Question 1

When a nurse is selecting a vein for IV placement,what is the most appropriate action?

Accepted Answer

A)   Select a vein that appears to be well dilated.
B)   Elevate the extremity to visualize the vein.
C)   Tap and rub the vein vigorously with friction.
D)   Stroke from proximal to distal above the site. A

Question 2

A patient complains of chills,dizziness,and feeling hot during a blood transfusion.What are the nurse's most appropriate actions? (Select all that apply.)

Accepted Answer

A)   Check the patient's vital signs.
B)   Stop the blood transfusion.
C)   Slow the rate of infusion.
D)   Notify the physician and blood bank. A,B,D

Question 3

A patient's arterial blood gas levels indicate a pH of 7.51,PaCO? of 40 mm Hg,PaO? of 85 mm Hg,and HCO? of 32 mEq/L.The patient has been vomiting.The nurse knows the patient has which imbalance?

Accepted Answer

A)   Metabolic acidosis
B)   Metabolic alkalosis
C)   Respiratory acidosis
D)   Respiratory alkalosis B

Question 4

A patient has a peripheral IV.The nurse should assess the IV site for what primary signs and symptoms of infiltration? (Select all that apply.)

Accepted Answer

A)   Redness
B)   Swelling
C)   Pallor
D)   Warmth
E)   Red streaks

Question 5

A patient presents to the emergency department complaining of increased urine output.The patient has been drinking alcohol and is still visibly impaired.He is aware of his condition and apologizes,stating that he has never gotten drunk before and if he survives he never will again,but he knows that if he drinks too much he will lose potassium and die.The nurse realizes that the patient is dealing with:

Accepted Answer

A)   antidiuretic hormone (ADH)  suppression.
B)   ADH stimulation.
C)   insensible water loss.
D)   angiotensin II release.

Question 6

A nurse is caring for a patient who is suffering from kidney failure and is receiving peritoneal dialysis.The nurse explains that peritoneal dialysis works by instilling a solution into the abdomen that contains dextrose that will pull extra fluid into the abdominal cavity.What is the name of this process?

Accepted Answer

A)   Diffusion
B)   Osmosis
C)   Filtration
D)   Active transport

Question 7

A patient has been admitted to the postsurgical nursing unit after surgery.The health care provider has ordered the patient to have an IV of 0.9% sodium chloride.The nurse who is caring for the patient recognizes this as what type of solution?

Accepted Answer

A)   Hypotonic
B)   Isotonic
C)   Hypertonic
D)   Hypnotic

Question 8

A patient has heart failure.The patient's medications include an angiotensin-converting enzyme (ACE)inhibitor,a beta blocker,and a diuretic.To keep the patient safe,the nurse should:

Accepted Answer

A)   weigh the patient daily using different scales for comparison.
B)   monitor daily weight, comparing with the previous day's weight.
C)   teach that daily weights are done in hospitals, but not at home.
D)   weigh the patient at different times of the day to determine trends.

Question 9

During a clinical rotation at an orthopedic unit,a nursing student is caring for a 67-year-old patient who has undergone a knee replacement.The patient is complaining of pain at the IV site.The nursing student assesses the site and finds that the site is cool and pale.The student stops the IV and reports the situation to the nurse.What does the nursing student suspect?

Accepted Answer

A)   Phlebitis
B)   Infiltration
C)   Thrombophlebitis
D)   Local inflammation

Question 10

Which measurement can the nurse delegate to nursing assistive personnel?

Accepted Answer

A)   Oral fluid intake
B)   Intravenous fluid intake
C)   Tube drainage output
D)   Nasogastric tube intake

Question 11

The patient is taking furosemide (Lasix)and has been complaining of muscle weakness.The nurse should be most concerned about which imbalance?

Accepted Answer

A)   Hyponatremia
B)   Hypokalemia
C)   Hypochloremia
D)   Hyperchloremia

Question 12

A patient has recently been diagnosed with heart failure and has been put on a low sodium diet in the hospital.In addition,the patient has a fluid restriction.The nurse should suggest that half the total oral fluid allotment occur between which two times?

Accepted Answer

A)   7 AM; 7 PM
B)   3 AM; 3 PM
C)   7 AM; 3 PM
D)   3 PM; 7 AM

Question 13

The body's fluid and electrolyte balance is maintained partially by hormonal regulation.The nurse conveys an understanding of this mechanism in which statement?

Accepted Answer

A)   "The pituitary gland secretes aldosterone."
B)   "The kidney secretes antidiuretic hormone."
C)   "The adrenal cortex secretes antidiuretic hormone."
D)   "The pituitary gland secretes antidiuretic hormone."

Question 14

The nurse suspects that the patient is experiencing a blood transfusion reaction.The nurse stops the infusion but is concerned about losing the IV line if blood clots in the catheter.The nurse should:

Accepted Answer

A)   replace the entire transfusion line with a new set primed with normal saline.
B)   turn off the blood and turn on the normal saline infusion to flush the tubing.
C)   discontinue the IV and start a new IV of lactated Ringer's in the other extremity.
D)   maintain the patency of the current IV line by hanging a new IV bag of D5W.

Question 15

A nurse is caring for a patient after a bowel resection.The nurse plans assessment based on the knowledge that body fluids maintain balance through homeostasis,which includes what processes? (Select all that apply.)

Accepted Answer

A)   Fluid intake
B)   Fluid distribution
C)   Fluid output
D)   Fluid catabolism

Question 16

A 27-year-old patient has seen a health care provider at the local clinic because he has had diarrhea for the past week.The health care provider instructed the patient to drink plenty of fluids,and the nurse clarifies these instructions by advising him to avoid which item as long as he has diarrhea?

Accepted Answer

A)   Ice chips
B)   Pedialyte
C)   Coffee
D)   Tap water

Question 17

The patient is unable to eat and there are no bowel sounds,indicating that his bowels are not functioning.The best approach to providing nourishment would be:

Accepted Answer

A)   intravenous crystalloids.
B)   blood product administration.
C)   parenteral nutrition (PN) .
D)   colloid administration.

Question 18

The nurse is working for a medical unit in a hospital.The nurse is responsible for obtaining intake and output measurements for patients.What items should be considered intake? (Select all that apply.)

Accepted Answer

A)   Gelatin eaten as a snack or for lunch or dinner
B)   Water used to flush tubing between jejunostomy feedings
C)   Amount of fluid contained in the gastric suction container
D)   Volume of the blood components that were given IV
E)   Volume of the postsurgical wound drainage

Question 19

A patient is diagnosed with renal insufficiency.The results of an ABG analysis indicate metabolic acidosis.In metabolic acidosis,the nurse would expect the pH to decrease to less than _____ and the bicarbonate level to decrease to less than _____.

Accepted Answer

The answer of A patient is diagnosed with renal insufficiency.The...

Question 20

The patient is on a ventilator.The health care provider has indicated concern about the patient's acid-base status.The nurse anticipates that the health care provider will determine the acid-base levels via:

Accepted Answer

A)   PaO2 measurement.
B)   SaO2 levels.
C)   chloride levels.
D)   arterial blood gas analysis.

Exam 18: Fluid,Electrolyte,and Acid-Base Balances