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NUR 168: CHAPTER 40: FLUID, ELECTROLYTE, ACID-BASE BALANCE: QUESTIONS WITH COMPLETE SOLUTIONS
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NUR 168: CHAPTER 40: FLUID, ELECTROLYTE, ACID-BASE BALANCE: QUESTIONS WITH COMPLETE SOLUTIONS
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NUR 168: CHAPTER 40: FLUID, ELECTROLYTE, ACID-BASE BALANCE: QUESTIONS WITH COMPLETE
SOLUTIONS
1. A nurse is caring for an older adult with type 2 diabetes who
is living in a long-term care facility. The nurse determines that
the patient's fluid intake and output is approximately 1,200 mL
daily. What patient teaching would the nurse provide for this
patient? Select all that apply.
A) "Try to drink at least six to eight glasses of water each day."
B) "Try to limit your fluid intake to 1 quart of water daily."
C) "Limit sugar, salt, and alcohol in your diet."
D) "Report side effects of medications you are taking, especially
diarrhea."
E) "Temporarily increase foods containing caffeine for their
diuretic effect."
F) "Weigh yourself daily and report any changes in your
weight." Correct Answers A) "Try to drink at least six to eight
glasses of water each day."
C) "Limit sugar, salt, and alcohol in your diet."
D) "Report side effects of medications you are taking, especially
diarrhea."
F) "Weigh yourself daily and report any changes in your
weight."
10. A nurse is monitoring a patient who is diagnosed with
hypokalemia. Which nursing intervention would be appropriate
for this patient?
A) Encourage foods and fluids with high sodium content.
B) Administer oral K supplements as ordered.
,C) Caution the patient about eating foods high in potassium
content.
D) Discuss calcium-losing aspects of nicotine and alcohol use.
Correct Answers B) Administer oral K supplements as ordered.
12. A nurse is initiating a peripheral venous access IV infusion
for a patient. Following the procedure, the nurse observes that
the fluid does not flow easily into the vein and the skin around
the insertion site is edematous and cool to the touch. What
would be the nurse's next action related to these findings?
A)Reposition the extremity and raise the height of the IV pole.
B) Apply pressure to the dressing on the IV.
C) Pull the catheter out slightly and reinsert it.
D) Put on gloves; remove the catheter Correct Answers D) Put
on gloves; remove the catheter
13. When monitoring an IV site and infusion, a nurse notes pain
at the access site with erythema and edema. What grade of
phlebitis would the nurse document?
A) 1
B) 2
C) 3
D) 4 Correct Answers B) 2
14. A nurse is administering a blood transfusion for a patient
following surgery. During the transfusion, the patient displays
signs of dyspnea, dry cough, and pulmonary edema. What would
be the nurse's priority actions related to these symptoms?
A) Slow or stop the infusion; monitor vital signs, notify the
health care provider, place the patient in upright position with
feet dependent.
,B) Stop the transfusion immediately and keep the vein open with
normal saline, notify the health care provider stat, administer
antihistamine parenterally as needed.
C) Stop the transfusion immediately and keep the vein open with
normal saline, notify the health care provider, and treat
symptoms.
D) Stop the infusion immediately, obtain a culture of the
patient's blood, monitor vital signs, notify the health care
provider, administer antibiotics stat. Correct Answers A) Slow
or stop the infusion; monitor vital signs, notify the health care
provider, place the patient in upright position with feet
dependent.
15. A nurse is performing physical assessments for patients with
fluid imbalance. Which finding indicates a fluid volume excess?
A) A pinched and drawn facial expression
B) Deep, rapid respirations.
C) Moist crackles heard upon auscultation
D) Tachycardia Correct Answers C) Moist crackles heard upon
auscultation
2. A nurse is performing a physical assessment of a patient who
is experiencing fluid volume excess. Upon examination of the
patient's legs, the nurse documents: "Pitting edema; 6-mm pit;
pit remains several seconds after pressing with obvious skin
swelling." What grade of edema has this nurse documented?
A) 1+ pitting edema
B) 2+ pitting edema
C) 3+ pitting edema
D) 4+ pitting edema Correct Answers C) 3+ pitting edema
, 3. A nurse is preparing an IV solution for a patient who has
hypernatremia. Which solutions are the best choices for this
condition? Select all that apply.
A) 5% dextrose in 0.9% NaCl
B) 0.9% NaCl (normal saline)
C) Lactated Ringer's solution
D) 0.33% NaCl (⅓-strength normal saline)
E) 0.45% NaCl (½-strength normal saline)
F) 5% dextrose in Lactated Ringer's solution Correct Answers
D) 0.33% NaCl (⅓-strength normal saline)
E) 0.45% NaCl (½-strength normal saline)
4. A nurse is assessing infants in the NICU for fluid balance
status. Which nursing action would the nurse depend on as the
most reliable indicator of a patient's fluid balance status?
A) Recording intake and output.
B) Testing skin turgor.
C) Reviewing the complete blood count.
D) Measuring weight daily. Correct Answers D) Measuring
weight daily.
5. Which acid-base imbalance would the nurse suspect after
assessing the following arterial blood gas values: pH, 7.30;
PaCO2, 36 mm Hg; HCO3−, 14 mEq/L?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Metabolic acidosis
D) Metabolic alkalosis Correct Answers C) Metabolic acidosis
6. A patient has been encouraged to increase fluid intake. Which
measure would be most effective for the nurse to implement?
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