fibrosis
d. Pulmonary embolism
____ 21. The nurse is caring for a patient who is being treating for fluid volume excess. Which assessment finding indicates that treatment has been effective?
a. Respiratory rate 24/min
b. Output 1500 mL in 24 hours
c. Blood pressure 132/80 mm Hg
d. Weight loss of 5 lb in 24 hours
____ 22. The nurse learns that a patient’s serum pH is less than 6.35. The nurse should plan care for which of the following health problems?
a. Acidosis
b. Alkalosis
c. Fluid volume excess
d. Fluid volume deficit
____ 23. A patient is hypoventilating and retaining carbon dioxide. On which acid-base imbalance should the nurse focus when caring for this patient?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
____ 24. A patient with uncontrolled diabetes mellitus develops metabolic acidosis. Which assessment finding indicates that the patient’s compensatory mechanisms are working?
a. Vomiting
b. Excessive thirst
c. Watery diarrhea
d. Deep rapid breathing
____ 25. A patient having a severe anxiety attack has an arterial blood gas result showing respiratory alkalosis. Which nursing action should the nurse take first?
a. Administer nasal oxygen at 6 L/min.
b. Give the patient a glass of orange juice.
c. Place the patient in high Fowler’s position.
d. Have the patient rebreathe air from a paper bag.
____ 26. A patient has been prescribed furosemide (Lasix). Which foods should the nurse recommend the patient consume while taking this medication?
a. Eggs and broths
b. Potatoes and fruits
c. Breads and cereals
d. Pasta and cream soups
____ 27. After an assessment, the nurse determines that a patient is at risk for respiratory acidosis. Which health problem did the nurse assess to come to this conclusion?
a. Anxiety
b. Diabetes
c. Kidney failure
d. Chronic lung disease
____ 28. The nurse is reviewing the composition of the body cells with a young adult patient admitted for treatment of type 1 diabetes mellitus. The nurse should teach the patient that which of the following is an approximate percentage of water in the young adult body?
a. 50%
b. 60%
c. 70%
d. 80%
____ 29. The nurse instructs a patient on how to safely take 20 mEq of an oral potassium supplement. Which patient statement indicates that teaching has been successful?
a. “I should crush the potassium tablets.”
b. “I should mix this medication in 4 ounces of juice.”
c. “I should use a salt substitute while taking this medication.”
d. “I should expect to be nauseated and vomit when taking this medication.”
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 30. A patient has a history of low calcium levels. Which foods should the nurse include when teaching a patient how to increase dietary calcium? (Select all that apply.)
a. Milk
b. Carrots
c. Spinach
d. Oatmeal
e. Peaches
f. Cauliflower
____ 31. A patient with hypertension is advised to follow a low-sodium diet. If chosen by the patient, which foods indicate further teaching is necessary? (Select all that apply.)
a. Coffee
b. Pretzels
c. Lemonade
d. Applesauce
e. Tomato juice
f. Dried black beans
____ 32. The nurse is preparing to assess an older patient for fluid balance. Which areas of the body should the nurse use to assess for skin turgor? (Select all that apply.)
a. Hand
b. Sternum
c. Forearm
d. Forehead
e. Upper thigh
____ 33. The nurse is planning care for a patient with a fluid volume excess and a serum sodium level of 125 mg/dL. Which interventions should the nurse include in this patient’s plan of care? (Select all that apply.)
a. Weigh daily.
b. Monitor strict intake and output.
c. Administer diuretics as prescribed.
d. Implement fluid restriction as prescribed.
e. Administer IV saline as prescribed.
____ 34. During an assessment, the nurse learns that an older patient has been taking twice the prescribed amount of calcium supplements. Which physical assessment findings should the nurse identify as being consistent with this patient’s intake of calcium? (Select all that apply.)
a. Muscle weakness
b. Faint bowel sounds
c. Increased heart rate
d. Elevated blood pressure
e. Dry mucous membranes
____ 35. The nurse suspects a patient is experiencing fluid volume excess. What did the nurse most likely assess in this patient? (Select all that apply.)
a. Thirst
b. Bounding pulse
c. Shallow respirations
d. Distended neck veins
e. Pitting edema of the feet
Other

36. Place the following individuals in order (1–4) related to their risk for dehydration, ranking from highest to lowest.
A. ___ A 28-year-old patient who is nothing by mouth (NPO) prior to an endoscopy
B. ___ An 8-year-old patient who has had diarrhea for 16 hours
C. ___ A 64-year-old patient who is taking potassium supplements
D. ___ A 72-year-old patient who has had a fever and anorexia for 48 hours

Chapter 6. Nursing Care of Patients With Fluid, Electrolyte, and Acid–Base Imbalances
Answer Section

MULTIPLE CHOICE

1. ANS: B
B. Electrolytes are chemicals that can conduct electricity when dissolved in water. Examples of electrolytes are sodium, potassium, calcium, magnesium, acids, and bases. A. A substance that enhances a chemical reaction is a catalyst. C. A substance that uses electrical current to attach to receptor sites does not define any substance having to do with an electrolyte. D. A substance secreted by a gland that carries messages to target tissues is a hormone.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

2. ANS: C
C. Diffusion is a process in which a substance moves from an area of higher concentration to an area of lower concentration. D. Movement of water refers to osmosis. A. Active transport involves expenditure of energy. B. Filtration is promoted by hydrostatic pressure differences between areas.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

3. ANS: B
B. A solution that has a lower osmolarity than blood is called hypotonic. A. A fluid that has the same osmolarity as the blood is called isotonic. C. Hypertonic solutions exert greater osmotic pressure than blood. D. A substance that is hydrophobic does not dissolve in water.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

4. ANS: D
D. Insensible losses may occur without the person recognizing the loss. Perspiration and water lost through respiration and feces are examples of insensible losses. A. B. C. Sensible losses are those of which the person is aware such as urination, vomiting, and diarrhea.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

5. ANS: A
A. This patient is at risk for dehydration. Daily weight is the most reliable indicator of fluid loss or gain. B. Specific gravity is an indirect measure of fluid balance. C. Pulse oximetry reflects oxygenation status and is not related to hydration. D. Creatinine clearance is a measure of kidney function.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

6. ANS: C
C. Elevated blood urea nitrogen (BUN) and hematocrit (Hct) show concentration due to Deficient fluid volume. B. Excess fluid volume would be associated with low BUN and Hct. A. D. Impaired skin integrity and Risk for injury are possible, but they are not indicated by the data provided.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

7. ANS: C
C. Processed cheeses and canned soups are high in sodium. A. B. D. Poultry, fish, fruits, and fresh vegetables have small amounts of sodium.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

8. ANS: D
D. This patient is at risk for fluid volume overload; newly noted crackles are indicative of fluid volume overload. A. Tenderness at the IV site is concerning, but is not the highest priority listed. B. C. The values listed for urine specific gravity and capillary refill are normal.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

9. ANS: B
B. A potassium level of 5.9 is high (nl 3.5 to 5 mEq/L). Since potatoes are high in potassium, this is the food that the nurse should instruct the patient to avoid. A. C. D. These food items are not high in potassium.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

10. ANS: A
A. Both hypokalemia and hyperkalemia can cause cardiac dysrhythmias and arrest. B. C. Fluid overload and internal bleeding are not associated with potassium abnormalities. D. Tetany is associated with hypocalcemia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Application

11. ANS: D
D. A patient having 16 stools a day is at risk for dehydration; furrowed tongue and sticky mucous membranes are signs of dehydration. A, B, and C are signs of fluid excess.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

12. ANS: A
A. Skeletal muscle activity diminishes with hypokalemia, resulting in shallow, ineffective respirations. The motility of the gastrointestinal (GI) system is slowed, causing nausea, vomiting, abdominal distention, and constipation. B. Edema and bounding pulse occur in fluid excess. C. A Positive Chvostek’s sign is associated with hypocalcemia. D. Kussmaul breathing is a sign of acidosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

13. ANS: A
A. A serum potassium level of 2 mEq/L is dangerously low and places the patient at risk for cardiac complications. B. Kayexalate will lower the potassium level further and is inappropriate. C. The result can be documented after the physician is notified STAT. D. Waiting to notify the physician during morning rounds places the patient at risk for a cardiac event.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

14. ANS: D
D. The patient is at risk for osteoporosis. Dairy products should be encouraged. A. B. C. Red meat, fresh fruits, and whole grains do not help prevent the development of osteoporosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

15. ANS: B
B. These are initial signs of hypocalcemia, which can occur with accidental removal of the parathyroid glands during thyroidectomy. A, C, and D will not raise serum calcium levels.

PTS: 1 DIF: Difficult
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

16. ANS: C
C. Spasticity indicates impending tetany. A. B. D. Weakness, redness, or pain may be signs of circulatory impairment but not tetany.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

17. ANS: C
C. Reduced sensation of thirst causes patients to take in less water, which can be dangerous in an older patient who has reduced body water. A, B, and D can potentially increase water retention.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

18. ANS: B
B. To facilitate ease in breathing, the head of the patient’s bed should be in semi-Fowler’s or high Fowler’s position. These positions allow greater lung expansion and thus aid respiratory effort. A. Oxygen is not necessary at this time, as the pulse oximeter reading is within normal limits. C. Voiding will not relieve fluid overload in the absence of diuretic therapy. D. Laying the patient flat in bed may cause dyspnea.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

19. ANS: B
All the listed electrolytes may be lost with furosemide therapy, but the one of most concern is potassium, as it can cause cardiac complications when out of balance.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

20. ANS: A
A. Acute fluid excess typically results in congestive heart failure. As the fluid builds up in the heart, the heart is not able to properly function as a pump. The fluid then backs up into the lungs, causing a condition known as pulmonary edema. B, C, and D are not related to fluid volume.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

21. ANS: D
D. Weight is the most reliable measure of fluid volume. A. The respiratory rate is slightly elevated, which can be a sign of fluid excess. B. Output of 1500 mL may be normal and does not necessarily indicate resolution of fluid excess. C. The blood pressure may be within the patient’s normal limits.

PTS: 1 DIF: Difficult
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

22. ANS: A
A. Any pH less than 7.35 is acidotic. Alkalosis occurs with a pH of more than 7.45. C. D. The blood pH is not used to determine fluid volume.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

23. ANS: C
C. Patients who are hypoventilating retain carbon dioxide, which combines with water in the body to form carbonic acid. Because the cause is respiratory, it is a respiratory acidosis, not a metabolic problem. A, B, and D are not associated with hypoventilation and carbon dioxide retention.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

24. ANS: D
D. Deep rapid breathing gets rid of carbon dioxide, which leaves less carbon dioxide to combine with water to make carbonic acid in the body. A. Vomiting causes acid loss and can result in alkalosis. B. Thirst corrects dehydration, not acidosis. C. Watery diarrhea can worsen metabolic acidosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

25. ANS: D
D. Rebreathing from a paper bag reduces carbon dioxide loss, which increases carbonic acid in the body, correcting alkalosis. A. B. Oxygen and orange juice will not help. C. The Fowler’s position will increase ventilation and could worsen alkalosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

26. ANS: B
B. Lasix is a potassium-wasting diuretic, so the patient is at risk for hypokalemia. Potatoes and fruits are high in potassium. A, C, and D are not high-potassium foods.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Application

27. ANS: D
D. Chronic lung disease is associated with hypoventilation, which causes carbon dioxide retention and acidosis. A. Anxiety is associated with respiratory alkalosis. B. C. Diabetes and kidney failure are associated with metabolic acidosis.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Reduction of Risk Potential | Cognitive Level: Analysis

28. ANS: B
B. Approximately 60% of a young adult’s body weight is water. A. Older adults are less than 50% water. C. D. Infants’ body composition is between 70% and 80% water.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

29. ANS: B
B. The medication should be diluted in the recommended liquid. The amount of fluid to use for dilution is most commonly 4 ounces of fluid to 20 mEq of potassium. A. Potassium tablets should not be crushed. C. Salt substitutes should not be used while taking this medication. D. Nausea and vomiting should be reported to the health care provider.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Pharmacological and Parenteral Therapies | Cognitive Level: Analysis

MULTIPLE RESPONSE

30. ANS: A, C, D
A. C. D. Spinach, oatmeal, and dairy products are good sources of calcium. B. E. F. Carrots, peaches, and cauliflower are not identified as foods high in calcium.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

31. ANS: B, E
B. E. Low-sodium foods are those with less than 140 mg sodium per serving. Tomato juice and pretzels have more than 200 mg per serving which indicates that further teaching is needed. A, C, D, F. These foods are not as high in sodium as tomato juice and pretzels.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Analysis

32. ANS: B, D
B. D. When assessing an older patient for skin turgor, skin over the forehead or sternum should be used. The skin over these areas usually retains elasticity and is therefore a more reliable indicator of skin turgor. A. C. E. The hand, forearm, or upper thigh are not reliable areas to assess for skin turgor.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

33. ANS: A, B, C, D
A. B. C. D. For patients who have a fluid excess and a low sodium level, a fluid restriction is often ordered. Diuretics that rid the body of fluid but do not cause sodium loss may also be used. Intake and output are strictly monitored, and the patient is weighed daily. E. IV saline is indicated if the patient does not have a fluid volume excess.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

34. ANS: A, B, C, D
A. B. C. D. Acute hypercalcemia is associated with increased heart rate and blood pressure, skeletal muscle weakness, and decreased GI motility. E. Dry mucous membranes are associated with fluid volume deficit and not hypercalcemia.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Application

35. ANS: B, C, D, E
B. C. D. E. Manifestations of fluid volume excess include a bounding pulse and shallow respirations, distended neck veins, and pitting edema in the feet. A. Thirst is a manifestation of fluid volume deficit.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis

OTHER

36. ANS:
D, B, A, C
D. Those at highest risk for dehydration are older patients, infants, children, and any patient with a condition that may cause fluid loss. Fever causes fluid loss, and anorexia will reduce oral intake. B. The patient with diarrhea is at risk for dehydration due to fluid loss, but has not had the condition for as long as the patient in option D, and there is no evidence that the 8-year-old is not taking fluids. A. Patients who are NPO have restricted fluid intake. C. Potassium supplements do not cause water loss.

PTS: 1 DIF: Difficult
KEY: Client Need: Physiological Integrity—Physiological Adaptation | Cognitive Level: Analysis