Question 1

The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis hypervolemia in the patient's care plan. Which goal statement has the highest priority for the patient and nurse?

Accepted Answer

A)   The patient's lung sounds will remain clear.
B)   The patient will have urine output of at least 30 mL/hr.
C)   The patient will verbalize understanding of fluid restrictions.
D)   The patient's pitting pedal edema will resolve within 72 hours. A

Question 2

The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform?

Accepted Answer

A)   Perform regular neurologic checks and institute seizure precautions.
B)   Encourage the patient to eat foods that are high in sodium.
C)   Administer hypotonic IV solutions as ordered by the physician.
D)   Assess for signs and symptoms of digoxin (Lanoxin)  toxicity. A

Question 3

The nurse is caring for a patient who is receiving a blood transfusion. Fifteen minutes into the transfusion, the patient's blood pressure decreases significantly, and the patient complains of a severe headache. What is the priority action of the nurse?

Accepted Answer

A)   Check the patient's temperature and administer acetaminophen (Tylenol)  if higher than 101 °F.
B)   Recheck the patient's blood pressure in 15 minutes after administering pain medication.
C)   Stop the blood transfusion and administer 0.9% normal saline through new IV tubing.
D)   Double-check that the transfusion blood type is an exact match to the patient. C

Question 4

The nurse is caring for a patient who is at risk for fluid overload due to a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?

Accepted Answer

A)   "Check to make sure that your urine is a bright yellow color."
B)   "Weigh yourself every morning before breakfast."
C)   "Count your heart rate every evening before you go to bed."
D)   "Drink plain water rather than soda, coffee, or fruit juice."

Question 5

The nurse is reviewing the patient's laboratory results. Which result must be communicated to the physician immediately?

Accepted Answer

A)   Serum chloride level 85 mEq/L
B)   Serum sodium level 134 mEq/L
C)   Serum potassium level 6.8 mEq/L
D)   Serum magnesium level 2.3 mEq/L

Question 6

The nurse is caring for a patient who has a serum magnesium level of 0.8 mEqL. Which is the highest priority goal to include in the patient's plan of care?

Accepted Answer

A)   The patient will maintain urine output of at least 30 mL/hr.
B)   The patient will verbalize the importance of sufficient dietary intake of magnesium.
C)   The patient's oral mucous membranes will remain free of ulceration and pain.
D)   The patient will remain alert and oriented  ×	imes×  3 with no confusion or seizure activity.

Question 7

The nurse is caring for a patient with renal failure who has a serum potassium level of 7.1 mEq/L and serum magnesium level of 3.5 mEq/L. The nurse prepares to administer 10 units of insulin and an ampule of 50% dextrose to the patient. The patient asks why he will be receiving insulin when he is not diabetic. What is the nurse's best answer?

Accepted Answer

A)   "The doctor has prescribed these medications for you to help heal your kidneys."
B)   "These medications will lower your potassium level and prevent an irregular heart rate."
C)   "These medications will prevent you from having a seizure from too little magnesium."
D)   "These medications will increase your urine output until your kidneys recover."

Question 8

The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur due to this therapy?

Accepted Answer

A)   Hypocalcemia
B)   Hypernatremia
C)   Hypokalemia
D)   Hyperphosphatemia

Question 9

The nurse is caring for a patient who is to receive dopamine (Intropin) through the IV line. Which intervention has the highest priority when administering this medication?

Accepted Answer

A)   Check for IV blood return prior to administration.
B)   Use a new IV tubing set each time the medication is administered.
C)   Document the date, time, and nurse's initials after each dose is administered.
D)   Use sterile gloves when drawing up and administering the medication.

Question 10

The nurse is caring for a patient who is very dehydrated. Which goal best indicates that dehydration has been corrected and that the patient's fluid balance has been restored?

Accepted Answer

A)   The patient had 1300 mL of light yellow urine in the last 24 hours.
B)   The patient's lung sounds are clear bilaterally.
C)   The patient has no jugular venous distention.
D)   The patient verbalizes need for adequate daily fluid intake.

Question 11

The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient to correct the patient's fluid imbalance?

Accepted Answer

A)   0.33% normal saline
B)   0.45% normal saline
C)   0.9% normal saline
D)   3% normal saline

Question 12

The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) to prevent fluid overload and pulmonary edema. The patient admits to stopping the medication due to nocturia. What is the nurse's best response?

Accepted Answer

A)   "You should ask your doctor to decrease the dose."
B)   "Take the diuretic early in the morning before breakfast."
C)   "Eat foods high in potassium and limit your salt intake."
D)   "Restrict your fluid intake after dinner and in the evening."

Question 13

The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus doses of furosemide (Lasix) to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert to administer the patient's medication?

Accepted Answer

A)   Peripherally inserted central catheter
B)   Midline inside-the-needle catheter
C)   Central venous catheter
D)   Over-the-needle catheter

Question 14

The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient's body to correct the pH?

Accepted Answer

A)   The patient's respirations are very deep and rapid.
B)   The patient's urine is dark and concentrated.
C)   The patient's skin is pale, cool, and diaphoretic.
D)   The patient is sleepy and difficult to arouse.

Question 15

The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is the nurse's best action?

Accepted Answer

A)   Discontinue the IV and start another line in the other arm.
B)   Aspirate to check for blood return and flush the IV with sterile saline.
C)   Clean the IV site with chlorhexidine and apply a new sterile dressing.
D)   Change the IV tubing and administer prescribed pain medication.

Question 16

The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. The nurse knows which condition to be the most likely cause of the patient's collapse?

Accepted Answer

A)   Orthostatic hypotension
B)   Circulatory overload
C)   Hemolytic reaction
D)   Catheter embolism

Question 17

The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of the three meals and had another 150 mL with medication administration. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume to stay within the prescribed fluid restriction?

Accepted Answer

A)   100 mL
B)   150 mL
C)   250 mL
D)   300 mL

Question 18

The nurse is caring for a patient who was brought to the ED after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient's arrival to the hospital. Which results will the nurse expect to see?

Accepted Answer

A)   pH 7.56, PaCO2 32 mm Hg, HCO3 32 mEq/L, PaO2 90 mm Hg
B)   pH 7.35, PaCO2 45 mm Hg, HCO3 26 mEq/L, PaO2 70 mm Hg
C)   pH 7.45, PaCO2 38 mm Hg, HCO3 28 mEq/L, PaO2 80 mm Hg
D)   pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg

Question 19

The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient's albumin level is critically low. What assessment finding will the nurse expect to note when assessing the patient?

Accepted Answer

A)   The patient has generalized 3+ pitting edema.
B)   The patient is confused and disoriented.
C)   The patient's urine is dark and very concentrated.
D)   The patient lung sounds are very diminished.

Question 20

The nurse is caring for a hospitalized patient with hyperparathyroid disease and a serum calcium level of 14.2 mg/dL. What is the priority intervention of the nurse?

Accepted Answer

A)   Instruct the patient to always call for assistance before getting out of bed.
B)   Assist the patient to change into dry clothing after episodes of diaphoresis.
C)   Teach stress-relieving techniques, including progressive muscle relaxation.
D)   Notify the provider if urine output is less than 30 mL/hr.

Exam 39: Fluid, Electrolytes, and Acid-Base Balance