and acid base imbalances questions and answers with rationales
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Medical Surgical Nursing: Fluid, Electrolyte, and
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Medical Surgical Nursing: Fluid, Electrolyte, and Acid-Base Imbalances
- Questions And Answers With Rationales
A patient asks why the primary health care provider prescribed a b-type natriuretic peptide
(BNP). Which response by the nurse is accurate?
1
It is a diagnostic procedure to rule out urine retention.
2
It is a blood test that is elevated in patients with hyponatremia.
3
It is a blood test that shows if there is excess fluid in the heart.
4
It is an x-ray that helps determine the presence of stomach ulcers
Correct Ans:- 3
BNP is a hormone that is produced when the atrial pressure increases. This blood test is used to
diagnose the severity and treatment outcomes of congestive heart failure (CHF). The atrial
pressure increases because of increased venous return and hypernatremia. The test gives no
information to rule out urine retention or the presence of stomach ulcers. A serum sodium level
is needed to determine hyponatremia.
Text Reference - p. 290
A nurse is caring for a patient who reports diarrhea and vomiting for the past five days. As a
result, the patient has developed severe hypokalemia. The primary health care provider
prescribes IV potassium chloride (KCl) treatment. How can the nurse ensure the safety of the
patient when administering IV KCl? Select all that apply.
1
Continuously monitor cardiac function
2
Check hourly for the presence of phlebitis at the IV site
3
Monitor the urine output
4
Assess for signs of tetany
5
Assess for laryngeal spasms
Correct Ans:- 1, 2, 3
IV potassium chloride (KCl) is administered to treat hypokalemia. IV administration of KCl may
cause rapid changes in potassium levels, which may adversely affect the heart. Therefore, the
patient should be under continuous cardiac monitoring. KCl is an irritant and may cause phlebitis
and infiltration, leading to necrosis and sloughing. So the nurse should frequently check the IV
site for phlebitis and infiltration. KCl is administered when the urine output is at least 0.5 mL/kg
of body weight per hour. The urine output should hence be monitored to check for its adequacy.
Tetany and laryngeal spasms occur when there are low levels of calcium. They are not related to
potassium levels.
,Text Reference - p. 298
The nurse is caring for a patient diagnosed with heat stroke and with a urine output of 4000 mL
per day. What is the most appropriate nursing action?
1
Transfusing blood
2
Applying moisturizer regularly
3
Administrating lactated Ringer's solution
4
Administrating supplementary water in enteric formula
Correct Ans:- 3
Heat stroke and an increased amount of urine output of about 4000 mL leads to a deficit in
extracellular fluid volume, causing dehydration. Administering lactated Ringer's solution to
maintain fluid and electrolyte balance is beneficial. Blood transfusions are performed only when
the fluid loss is due to blood loss. Moisturizers are applied to patients with dry skin to prevent
the fluid loss. Tube feeding is preferred in the patient with severe extracellular fluid loss. The
patient on tube feeding must be thereby supplemented with water added to the enteric formula.
Text Reference - p. 291
On assessment, the nurse finds that a patient has a headache, increased blood pressure, peripheral
edema, dyspnea, and jugular venous distention. The symptoms indicate excess fluid volume.
Which causes of excess fluid volume might the nurse find in the patient? Select all that apply.
1
Heart failure
2
Hemorrhage
3
Diabetic insipidus
4
Long-term use of corticosteroids
5
Syndrome of inappropriate antidiuretic hormone (SIADH
Correct Ans:- 1, 4, 5
Excess volume of fluid can accumulate in illnesses such as heart failure and SIADH, or due to
long-term use of corticosteroids. In heart failure, the heart is unable to pump adequate blood to
the body, resulting in pooling of blood in the periphery. In SIADH, abnormal levels of ADH
cause reabsorption of water from the kidneys, leading to water retention in the body. Long-term
use of corticosteroids causes altered homeostatic regulation of sodium and water, resulting in
excess fluid volume. Hemorrhage and diabetic insipidus cause a deficit in fluid volume.
Text Reference - p. 292
,A nurse is teaching the nursing assistants the importance of performing accurate weighings.
Which content should be included? Select all that apply.
1
Calibrate the scale before using
2
Weigh patient with same garments each day
3
Weigh the patient at the same time each day
4
Empty the Foley catheter after weight obtained
5
Teach the patient the importance of daily weighings
6
If bed scale used, weigh with same number of linens on the bed
Correct Ans:- 1, 2, 3, 6
In many settings the nursing assistant weighs the patient. Accurate weighings help determine
medical treatment. It is essential to teach these health care providers the importance of
calibrating the scale before using, weighing the patients with the same garments and at the same
time each day, and if using a bed scale, documenting and weighing with the same number of
linens and pillows on the bed. The drains, including the Foley catheter, should be drained before
weighing. If the patient does not have an indwelling catheter, the weight should be obtained after
the patient voids. Teaching the patient the importance of weighing daily is a nurse function and
should not be delegated to the nursing assistant.
Text Reference - p. 292
A patient has been admitted for dehydration. What is a priority nursing intervention?
1
Reorient the patient hourly
2
Perform daily weights
3
Provide continuous oxygen saturation monitoring
4
Restrict sodium intake to 2 grams per day
Correct Ans:- 2
Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss
would indicate that the dehydration is worsening, whereas weight gain would indicate restoration
of fluid volume. The nurse would recall that a 1-kg weight gain indicates a gain of approximately
1000 mL of body water. This patient is not disoriented, and that is not a common assessment
finding in the patient with dehydration. Continuous oxygen saturation monitoring is not
indicated. Sodium intake does not need to be restricted.
Text Reference - p. 292
, The nurse is caring for a 92-year-old patient who has dehydration. The nurse would instruct the
unlicensed assistive personnel (UAP) to report which finding?
1
Ambulation in the hallway without assistance
2
Temperature 97.1o F
3
Frequent use of the urinal
4
Urine output of 350 mL in 24 hours
Correct Ans:- 4
The minimal urine output necessary to maintain kidney function is 30 mLs per hour, or 720 mL
per 24 hours. The nurse should be notified of a decrease in urine output so that additional fluid
volume-replacement therapy can be instituted. Ambulation is encouraged. The temperature is
normal. Frequent use of the urinal would not indicate dehydration. Text Reference - p. 292
A 71-year-old patient is admitted with nausea and vomiting. Which manifestations would the
nurse assess to check for the presence of dehydration? Select all that apply.
1
Hypertension
2
Bradypnea
3
Urine output 10 mL/hr
4
Tachycardia
5
Sunken eyes
Correct Ans:- 3, 4, 5
Decreased urine output below 30 mL/hour, tachycardia, and sunken eyes are all signs of
dehydration. Dehydration will cause hypotension and would increase, not decrease, respiratory
rate.
Text Reference - p. 292
A patient is diagnosed with Cushing syndrome. What manifestation does the nurse anticipate
while assessing this patient?
1
Dyspnea
2
Dry mouth
3
Weight loss
4
Restlessness
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