Exam (elaborations)
Chapter 39 Fluid, Electrolytes, and Acid-Base Balance
- Course
- Fundamentals of Nursing
- Institution
- Oxford College Of Emory University
Chapter 39 Fluid, Electrolytes, and Acid-Base Balance
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DAWITChapter 39: Fluid, Electrolytes, and Acid-Base Balance
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 3RD Edition
MULTIPLE CHOICE
1. 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?
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.
ANS: A
The patient‘s low albumin level will lead to generalized pitting edema because there isn‘t
enough protein in the blood to keep water within the bloodstream. Lack of oncotic pressure
from low serum albumin leads to edema. The other findings are not related to malnutrition.
DIF: Understanding OBJ: 39.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Fluid and Electrolyte Balance
2. The nurse is reviewing the patient‘s laboratory results. Which result must be communicated to
the physician immediately?
a. Serum chloride level 85 mEq/L
N R I G B.C M
b. Serum sodium level 134 mU S N T
Eq/L O
c. Serum potassium level 6.8 mEq/L
d. Serum magnesium level 2.3 mEq/L
ANS: C
Normal serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 6.8 mEq/L is
very high and puts the patient at risk for cardiac arrhythmias. The potassium level should be
reported to the physician immediately. The chlorine and sodium levels are slightly low and the
magnesium level is slightly elevated.
DIF: Understanding OBJ: 39.2 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Fluid and Electrolyte Balance
3. 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?
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.‖
ANS: B
, DAWIT
Checking the weight every morning before breakfast is a sensitive indicator of the patient‘s
fluid volume status. Weight gain of 2 kg in 3 days generally indicates fluid retention and
should be reported to the physician.
DIF: Understanding OBJ: 39.6 TOP: Teaching/Learning
MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
NOT: Concepts: Patient Education
4. 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?
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.
ANS: A
The patient with diabetic ketoacidosis is in a state of metabolic acidosis. The body will
attempt to compensate for the acidosis by blowing off extra amounts of carbon dioxide
through deep, rapid respirations. Since carbon dioxide is converted to carbonic acid, removal
of carbon dioxide will help shift the body‘s pH to a less acidotic state.
DIF: Applying OBJ: 39.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Acid-Base Balance
5. 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? NURSINGTB.COM
a. Hypocalcemia
b. Hypernatremia
c. Hypokalemia
d. Hyperphosphatemia
ANS: C
Furosemide is a loop diuretic that causes loss of potassium through the urine. Patients taking
this medication are at risk for hypokalemia, so the nurse should check the patient‘s electrolyte
values closely, particularly the serum potassium level.
DIF: Understanding OBJ: 39.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies NOT: Concepts: Fluid and Electrolyte Balance
6. 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?
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
ANS: D
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