30 Items Fluid and Electrolytes Medsurg

Med Surg Ch 8 Fluid and Electrolyte Management
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The nurse is providing care to a patient who is diagnosed with
multisystem fluid volume deficit. The patient is currently experi-
encing tachycardia and decreased urine output along with skin
ANS: 3
that is pale and cool to the touch. The patient has a decreased
The internal vasoconstrictive compensatory reactions within the
urine output. Which probable cause to the patient's symptoms
body are responsible for the symptoms exhibited. The body natu-
should the nurse include when educating the family?
rally attempts to conserve fluid internally specifically for the brain
1) Congestive heart failure
and heart.
2) Rapidly infused intravenous fluids
3) Natural compensatory mechanisms
4) Pharmacological effects of a diuretic
The nurse is providing care to a patient whose serum calcium
levels have increased since a surgical procedure performed three
days prior. Which intervention should the nurse implement to
ANS: 2
decrease the risk for the development of hypercalcemia?
Hypercalcemia can occur from immobility. Ambulation of the client
1) Monitor vital signs every eight hours
helps to prevent leaching of calcium from the bones into the
2) Encourage ambulation three times a day
serum.
3) Irrigate the Foley catheter one time a day
4) Recommend turning, coughing, and deep breathing every two
hours
Which intervention should the nurse implement for a patient
whose serum phosphorus level is 2.0 mg/dL? ANS: 3
1) Enforce contact precautions A phosphorus level of 2.0 is low, and the client will need additional
2) Strain all urine for kidney stones dietary phosphorus. Providing phosphorus-rich foods such as milk
3) Encourage consumption of milk and yogurt and yogurt is a good way to provide that additional phosphorus.
4) Discourage the consumption of a high-calorie diet
The nurse is providing care to a patient who is prescribed
furosemide as part of the treatment for congestive heart failure
(CHF). The patient's serum potassium level is 3.4 mEq/L. Which
ANS: 3
food should the nurse encourage the patient to eat based on this
A potassium level of 3.4 is low, so the client should be encouraged
data?
to consume potassium-rich foods. Of the foods listed, the highest
1) Peas
in potassium is banana.
2) Iced tea
3) Bananas
4) Baked fish
A patient is admitted to the emergency department (ED) for de-
hydration. The patient is 154 lbs. Which urine output indicate the
ANS: 4
rehydration efforts for this patient have been effective?
Expected urine output for an adult patient is 0.5 mL/kg/hr. The
1) 20 mL/hr
patient currently weighs 70 kg; therefore, adequate urine output
2) 25 mL/hr
would be at least 35 mL/hr.
3) 30 mL/hr
4) 35 mL/hr
An older adult patient, who appears intermittently confused, is
admitted to the hospital after a fall. Based on the current data,
ANS: 2
which is the patient at an increased risk for developing?
During the aging process, the thirst mechanism declines. In a
1) Brain attack
patient with an altered level of consciousness, this can increase
2) Dehydration
the risk of dehydration and high serum osmolality.
3) Hemorrhage
4) Kidney damage
The nurse is providing care to an older adult patient who is receiv-
ing intravenous (IV) fluids at 150 mL/hr. The patient is currently
exhibiting crackles in the lungs, shortness of breath, and jugular
vein distention. Which complication of IV fluid therapy does the ANS: 2
nurse suspect the patient is experiencing? Fluid volume excess may occur when older adult patients receive
1) Speed shock intravenous fluids rapidly.
2) Fluid volume excess
3) Anaphylactic reaction
4) Pulmonary embolism
A patient is prescribed 20 mEq of potassium chloride due to
excessive vomiting. Which is the rationale for this drug the nurse
should provide to the patient?
1/5
1) It controls and regulates water balance in the body.
ANS: 4
2) It is used in the body to synthesize ingested protein.
Potassium is the major cation in intracellular fluids, with only a
3) It is vital in regulating muscle contraction and relaxation.
small amount found in plasma and interstitial fluid. Potassium is a
4) It is needed to maintain skeletal, cardiac, and neuromuscular
vital electrolyte for skeletal, cardiac, and smooth muscle activity.
activity.
Which data collected by the nurse during the assessment process
ANS: 4
places the older adult patient at risk for dehydration?
A poor intake of water could indicate a loss of the thirst response,
1) Poor skin turgor
which occurs as a normal age-related change. Since the patient
2) Body mass index of 20.5
only ingests two glasses of water each day, this could indicate a
3) Blood pressure of 140/98 mmHg
reduction in the normal thirst response.
4) Water intake of 2 glasses per day
The nurse is reviewing laboratory values for a female patient
ANS: 2
suspected of having a fluid imbalance. Which laboratory value
The hematocrit measures the volume of whole blood that is com-
evaluated by the nurse supports the diagnosis of dehydration?
posed of RBCs. Because the hematocrit is a measure of the
1) Hematocrit 30%
volume of cells in relation to plasma, it is affected by changes in
2) Hematocrit 53%
plasma volume. The hematocrit increases with severe dehydra-
3) Serum potassium 3.8 mEq/L
tion.
4) Serum osmolality 230 mOsm/kg
The nurse is analyzing the intake and output record for a patient
ANS: 3
being treated for dehydration. The patient weighs 176 lbs. and
Urinary output is normally equivalent to the amount of fluids in-
had a 24-hour intake of 2,000 mL and urine output of 1,200 mL.
gested; the usual range is 1,500-2,000 mL in 24 hours, or 40-80
Based on this data, which conclusion by the nurse is the most
mL in 1 hour (0.5 mL/kg per hour). Patients whose intake substan-
appropriate?
tially exceeds output are at risk for fluid volume excess; however,
1) Treatment has not been effective.
the patient is dehydrated. The extra fluid intake is being used to
2) Treatment needs to include a diuretic.
improve body fluid balance. The patient's output is 40 mL/hr, which
3) Treatment is effective and should continue.
is within the normal range.
4) Treatment has been effective and should end.
The nurse is providing care to a patient who seeks emergency
treatment for headache and nausea. The patient works in a mill
ANS: 2
without air conditioning. The patient states, "I drink water several
Both salt and water are lost through sweating. When only water
times each day but I seem to sweat more than I am able to
is replaced, the individual is at risk for salt depletion. Symptoms
replace." Which suggestions should the nurse provide to this
include fatigue, weakness, headache, and gastrointestinal symp-
patient?
toms such as loss of appetite and nausea. The client should be
1) Drink juices and carbonated sodas.
instructed to eat something salty when drinking water to help
2) Eat something salty when drinking water.
replace the loss of sodium.
3) Eat something sweet when drinking water.
4) Double the amount of water being ingested.
An older adult patient, who lives in a long-term care facility, pre-
sents in the emergency department (ED) due to fever, nausea, ANS: 1
and vomiting over the past two days. The patient denies thirst. The Older adult patients are less able to concentrate their urine, mak-
urine dipstick indicates a decreased urine specific gravity. Which ing them susceptible to dehydration. In addition, there is a deficit of
medical diagnosis should the nurse anticipate when planning care the thirst response. However, fever, nausea, and vomiting resulting
for this patient? from these changes are not considered normal. The patient's
1) Dehydration symptoms of nausea and vomiting suggest decreased intake and
2) Hypertension increased output through vomiting, placing the client at risk for
3) Fluid overload dehydration.
4) Congestive heart failure
The nurse receives shift report on a pediatric medical-surgical
unit. The nurse has been assigned four patients for the shift. Which
child does the nurse plan to assess first based on the increased ANS: 2
risk for dehydration? The pediatric patient with the greatest risk for dehydration is the
1) A 4-year-old child with a broken leg child who is under 2 years of age experiencing tachypnea which
2) A 15-month-old child with tachypnea increases insensible fluid loss.
3) A 16-year-old child with migraine headaches
4) A 10-year-old child with cellulitis of the left leg
The nurse is teaching a group of children and their parents about
the prevention of heat-related illness during exercise. Which state-
ment by a parent indicates an appropriate understanding of the
preventive techniques taught during the teaching session?
1) "My child only needs to hydrate at the end of an exercise
2/5
session."
2) "Water is the drink of choice to replenish fluids that are lost
during exercise." ANS: 3
3) "I will have my child stop every 15-20 minutes during the activity During activity, stopping for fluids every 15-20 minutes is recom-
for fluids." mended.
4) "It is important for my child to wear dark clothing while exercis-
ing in the heat."
The nurse is providing care to an adult patient admitted with
dehydration and hyponatremia. Which medical condition supports
ANS: 4
the current nursing diagnosis of Electrolyte Imbalance?
Hypotonic dehydration occurs when fluid loss is characterized by a
1) Osmotic pressure
proportionately greater loss of sodium than water, causing serum
2) Hydrostatic pressure
sodium to fall below normal levels.
3) Isotonic dehydration
4) Hypotonic dehydration
The nurse is caring for a patient who is receiving intravenous fluids
postoperatively following cardiac surgery. The nurse is aware that
this patient is at risk for fluid volume excess. The family asks why
ANS: 4
the patient is at risk for this condition. Which response by the nurse
Antidiuretic hormone (ADH) and aldosterone levels are common-
is the most appropriate?
ly increased following the stress response before, during, and
1) "Fluid volume excess is caused by inactivity."
immediately after surgery. This increase leads to sodium and
2) "Fluid volume excess is caused by the intravenous fluids."
water retention. Adding more fluids intravenously can cause a fluid
3) "Fluid volume excess is caused by new onset liver failure
volume excess and stress upon the heart and circulatory system.
caused by the surgery."
4) "Fluid volume excess is common due to increased levels of
antidiuretic hormone in response to the stress of surgery."
The nurse is providing care to a patient following hemodialysis.
The patient is experiencing tachycardia and decreased urine out-
put along with skin that is pale and cool to the touch. Which goal
of hemodialysis does the nurse determine the patient has not met
ANS: 2
based on the current data?
The patient receiving hemodialysis is expected to have a reduction
1) Cardiac decompensation
of extracellular fluid, not a fluid deficit that puts the patient at risk.
2) A reduction of extracellular fluid
3) The effects of rapidly infused intravenous fluids
4) The pharmacological effects of a diuretic infused in the
dialysate
The nurse is caring for a patient with congestive heart failure who
is admitted to the medical-surgical unit with acute hypokalemia.
ANS: 1
Which prescribed medication may have contributed to the pa-
Excess potassium loss through the kidneys is often caused by
tient's current hypokalemic state?
such medications as corticosteroids, potassium-wasting (loop)
1) Cortisol
diuretics, amphotericin B, and large doses of some antibiotics.
2) Demerol
Cortisol is a type of corticosteroid and can cause hypokalemia.
3) Skelaxin
4) Nonsteroidal anti-inflammatory drugs (NSAIDs)
The nurse is caring for a patient with a potassium level of 5.9
mEq/L. The health-care provider prescribes both glucose and
insulin for the patient. The patient's spouse asks, "Why is insulin
needed?" Which response by the nurse is the most appropriate?
ANS: 4
1) "The insulin will help his kidneys excrete the extra potassium."
Serum potassium levels may be temporarily lowered by admin-
2) "The insulin is safer than other medications that can lower
istering glucose and insulin, which cause potassium to leave the
potassium levels."
extracellular fluid and enter cells.
3) "The insulin lowers his blood sugar levels and this is how the
extra potassium is excreted."
4) "The insulin will cause his extra potassium to move into his cells,
which will lower potassium in the blood."
A patient is admitted to the emergency department (ED) for fluid ANS: 3

volume deficit. Which body system should the nurse focus to de- The most common cause of fluid volume deficit is excessive loss
termine the cause of this imbalance when assessing this patient? of gastrointestinal fluids, which can result from vomiting, diarrhea,
1) Genitourinary suctioning, intestinal fistulas, or intestinal drainage. Other causes
2) Cardiovascular of fluid losses include chronic abuse of laxatives and/or enemas.
3/5
3) Gastrointestinal
4) Musculoskeletal
The nurse is instructing a patient with heart failure about a pre-
scribed sodium-restricted diet. Which patient statement indicates
that additional teaching is required?
ANS: 1
1) "I can use as much salt substitute as I want."
Low-sodium salt substitutes are not really sodium-free. They may
2) "I have to read the labels on foods to find out the sodium
contain half as much sodium as regular salt. The patient should
content."
be instructed to use salt substitutes sparingly because larger
3) "I have to limit the intake of food with baking soda or baking
amounts often taste bitter instead of salty.
powder."
4) "I can use spices and lemon juice to add flavor to food when
cooking."
The nurse is planning care for the patient with acute renal failure.
The nurse plans the patient's care based on the nursing diagnosis
of Excess Fluid Volume. Which assessment data supports this
ANS: 4
nursing diagnosis?
The patient in acute renal failure will likely be edematous, as the
1) Wheezing in the lungs
kidneys are not producing urine.
2) Generalized weakness
3) Bowel sounds positive in four quadrants
4) Pitting edema in the lower extremities
A patient with acute renal failure has jugular vein distention, lower
extremity edema, and elevated blood pressure. Based on this
ANS: 2
data, which nursing diagnosis is the most appropriate?
Jugular vein distention, edema, and elevated blood pressure are
1) Risk for Infection
indications of excessive fluid. The diagnosis Excess Fluid Volume
2) Excess Fluid Volume
should be selected to guide this patient's care.
3) Ineffective Renal Tissue Perfusion
4) Risk for Altered Cardiac Perfusion
The nurse is caring for a patient admitted with hypertension and
chronic renal failure who receives hemodialysis three times per
week. The nurse is assessing the patient's diet and notes the
ANS: 1
use of salt substitutes. When teaching the patient to avoid salt
Many salt substitutes use potassium chloride. Potassium intake is
substitute, which rationale supports this teaching point?
carefully regulated in patients with renal failure, and the use of salt
1) They can potentiate hyperkalemia.
substitutes will worsen hyperkalemia.
2) They will cause the client to retain fluid.
3) They will increase the risk of AV fistula infection.
4) They will interact with the client's antihypertensive medications.
The nurse is providing care to a patient who is exhibiting clinical ANS: 3, 4, 5
manifestations of a fluid and electrolyte deficit. Based on this data, 3. This is correct. Hypodermoclysis, fluid administered subcuta-
which health-care provider prescriptions does the nurse prepare neously, may be employed as a fluid delivery method, especially
to implement? Select all that apply. among older adults.
1) Administer diuretics 4. This is correct. Monitoring patient's intake and output is one of
2) Administer antibiotics several ways to assess the patient's fluid status.
3) Initiate hypodermoclysis 5. This is correct. Intravenous fluids may be ordered for the patient
4) Closely monitor patient's I&O's with a fluid volume deficit if replacement oral fluids cannot be taken
5) Initiate intravenous therapy in sufficient quantity.
A patient's serum sodium level is 150 mg/dL. Based on this data,
which interventions should the nurse plan for this patient? Select
ANS: 2, 4
all that apply.
2. This is correct. For an elevated sodium level, the electrolyte will
1) Elevate the head of the bed.
need to be restricted, in the form of a low-sodium diet.
2) Instruct on a low-sodium diet.
4. This is correct. Diuretics will remove excess fluid being held in
3) Monitor heart rate and rhythm.
the body because of the extra sodium.
4) Administer diuretics as prescribed.
5) Administer potassium supplement as prescribed.
ANS: 2, 3, 4
The school nurse is preparing a class session for high school
2. This is correct. Actions to prevent fluid volume deficit during the
students on ways to maintain fluid balance during the summer
summer months include increasing fluid intake, drinking flat cola
months. Which interventions should the nurse recommend Select
or ginger ale if vomiting, and reducing the intake of coffee and tea.
all that apply.
3. This is correct. Actions to prevent fluid volume deficit during the
1) Drink diet soda.
summer months include increasing fluid intake, drinking flat cola
2) Reduce the intake of coffee and tea.
or ginger ale if vomiting, and reducing the intake of coffee and tea.
4/5
3) Drink more fluids during hot weather. 4. This is correct. Actions to prevent fluid volume deficit during the
4) Drink flat cola or ginger ale if vomiting. summer months include increasing fluid intake, drinking flat cola
5) Exercise during the hours of 10 am and 2 pm. or ginger ale if vomiting, and reducing the intake of coffee and tea.
ANS: 1, 2, 5
1. This is correct. Older adults develop acute renal failure more
frequently because of the higher incidence of serious illnesses,
hypotension, major surgeries, diagnostic procedures, and treat-
ment with nephrotoxic drugs. Decreased kidney function associ-
ated with aging also puts the older patient at risk for kidney fail-
ure. Hypotension, scheduled for aortic valve replacement surgery,
and receiving high doses of intravenous antibiotics increase this
patient's risk for developing acute renal failure.
The nurse is concerned that an older adult patient is at risk for
developing acute renal failure. Which information in the patient's
history support the nurse's concern? Select all that apply.
1) Diagnosed with hypotension
2) Recent aortic valve replacement surgery
3) Total hip replacement surgery five years ago
4) Taking medication for type 2 diabetes mellitus
5) Prescribed high doses of intravenous antibiotics
ANS: 1, 3, 5
1. This is correct. Pediatric manifestations of acute renal failure
characteristically begin with a healthy child who suddenly be-
comes ill with nonspecific symptoms that indicate a significant
illness or injury. These symptoms may include any combination of
The community nurse visits the home of a young child who is
the following: nausea, vomiting, lethargy, edema, gross hematuria,
home from school because of sudden onset of nausea, vomiting,
oliguria, and hypertension.
and lethargy. The nurse suspects acute renal failure. Which clinical
manifestations support the nurse's suspicions? Select all that
apply.
1) Edema
2) Wheezing
3) Hematuria
4) Postural hypotension
5) Elevated blood pressure
5/5

30 Items Fluid and Electrolytes Medsurg

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Med Surg Ch 8 Fluid and Electrolyte Management

Study online at https://quizlet.com/_8gmc7z

A patient is admitted to the emergency department (ED) for fluid ANS: 3

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