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?

pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L

pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L

pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L

pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L

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

Retention of HCO3 by the kidneys to increase the pH level

Hyperventilation to decrease the CO2 levels

Hypoventilation to increase the CO2 levels

Excretion of HCO3 by the kidneys to decrease the pH level

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

A 42-year-old with severe diarrhea

A 6-month-old learning to drink from a cup

A 12-year-old who is moderately active in 80° F weather

A 90-year-old with frequent headaches

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:

5% dextrose in lactated Ringer’s

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:

Avoid sites on the extremity away from a dialysis graft

Start with the most proximal site

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?

Warmth of integument surrounding the IV site

Skin discoloration of a bruised nature

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?

Slow down the rate of blood flow.

Notify the health care provider and blood bank personnel.

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

Increased urine specific gravity

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:

5% dextrose in lactated Ringer’s

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:

Obtain and send a urine specimen to the laboratory

Begin an infusion of epinephrine

Run normal saline through the blood tubing

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:

Expand the volume of fluid in the vascular system

Fluid 2

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1/54 Questions

1. When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except:
- Rales
- A bounding pulse
- Engorged peripheral veins
- An elevated hematocrit level

About This Quiz

The 'Fluid 2' quiz assesses knowledge in nursing fluid management, focusing on intravascular volume, nutritional impacts on blood gases, electrolyte imbalances, and acid-base disturbances. It is crucial for nursing professionals to understand these concepts to provide optimal patient care.

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2.

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?
- PH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L
- PH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L
- PH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L
- PH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L
Correct Answer

A. pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L

Explanation

The correct answer is pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L. This combination of arterial blood gas levels indicates metabolic acidosis. The pH is below the normal range, indicating acidosis. The PaCO2 is within the normal range, ruling out respiratory acidosis. The HCO3 is below the normal range, indicating a deficit of bicarbonate, which is a base, contributing to the acidosis. This is consistent with extremely poor nutrition, as malnutrition can lead to metabolic acidosis due to the accumulation of metabolic acids in the body.

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1
3.

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?
- Neurological
- Gastrointestinal
- Pulmonary
- Hepatic
Correct Answer

A. Neurological

Explanation

When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of the neurological system. This is because a low serum sodium level can indicate hyponatremia, which can lead to neurological symptoms such as confusion, seizures, and coma. Monitoring the neurological system is important to assess for any changes in mental status or neurological function that may require immediate intervention.

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4.

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:
- Metabolic acidosis
- Respiratory acidosis
- Respiratory alkalosis
- Metabolic alkalosis
Correct Answer

A. Respiratory acidosis

Explanation

The correct answer is respiratory acidosis because the child is exhibiting symptoms such as difficulty breathing, moist rales, and lethargy, which are indicative of respiratory distress. Respiratory acidosis occurs when there is an excess of carbon dioxide in the blood due to inadequate ventilation, leading to an increase in acidity.

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5.

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?
- Metabolic acidosis
- Respiratory acidosis
- Respiratory alkalosis
- Metabolic alkalosis
Correct Answer

A. Metabolic alkalosis

Explanation

The client's arterial blood gas levels indicate a pH of 7.48, CO2 of 42 mm Hg, and HCO3 of 32 mEq/L. These values suggest that the client is experiencing metabolic alkalosis. Metabolic alkalosis occurs when there is an excess of bicarbonate (HCO3) in the blood, leading to an increase in pH. In this case, the elevated HCO3 level indicates a primary metabolic alkalosis.

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6.

6. The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is:
- Hyperventilation to decrease the CO2 levels
- Hypoventilation to increase the CO2 levels
- Retention of HCO3 by the kidneys to increase the pH level
- Excretion of HCO3 by the kidneys to decrease the pH level
Correct Answer

A. Retention of HCO3 by the kidneys to increase the pH level

Explanation

In respiratory acidosis, there is an increase in carbon dioxide (CO2) levels in the blood, leading to a decrease in pH. To compensate for this, the kidneys retain bicarbonate (HCO3) to increase the pH level. By retaining HCO3, the kidneys help to neutralize the excess CO2 and restore the acid-base balance in the body. This compensating mechanism helps to increase the pH level and counteract the effects of respiratory acidosis.

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7.

7. Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is:
- A 6-month-old learning to drink from a cup
- A 12-year-old who is moderately active in 80° F weather
- A 42-year-old with severe diarrhea
- A 90-year-old with frequent headaches
Correct Answer

A. A 42-year-old with severe diarrhea

Explanation

A 42-year-old with severe diarrhea is most at risk for a fluid volume deficit because diarrhea can lead to excessive loss of fluids and electrolytes from the body. This can result in dehydration and imbalances in the body's fluid levels. The other clients mentioned may also be at risk for fluid volume deficit to some extent, but severe diarrhea poses the highest risk due to the rapid loss of fluids.

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8.

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:
- 0.45% normal saline (NS)
- 10% dextrose
- 5% dextrose in lactated Ringer’s
- Dextrose 5% in NS
Correct Answer

A. 0.45% normal saline (NS)

Explanation

The correct answer is 0.45% normal saline (NS) because it is a hypotonic solution that will help replace the loss of intracellular fluid. Hypotonic solutions have a lower concentration of solutes compared to the intracellular fluid, causing water to move into the cells and rehydrate them. The other options, such as 10% dextrose, 5% dextrose in lactated Ringer's, and Dextrose 5% in NS, are not appropriate for replacing intracellular fluid loss as they are either hypertonic or do not contain electrolytes necessary for cellular function.

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9.

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?
- Serum potassium
- Serum sodium
- Serum magnesium
- Serum calcium
Correct Answer

A. Serum calcium

Explanation

The nurse would want to obtain the client's serum calcium levels because the symptoms of right flank and lower back pain could be indicative of kidney stones or renal colic. Calcium imbalances can contribute to the formation of kidney stones, so checking the serum calcium levels would help determine if this is a possible cause for the client's pain.

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10.

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:
- 12 gtt/min
- 22 gtt/min
- 32 gtt/min
- 42 gtt/min
Correct Answer

A. 32 gtt/min

Explanation

The nurse calculates the flow rate by dividing the total volume (1000 mL) by the total time (8 hours) and then multiplying it by the drop factor (15 gtt/mL). This gives a flow rate of 125 gtt/hour. To convert this to gtt/minute, the nurse divides 125 by 60 (minutes in an hour), which gives a flow rate of approximately 2.08 gtt/min. However, since the drop factor is given as 15 gtt/mL, the nurse needs to divide 2.08 by 15 to get the final flow rate of approximately 0.14 mL/min. To convert this to gtt/min, the nurse multiplies 0.14 by 15, which gives a flow rate of approximately 2.1 gtt/min. Rounded to the nearest whole number, the flow rate is 32 gtt/min.

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11.

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:
- Start with the most proximal site
- Look for hard, cordlike veins
- Use the dominant arm
- Avoid sites on the extremity away from a dialysis graft
Correct Answer

A. Avoid sites on the extremity away from a dialysis graft

Explanation

The nurse should avoid selecting sites on the extremity away from a dialysis graft because these sites may have compromised blood flow and could potentially cause complications during the insertion of the intravenous infusion.

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12.

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?
- Intensity of the pain
- Warmth of integument surrounding the IV site
- Amount of subcutaneous edema
- Skin discoloration of a bruised nature
Correct Answer

A. Warmth of integument surrounding the IV site

Explanation

Phlebitis is inflammation of the vein, while infiltration is the leakage of IV fluid into the surrounding tissue. The warmth of the integument surrounding the IV site indicates the presence of phlebitis because inflammation typically causes warmth in the affected area. Infiltration, on the other hand, would not cause warmth but may result in subcutaneous edema, skin discoloration, and pain of varying intensity. Therefore, the warmth of the integument is a specific indicator of phlebitis rather than infiltration.

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13.

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?
- Check the vital signs.
- Stop the blood transfusion.
- Slow down the rate of blood flow.
- Notify the health care provider and blood bank personnel.
Correct Answer

A. Stop the blood transfusion.

Explanation

The client's symptoms of headache, nausea, and vomiting during a blood transfusion indicate a possible transfusion reaction. The most appropriate action for the nurse to take immediately is to stop the blood transfusion. This is to prevent any further complications or adverse reactions that the client may experience. The nurse should then assess the client's vital signs and notify the healthcare provider and blood bank personnel for further instructions and evaluation. Slowing down the rate of blood flow may not address the underlying issue and could potentially worsen the client's symptoms.

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14.

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?
- Weak, thready pulse
- Hypertension
- Dry mucous membranes
- Flushed skin
Correct Answer

A. Hypertension

Explanation

Excess fluid volume refers to an abnormal increase in the amount of fluid in the body, which can lead to hypertension or high blood pressure. Hypertension is a common sign and symptom of excess fluid volume because the increased fluid puts extra pressure on the blood vessels, causing them to constrict and leading to higher blood pressure. Weak, thready pulse, dry mucous membranes, and flushed skin are not typically associated with excess fluid volume.

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15.

15. A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert to the presence of:
- Cardiac dysrhythmias
- Severe diarrhea
- Hyperactive reflexes
- Peripheral cyanosis
Correct Answer

A. Cardiac dysrhythmias

Explanation

Lasix (furosemide) is a loop diuretic that helps the body get rid of excess water and salt. Digoxin is a medication used to treat heart failure and certain heart rhythm problems. Both Lasix and digoxin can affect the electrical conduction in the heart, increasing the risk of cardiac dysrhythmias or abnormal heart rhythms. Therefore, the nurse should be alert to the presence of cardiac dysrhythmias in the client taking these medications. Severe diarrhea, hyperactive reflexes, and peripheral cyanosis are not directly associated with Lasix and digoxin use.

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16.

16. A rapid infusion of citrated blood has been given to the client. The nurse observes for:
- Diaphoresis
- Anxiety
- Chvostek’s sign
- Nausea and vomiting
Correct Answer

A. Chvostek’s sign

Explanation

Chvostek's sign is a clinical manifestation of hypocalcemia, which can occur as a result of citrated blood infusion. It is characterized by facial muscle twitching or spasm when the facial nerve is tapped. Therefore, the nurse should observe for Chvostek's sign as a potential complication of the rapid infusion of citrated blood. Diaphoresis, anxiety, and nausea and vomiting are not directly associated with this specific intervention.

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17.

17. For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and symptoms consistent with:
- Metabolic acidosis
- Metabolic alkalosis
- Respiratory acidosis
- Respiratory alkalosis
Correct Answer

A. Respiratory alkalosis

Explanation

When a child ingests the remaining contents of an aspirin bottle, it can lead to toxicity and cause respiratory alkalosis. Aspirin overdose can stimulate the respiratory center in the brain, leading to hyperventilation and increased breathing rate. This results in excessive elimination of carbon dioxide from the body, leading to a decrease in carbonic acid levels and an increase in blood pH, causing respiratory alkalosis. Symptoms of respiratory alkalosis include rapid breathing, lightheadedness, numbness, and tingling in the extremities.

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18.

18. The single best indicator of fluid status is the nurse’s assessment of the client’s:
- Skin turgor
- Intake and output
- Serum electrolyte levels
- Daily weight
Correct Answer

A. Daily weight

Explanation

Daily weight is the single best indicator of fluid status because it provides a direct measure of fluid balance. Changes in weight can indicate fluid retention or loss, which can be a sign of fluid overload or dehydration. Skin turgor, intake and output, and serum electrolyte levels can also provide valuable information, but they are not as reliable or immediate as daily weight measurements.

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19.

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:
- 32 gtt/min
- 60 gtt/min
- 125 gtt/min
- 250 gtt/min
Correct Answer

A. 125 gtt/min

Explanation

The nurse calculates the infusion rate as 125 gtt/min because the IV solution is to be infused over a 1-hour period and a microdrip infusion set will be used. A microdrip infusion set typically delivers 60 drops per minute, so the nurse can set the rate to 125 gtt/min to ensure that the full 125 mL is infused within the 1-hour timeframe.

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20.

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:
- Decreased muscle tone
- Hypertension
- Diarrhea
- Fever
Correct Answer

A. Diarrhea

Explanation

Adrenal insufficiency, also known as Addison's disease, is characterized by the inadequate production of hormones by the adrenal glands. One of the main functions of these hormones is to regulate fluid and electrolyte balance in the body. In adrenal insufficiency, the lack of hormones can lead to decreased sodium and increased potassium levels, which can result in diarrhea. This is because the imbalance of electrolytes affects the absorption and movement of water in the intestines, leading to loose stools. Therefore, diarrhea is a common symptom in clients with adrenal insufficiency.

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21.

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:
- Calcium 3.9 mEq/L
- Sodium 140 mEq/L
- Potassium 3.5 mEq/L
- Magnesium 2.1 mEq/L
Correct Answer

A. Calcium 3.9 mEq/L

Explanation

The normal range for calcium levels in the blood is 8.5-10.2 mg/dL or 2.1-2.6 mmol/L. A calcium level of 3.9 mEq/L is significantly lower than the normal range, indicating hypocalcemia. Hypocalcemia can have serious consequences, such as muscle cramps, numbness, and tingling, and can even lead to seizures or cardiac arrhythmias. Therefore, this unexpected value should be reported to the healthcare provider for further evaluation and intervention.

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22.

22. The nurse anticipates that the client with a fluid volume excess will manifest a(n):
- Increased urine specific gravity
- Decreased body weight
- Increased blood pressure
- Decreased pulse strength
Correct Answer

A. Increased blood pressure

Explanation

A client with fluid volume excess will likely manifest increased blood pressure. This is because fluid volume excess causes an increase in the amount of fluid in the blood vessels, leading to increased pressure against the vessel walls. This can result in hypertension. The other options are not consistent with fluid volume excess. Increased urine specific gravity is more commonly associated with fluid volume deficit, while decreased body weight and decreased pulse strength are not specific manifestations of fluid volume excess.

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23.

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:
- 0.45% saline
- Lactated Ringer’s
- 5% dextrose in normal saline
- 5% dextrose in lactated Ringer’s
Correct Answer

A. Lactated Ringer’s

Explanation

Lactated Ringer's is an isotonic solution that is commonly used for fluid replacement. It contains a balanced combination of electrolytes, such as sodium, potassium, and calcium, which helps to restore the body's fluid and electrolyte balance. This solution is often used in situations where there is a need for volume expansion, such as in cases of dehydration or hypovolemia. Lactated Ringer's is preferred over other options listed because it closely resembles the electrolyte composition of plasma, making it an effective choice for fluid replacement.

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24.

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:
- Administer an antipyretic
- Begin an infusion of epinephrine
- Run normal saline through the blood tubing
- Obtain and send a urine specimen to the laboratory
Correct Answer

A. Obtain and send a urine specimen to the laboratory

Explanation

The client's symptoms of tachycardia, chills, and low back pain are indicative of a transfusion reaction, specifically a hemolytic reaction. A hemolytic reaction occurs when there is a mismatch between the blood types of the donor and recipient, leading to the destruction of red blood cells. This can result in the release of hemoglobin into the bloodstream, which can then be filtered by the kidneys and excreted in the urine. Therefore, obtaining and sending a urine specimen to the laboratory would allow for further evaluation of the client's condition and confirmation of a hemolytic reaction.

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25.

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:
- Expand the volume of fluid in the vascular system
- Pull fluid from the cells
- Keep protein levels normal
- Move fluid into the cells
Correct Answer

A. Expand the volume of fluid in the vascular system

Explanation

The primary goal of prescribing 0.9% sodium chloride (normal saline) as an intravenous therapy is to expand the volume of fluid in the vascular system. This solution has the same osmolarity as blood, which means it will not cause a shift of fluid into or out of the cells. Instead, it will increase the volume of fluid in the blood vessels, helping to restore or maintain adequate blood volume and blood pressure.

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26.

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:
- Expand the volume of fluid in the vascular system
- Pull fluid from the cells
- Keep protein levels normal
- Move fluid into the cells
Correct Answer

A. Pull fluid from the cells

Explanation

The correct answer is "Pull fluid from the cells." A hypertonic solution has a higher concentration of solutes compared to the cells. When this solution is administered intravenously, it creates an osmotic gradient that causes water to move out of the cells and into the bloodstream, resulting in the pulling of fluid from the cells. This can be beneficial in certain conditions, such as when there is excess fluid in the cells or when there is a need to decrease swelling or edema.

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27.

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:
- Expand the volume of fluid in the vascular system
- Pull fluid from the cells
- Keep protein levels normal
- Move fluid into the cells
Correct Answer

A. Move fluid into the cells

Explanation

The primary goal of prescribing a hypotonic solution like 0.45% sodium chloride is to move fluid into the cells. Hypotonic solutions have a lower concentration of solutes compared to the intracellular fluid, causing water to move into the cells to equalize the concentration. This helps to rehydrate the cells and restore their normal functioning. Expanding the volume of fluid in the vascular system, pulling fluid from the cells, and keeping protein levels normal are not the primary goals of prescribing a hypotonic solution.

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28.

28. The nurse recognizes which of the following clients is at the greatest risk for dehydration?
- A 35-year-old client diagnosed with Crohn’s disease
- A 15-year-old client who is following a low-carbohydrate diet
- A 2-year-old client diagnosed with an allergy to milk proteins
- A 79-year-old client who has been diagnosed with advanced Alzheimer’s disease
Correct Answer

A. A 79-year-old client who has been diagnosed with advanced Alzheimer’s disease

Explanation

The 79-year-old client with advanced Alzheimer's disease is at the greatest risk for dehydration because Alzheimer's disease can impair the individual's ability to recognize thirst and communicate their needs. Additionally, the client may have difficulty swallowing or may refuse to eat or drink, leading to inadequate fluid intake. Advanced age can also contribute to a higher risk of dehydration.

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29.

29. Which of the following clients is at greatest risk for insensible water loss?
- A 37-year-old with a superficial burn to the left hand
- A 15-year-old experiencing an asthmatic attack
- A 50-year-old with type 2 diabetes
- A 73-year-old with a history of pneumonia
Correct Answer

A. A 15-year-old experiencing an asthmatic attack

Explanation

A 15-year-old experiencing an asthmatic attack is at the greatest risk for insensible water loss. During an asthmatic attack, there is increased respiratory effort and rapid breathing, leading to increased water loss through respiration. This can result in significant dehydration if not properly managed.

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30.

30. Which of the following foods will have the greatest impact on the water balance of the person consuming it?
- A pickle
- A banana
- A milkshake
- A spinach salad
Correct Answer

A. A pickle

Explanation

A pickle will have the greatest impact on the water balance of the person consuming it because pickles are typically high in sodium. Sodium is known to increase water retention in the body, leading to an imbalance in water levels. This can cause bloating and an increase in overall water weight.

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31.

31. Which of the following foods will have the greatest impact on the heart’s conductivity of the person consuming it?
- A pickle
- A banana
- A milkshake
- A spinach salad
Correct Answer

A. A banana

Explanation

A banana will have the greatest impact on the heart's conductivity of the person consuming it. Bananas are rich in potassium, which is an essential mineral for maintaining proper heart function. Potassium helps regulate the electrical impulses that control the heart's rhythm and conductivity. Consuming foods high in potassium, like bananas, can help prevent irregular heartbeats and maintain a healthy heart.

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32.

32. Which of the following foods will have the greatest impact on the blood-clotting mechanism of the person consuming it?
- A pickle
- A banana
- A milkshake
- A spinach salad
Correct Answer

A. A milkshake

Explanation

A milkshake will have the greatest impact on the blood-clotting mechanism of the person consuming it. This is because milkshakes are often high in fat and sugar content, which can lead to increased blood clotting. Fat can cause an increase in blood viscosity, making it more likely for clots to form. Additionally, excessive sugar consumption can lead to inflammation and damage to blood vessels, further increasing the risk of blood clot formation.

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0
33.

33. Which of the following foods will have the greatest impact on the neurochemical activity of the person consuming it?
- A pickle
- A banana
- A milkshake
- A spinach salad
Correct Answer

A. A spinach salad

Explanation

A spinach salad will have the greatest impact on the neurochemical activity of the person consuming it. Spinach is rich in nutrients such as folate, vitamin K, and antioxidants, which are known to support brain health and function. These nutrients can help improve cognitive function, memory, and overall brain health. Additionally, spinach contains high levels of magnesium, which plays a crucial role in regulating neurotransmitters and promoting healthy brain activity. Therefore, consuming a spinach salad can have a significant impact on neurochemical activity compared to the other food options listed.

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34.

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?
- Dry, sticky tongue
- Increased anxiety
- Nausea and vomiting
- Decreased bowel sounds
Correct Answer

A. Nausea and vomiting

Explanation

A client experiencing partial-thickness burns over 35% of the body as a result of hyponatremia is likely to experience nausea and vomiting. Hyponatremia refers to low levels of sodium in the blood, which can occur due to fluid loss from burns. Nausea and vomiting are common symptoms of hyponatremia as the body tries to eliminate excess fluid and restore electrolyte balance. The other options, including a dry, sticky tongue, increased anxiety, and decreased bowel sounds, are not specifically associated with hyponatremia.

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35.

35. Which of the following clinical assessment findings is most likely seen in a client experiencing hypernatremia as a result of diabetes insipidus?
- Dry, sticky tongue
- Increased anxiety
- Nausea and vomiting
- Decreased bowel sounds
Correct Answer

A. Dry, sticky tongue

Explanation

In hypernatremia, there is an excessive amount of sodium in the blood. Diabetes insipidus is a condition where the body is unable to properly regulate water balance, leading to excessive urination and dehydration. Dry, sticky tongue is a common symptom of dehydration, which is likely to occur in a client experiencing hypernatremia as a result of diabetes insipidus. Increased anxiety, nausea and vomiting, and decreased bowel sounds are not specific findings associated with hypernatremia or diabetes insipidus.

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36.

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?
- Dry, sticky tongue
- Increased anxiety
- Nausea and vomiting
- Decreased bowel sounds
Correct Answer

A. Decreased bowel sounds

Explanation

Hypokalemia refers to low levels of potassium in the blood. Potassium-wasting diuretics can cause excessive loss of potassium through urine, leading to hypokalemia. Decreased bowel sounds can be seen in hypokalemia as it affects the smooth muscle contractions in the gastrointestinal tract, leading to slowed or absent bowel sounds. Dry, sticky tongue is not a specific finding related to hypokalemia. Increased anxiety is not a common symptom of hypokalemia. Nausea and vomiting can be seen in hypokalemia, but decreased bowel sounds is a more specific finding.

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37.

37. Which of the following clinical assessment findings is most likely seen in a client experiencing hyperkalemia as a result of adrenal insufficiency?
- Dry, sticky tongue
- Increased anxiety
- Nausea and vomiting
- Decreased bowel sounds
Correct Answer

A. Increased anxiety

Explanation

Hyperkalemia is a condition characterized by high levels of potassium in the blood. Adrenal insufficiency can lead to hyperkalemia because the adrenal glands are responsible for producing hormones that regulate potassium levels. Increased anxiety is a common clinical assessment finding in clients with hyperkalemia as it is a symptom of the condition. The other options, such as dry, sticky tongue, nausea and vomiting, and decreased bowel sounds, are not typically associated with hyperkalemia.

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38.

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:
- Hypokalemia
- Hyperkalemia
- Hyponatremia
- Hypocalcemia
Correct Answer

A. Hypokalemia

Explanation

The client's symptoms of weakness, fatigue, nausea, and vomiting, along with the findings of decreased bowel sounds and ECG abnormalities such as flattened T wave and flattened ST segment, are consistent with hypokalemia. Furosemide is a loop diuretic that increases the excretion of potassium in the urine, leading to low potassium levels in the body. Hypokalemia can cause muscle weakness, fatigue, gastrointestinal disturbances, and ECG changes such as flattened T wave and flattened ST segment. Therefore, hypokalemia is the correct answer.

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39.

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?
- Give the child some juice to drink.
- Prepare to start an IV.
- Get an order for an antipyretic.
- Sponge the child to bring down the fever.
Correct Answer

A. Prepare to start an IV.

Explanation

The child's symptoms of vomiting, fever, and lethargy, along with the history of a fever of unknown origin and a rectal temperature of 101.1°F, indicate that the child is likely dehydrated. Giving the child some juice to drink may not be sufficient to rehydrate her, especially if she is lethargic and unable to tolerate oral fluids. Therefore, the nurse should prepare to start an IV to administer fluids and rehydrate the child effectively.

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40.

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:
- Urine output
- Intake of sodium
- Activity level
- Oxygen level
Correct Answer

A. Urine output

Explanation

The nurse should closely monitor urine output because the increased secretion of aldosterone, glucocorticoids, and antidiuretic hormone (ADH) during the second to fifth postoperative day can cause fluid imbalances. Monitoring urine output will help the nurse assess the client's fluid status and ensure that the client is adequately hydrated. This is especially important in older adults who may be more susceptible to dehydration. Monitoring intake of sodium, activity level, and oxygen level are also important aspects of postoperative care, but they are not directly related to the fluid-balance changes caused by the stress response of surgery.

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41.

41. Which of the following clients is most at risk for fluid volume deficit?
- 25-year-old male near-drowning victim
- 56-year-old woman with salicylate poisoning
- 45-year-old woman with second-degree burns over 20% of her body
- 13-year-old boy with an oral temperature of 103.4° F
Correct Answer

A. 45-year-old woman with second-degree burns over 20% of her body

Explanation

The 45-year-old woman with second-degree burns over 20% of her body is most at risk for fluid volume deficit. Burns can cause fluid loss through damaged skin, leading to dehydration and decreased blood volume. The extent of the burns (20% of her body) suggests a significant loss of fluids, making her more vulnerable to fluid volume deficit. The other clients may have their own health concerns, but they do not have the same level of fluid loss as the burn victim.

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42.

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)?
- IV fluids
- Cream of mushroom soup
- Gelatin
- Mashed potatoes
Correct Answer

A. Mashed potatoes

Explanation

Mashed potatoes would not be counted on the daily intake and output because they are not administered through the IV line. Intake and output refers to the measurement of fluids that are taken in and eliminated from the body, and in this case, only the IV fluids would be counted as intake. The cream of mushroom soup and gelatin may be counted as intake if they are consumed orally, and the IV fluids would be counted as both intake and output.

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43.

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 to 2 minutes
- 2 to 3 minutes
- 3 to 5 minutes
- 5 to 10 minutes
Correct Answer

A. 5 to 10 minutes

Explanation

The nurse needs to hold pressure on the IV site for 5 to 10 minutes in order to prevent a hematoma. Holding pressure on the site helps to promote clotting and prevent bleeding. Since the client has been taking aspirin daily, which is a blood thinner, there is a higher risk of bleeding and a longer duration of pressure is needed to ensure proper clotting and prevent hematoma formation.

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44.

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

A. Carefully adjust the roller clamp to see an increase in flow rate.

Explanation

The nurse should carefully adjust the roller clamp to see an increase in flow rate. This is because a decrease or absence of flow may indicate that the IV site is not patent, meaning that the catheter may be blocked or the vein may have collapsed. By adjusting the roller clamp, the nurse can determine if the issue is with the flow rate and take appropriate action to ensure the IV site is patent and the client is receiving the necessary fluids.

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45.

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:
- Every shift
- Daily
- Every 48 hours
- Every 72 hours
Correct Answer

A. Every 72 hours

Explanation

The correct answer is "Every 72 hours". The nurse knows that the CDC recommends changing IV tubing every 72 hours to prevent the risk of infection. This is because IV tubing can become contaminated over time, increasing the risk of introducing bacteria into the client's bloodstream. By changing the tubing every 72 hours, the nurse can help maintain a sterile environment and reduce the risk of infection for the client.

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46.

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:
- Immediately discontinue the IV line and remove the cannula
- Put cool compresses on the IV site to decrease the edema
- Notify the health care provider of the situation
- Put warm compresses on the IV site to decrease the pain
Correct Answer

A. Notify the health care provider of the situation

Explanation

The nurse should notify the health care provider of the situation because the redness, edema, and pain at the IV insertion site may indicate an infection or infiltration. The health care provider needs to be informed so that appropriate interventions can be initiated, such as ordering a culture and sensitivity test, prescribing antibiotics if necessary, and evaluating the need for a new IV line. Discontinuing the IV line and removing the cannula may be necessary, but this should be done under the guidance of the health care provider. Applying cool or warm compresses may provide temporary relief, but it does not address the underlying issue and should not be the nurse's first action.

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47.

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:
- 24 gauge
- 22 gauge
- 20 gauge
- 18 gauge
Correct Answer

A. 20 gauge

Explanation

The minimum gauge IV cannula necessary for administering a blood transfusion is 20 gauge. This is because blood transfusions require a larger diameter cannula to accommodate the flow rate of blood products. A larger gauge cannula allows for a faster and smoother administration of the transfusion, reducing the risk of complications such as clotting or hemolysis. A 20 gauge cannula is commonly used for blood transfusions, providing an appropriate balance between flow rate and patient comfort.

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48.

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:
- Notify the health care provider immediately
- Apply pressure to the IV site
- Apply a tourniquet high on the extremity
- Ask another nurse to double-check the cannula
Correct Answer

A. Apply a tourniquet high on the extremity

Explanation

When the nurse notices that the tip of the cannula is missing, it is important to apply a tourniquet high on the extremity to prevent any potential bleeding or further complications. Applying pressure to the IV site may not be sufficient in this case, as the missing tip could cause bleeding that cannot be controlled by simple pressure. Notifying the health care provider and asking another nurse to double-check the cannula may be necessary steps, but the immediate priority is to apply a tourniquet to prevent any potential harm to the client.

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49.

1. A client with partial-thickness burns over 40% of the body is likely to lose body fluid via: (Select all that apply.)
- Water vapor that is lost through the skin that is burned
- Plasma and interstitial fluids that are lost as burn exudate
- Blood leakage via damaged capillaries in the dermis
- Respiratory acidosis resulting from altered respiratory function
- Plasma that leaves the intravascular space and becomes trapped in blisters
- Sodium and water shift that out of the vessels because of increased permeability
Correct Answer(s)

A. Water vapor that is lost through the skin that is burned
A. Plasma and interstitial fluids that are lost as burn exudate
A. Blood leakage via damaged capillaries in the dermis
A. Plasma that leaves the intravascular space and becomes trapped in blisters
A. Sodium and water shift that out of the vessels because of increased permeability

Explanation

A client with partial-thickness burns over 40% of the body is likely to lose body fluid via several mechanisms. Firstly, water vapor is lost through the skin that is burned. Secondly, plasma and interstitial fluids are lost as burn exudate, which is the fluid that oozes from the burned area. Thirdly, there is blood leakage via damaged capillaries in the dermis, which further contributes to fluid loss. Additionally, plasma can leave the intravascular space and become trapped in blisters, leading to fluid loss. Lastly, there is a shift of sodium and water out of the vessels due to increased permeability, causing further fluid loss.

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Quiz Edited by
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Mar 08, 2012

Quiz Created by
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Fluid 2

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

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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?

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?

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:

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?

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

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

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:

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?

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:

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:

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?

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?

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?

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

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

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

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

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:

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:

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:

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

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:

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:

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:

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:

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:

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

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

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

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

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

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

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?

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

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?

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

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

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)?

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:

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?

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:

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:

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

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?

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: