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Ch 13 - Test bank questions with accurate/correct
answers already graded A+ 2024/25 latest
Medical Surgical 1 (Southeastern University)
Chapter 13: Fluid and Electrolytes: Balance and Disturbance
- You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health?
A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status
Ans: D
Feedback:
A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.
- You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems?
A) Diminished deep tendon reflexes
B) Tachycardia
C) Cool, clammy skin
D) Acute flank pain
Ans: A
Feedback:
To gauge a patients magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.
- You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?
C) Metabolic acidosis with no compensation
D) Metabolic acidosis with a compensatory respiratory alkalosis
Ans: D
Feedback:
A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO 3 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem.
- You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
A) Air emboli
B) Phlebitis
C) Infiltration
D) Fluid overload
Ans: C
Feedback:
Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration.
- You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?
A) Overhydration is common among healthy older adults.
B) Dehydration causes the skin to appear spongy.
C) Inelastic skin turgor is a normal part of aging.
D) Skin turgor cannot be assessed in patients over 70.
Ans: C
Feedback:
Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.
- The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
A) Choose a hairless site if available.
B) Consider potential effects on the patients mobility when selecting a site.
C) Have the patient briefly hold his arm over his head before insertion.
D) Leave the tourniquet on for at least 3 minutes.
Ans: B
Feedback:
Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair.
- A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?
A) Hydrostatic pressure
B) Osmosis and osmolality
C) Diffusion
D) Active transport
Ans: B
Feedback:
The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH. Carbonic acid works as the chemical medium to exchange O 2 and CO 2 in the lungs to maintain a stable pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.
- You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance?
A) Hypercalcemia
B) Metabolic acidosis
C) Metabolic alkalosis
D) Respiratory acidosis
Ans: C
Feedback:
Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This patient would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise pH. Respiratory acidosis is unlikely since no change was reported in the patients respiratory status.
- The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?
A) Leave one hand ungloved to assess the site.
B) Cleanse the skin with normal saline.
C) Ask the patient about allergies to latex or iodine.
D) Remove excessive hair from the selected site.
Ans: C
Feedback:
Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in preparing for IV therapy. A local reaction could result in irritation to the IV site, or, in the extreme, it could result in anaphylaxis, which can be life threatening. Both hands should always be gloved when preparing for IV insertion, and latex-free gloves must be used or the patient must report not having latex allergies. The skin is not usually cleansed with normal saline prior to insertion. Removing excessive hair at the selected site is always secondary to allergy inquiry.
- A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO 2 64 mm Hg, HCO 3 = 24 mm Hg. What does the ABG reflect?
A) Respiratory acidosis
B) Metabolic alkalosis
C) Respiratory alkalosis
D) Metabolic acidosis
Ans: A
Feedback:
The pH is below 7.40, PaCO 2 is greater than 40, and the HCO 3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO 3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7. indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO 3 of 24 is within the normal range, ruling out metabolic acidosis.
- One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?
A) Help distinguish hyponatremia from hypernatremia
B) Help evaluate pituitary gland function
C) Help distinguish reduced renal blood flow from decreased renal function
D) Help provide an effective treatment for hypertension-induced oliguria
Ans: C
Feedback:
If a patient is not excreting enough urine, the health care provider needs to determine whether the
D) The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.
Ans: D
Feedback:
Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.
- A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?
A) Leave the hair intact.
B) Shave the area.
C) Clip the hair in the area.
D) Remove the hair with a depilatory.
Ans: C
Feedback:
Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.
- You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?
A) Increased serum sodium
B) Decreased serum potassium
C) Decreased hemoglobin
D) Increased platelets
Ans: A
Feedback:
Increased serum sodium causes increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.
- A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO 2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?
A) The patients calcium will rise dramatically due to pituitary stimulation.
B) Oxygen will increase the patients intracranial pressure and create confusion.
C) Oxygen may cause the patient to hyperventilate and become acidotic.
D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
Ans: D
Feedback:
When PaCO 2 chronically exceeds 50 mm Hg, it creates insensitivity to CO 2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patients calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patients intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.
- The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?
A) Diffusion
B) Osmosis
C) Active transport
D) Filtration
Ans: A
Ans: D
Feedback:
Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased sympathetic stimulation.
- You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults?
A) Substantially reduced renal function
B) Acute kidney injury
C) Decreased cardiac output
D) Alterations in ratio of body fluids to muscle mass
Ans: A
Feedback:
Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acidbase disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production. Therefore, high-normal and minimally elevated serum creatinine values may indicate substantially reduced renal function in older adults. Acute kidney injury is likely to cause a more significant increase in serum creatinine.
- You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?
A) Extravasation of the medication
B) Discomfort to the patient
C) Blanching at the site
D) Hypersensitivity reaction to the medication
Ans: A
Feedback:
Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue damage is determined by the medication concentration, the quantity that extravasated, infusion site location, the tissue response, and the extravasation duration. Extravasation is the priority over the other listed consequences.
- The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to- rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit?
A) Diarrhea
B) Dilute urine
C) Increased muscle tone
D) Joint pain
Ans: B
Feedback:
Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. Decreased muscle strength and DTRs can be found on physical assessment. You would expect decreased, not increased, muscle strength with hypokalemia. The patient would not have diarrhea following bowel surgery, and increased bowel motility is inconsistent with hypokalemia.
- You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?
A) Hypernatremia
B) Hypomagnesemia
C) Hypophosphatemia
D) Hypercalcemia
Ans: C
Feedback:
Respiratory acidosis is always due to inadequate excretion of CO 2 with inadequate ventilation, resulting in elevated plasma CO 2 concentrations and, consequently, increased levels of carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea, administration of oxygen to a patient with chronic hypercapnia (excessive CO 2 in the blood), severe pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain-Barr syndrome. The other listed diagnoses are not associated with respiratory acidosis.
- The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO 2 50 mm Hg, HCO 3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?
A) Respiratory acidosis
B) Metabolic alkalosis
C) Respiratory alkalosis
D) Mixed acidbase disorder
Ans: D
Feedback:
Patients can simultaneously experience two or more independent acidbase disorders. A normal pH in the presence of changes in the PaCO 2 and plasma HCO 3 concentration immediately suggests a mixed disorder, making the other options incorrect.
- A patient has questioned the nurses administration of IV normal saline, asking whether sterile water would be a more appropriate choice than saltwater. Under what circumstances would the nurse administer electrolyte-free water intravenously?
A) Never, because it rapidly enters red blood cells, causing them to rupture.
B) When the patient is severely dehydrated resulting in neurologic signs and symptoms
C) When the patient is in excess of calcium and/or magnesium ions
D) When a patients fluid volume deficit is due to acute or chronic renal failure
Ans: A
Feedback:
IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte- free water can never be administered by IV because it rapidly enters red blood cells and causes them to rupture.
- A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that apply.
A) Decreased kidney mass
B) Increased conservation of sodium
C) Increased total body water
D) Decreased renal blood flow
E) Decreased excretion of potassium
Ans: A, D, E
Feedback:
Dehydration in the elderly is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.
- You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?
A) Hypocalcemia
B) Hyponatremia
C) Hyperchloremia
D) Hypophosphatemia
Ans: C
Feedback:
break up gas in the GI system and would be of no benefit in treating a patient in metabolic alkalosis. KCl would only be given if the patient were hypokalemic, which is not stated in the scenario. Furosemide (Lasix) would only be given if the patient were fluid overloaded, which is not stated in the scenario.
- You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly?
A) Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly.
B) Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.
C) Malnourished patients who receive fluids too rapidly are at risk for hypernatremia.
D) Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate
Ans: B
Feedback:
The nurse identifies patients who are at risk for hypophosphatemia and monitors them. Because malnourished patients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Patients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration.
- You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that apply.
A) Milk
B) Beef
C) Poultry
D) Green vegetables
E) Liver
Ans: A, C, E
Feedback:
If the patient experiences mild hypophosphatemia, foods such as milk and milk products, organ meats, nuts, fish, poultry, and whole grains should be encouraged.
- You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?
A) Hypertension
B) Kussmaul respirations
C) Increased DTRs
D) Shallow respirations
Ans: D
Feedback:
If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs.
- A patients most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patients dietary intake of potassium. Which of the following would be a good source of potassium?
A) Apples
B) Asparagus
C) Carrots
D) Bananas
Ans: D
Feedback:
Bananas are high in potassium. Apples, carrots, and asparagus are not high in potassium.
- The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?
