Question 1

The nurse is planning care for a patient with a fluid volume excess and a serum sodium level of 125 mg/dL.Which interventions should the nurse include in this patient's plan of care? (Select all that apply.)

Accepted Answer

A)  Weigh daily. 
B)  Monitor strict intake and output. 
C)  Administer diuretics as prescribed. 
D)  Implement fluid restriction as prescribed. 
E)  Administer IV saline as prescribed.

Question 2

An older adult with gastroenteritis is disoriented and weak and has the following laboratory test results:
Hct 56% (normal 40% to 51%)
BUN 32 mg/dL (normal 6 mg/dL to 20 mg/dL)
Which nursing diagnosis should the nurse select for this patient?

Accepted Answer

A)  Risk for injury 
B)  Excess fluid volume 
C)  Deficient fluid volume 
D)  Impaired skin integrity

Question 3

A patient has a history of low calcium levels.Which foods should the nurse include when teaching a patient how to increase dietary calcium? (Select all that apply.)

Accepted Answer

A)  Milk 
B)  Carrots 
C)  Spinach 
D)  Oatmeal 
E)  Peaches
F) Cauliflower

Question 4

A patient is prescribed an electrolyte replacement.How should the nurse explain the purpose of an electrolyte to the patient?

Accepted Answer

A)  Any substance that enhances a chemical reaction 
B)  A chemical that can conduct electricity when dissolved in water 
C)  A substance that uses electrical current to attach to receptor sites 
D)  A substance secreted by a gland and carries messages to target tissues

Question 5

A patient having a severe anxiety attack has an arterial blood gas result showing respiratory alkalosis.Which nursing action should the nurse take first?

Accepted Answer

A)  Administer nasal oxygen at 6 L/min. 
B)  Give the patient a glass of orange juice. 
C)  Place the patient in high Fowler's position. 
D)  Have the patient rebreathe air from a paper bag.

Question 6

A patient with acute abdominal pain has a serum potassium level of 2 mEq/L.What should the nurse do first?

Accepted Answer

A)  Call the physician STAT. 
B)  Administer a Kayexalate enema. 
C)  Document the result on the chart. 
D)  Notify the physician during morning rounds.

Question 7

A student nurse is reviewing the use of intravenous (IV)fluids for a school paper.Which definition should the student use to explain the process of diffusion?

Accepted Answer

A)  The expenditure of energy to transport a solute 
B)  The movement of solute and water caused by hydrostatic pressure differences 
C)  Movement of a solute from an area of higher concentration to an area of lesser concentration 
D)  Movement of water from an area of lesser concentration to an area of higher concentration

Question 8

The nurse is preparing diet teaching for a female patient who is postmenopausal,weighs 100 lbs.and is 5 feet 1 inch tall.Which food should the nurse encourage the patient consume?

Accepted Answer

A)  Red meat 
B)  Fresh fruits 
C)  Whole grains 
D)  Dairy products

Question 9

The nurse suspects a patient is experiencing fluid volume excess.What did the nurse most likely assess in this patient? (Select all that apply.)

Accepted Answer

A)  Thirst 
B)  Bounding pulse 
C)  Shallow respirations 
D)  Distended neck veins 
E)  Pitting edema of the feet

Question 10

A patient has been prescribed furosemide (Lasix).Which foods should the nurse recommend the patient consume while taking this medication?

Accepted Answer

A)  Eggs and broths 
B)  Potatoes and fruits 
C)  Breads and cereals 
D)  Pasta and cream soups

Question 11

While assessing an older adult patient with fluid excess,the nurse notes the following: T = 98.6°F,P = 92,R = 18,BP = 166/88 mm Hg,bilateral crackles,oxygen saturation = 95%.Which action should the nurse take first?

Accepted Answer

A)  Provide oxygen at 2 L per nasal cannula. 
B)  Place the patient in a high Fowler's position. 
C)  Provide a urinal and encourage the patient to void. 
D)  Lay the patient flat in bed to listen to bowel sounds.

Question 12

The nurse is caring for a patient who is being treating for fluid volume excess.Which assessment finding indicates that treatment has been effective?

Accepted Answer

A)  Respiratory rate 24/min 
B)  Output 1500 mL in 24 hours 
C)  Blood pressure 132/80 mm Hg 
D)  Weight loss of 5 lb in 24 hours

Question 13

A patient with hypertension is advised to follow a low-sodium diet.If chosen by the patient,which foods indicate further teaching is necessary? (Select all that apply.)

Accepted Answer

A)  Coffee 
B)  Pretzels 
C)  Lemonade 
D)  Applesauce 
E)  Tomato juice
F) Dried black beans

Question 14

A patient is diagnosed with an abnormal potassium level.Which complication should the nurse assess for in this patient?

Accepted Answer

A)  Cardiac arrest 
B)  Fluid overload 
C)  Internal bleeding 
D)  Tetany with laryngospasm

Question 15

The nurse instructs a patient on how to safely take 20 mEq of an oral potassium supplement.Which patient statement indicates that teaching has been successful?

Accepted Answer

A)  "I should crush the potassium tablets." 
B)  "I should mix this medication in 4 ounces of juice." 
C)  "I should use a salt substitute while taking this medication." 
D)  "I should expect to be nauseated and vomit when taking this medication."

Question 16

During an assessment,the nurse learns that an older patient has been taking twice the prescribed amount of calcium supplements.Which physical assessment findings should the nurse identify as being consistent with this patient's intake of calcium? (Select all that apply.)

Accepted Answer

A)  Muscle weakness 
B)  Faint bowel sounds 
C)  Increased heart rate 
D)  Elevated blood pressure 
E)  Dry mucous membranes

Exam 6: Nursing Care of Patients With Fluid,Electrolyte,and Acid–Base Imbalances