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FLUID AND ELECTROLYTE IMBALANCE UNIT 3 TEST QUESTIONS AND CORRECT ANSWERS…
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FLUID AND ELECTROLYTE IMBALANCE UNIT 3 TEST QUESTIONS AND CORRECT ANSWERS…
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Which client is most likely to exhibit dehydration? - ANSWER an 8-month-old infant with persistent diarrhoea for 24 hours
Infants and elderly persons have the greatest risk of fluid-related health
problems. An infant's body weight is 70% to 80% water content. An infant who
is ill and has had persistent diarrhoea for 24 hours will quickly lose a significant
amount of fluid and electrolytes if the diarrhoea is not stopped and replacement
fluids are given. Healthy young adults have a higher tolerance for fluid loss and
can quickly regain their fluid balance when fluids are lost through normal
activity. The 75-year-old woman who was placed on NPO status before surgery
is not likely to develop a fluid volume deficit within 8 hours unless there are
other fluid conditions present that would precipitate fluid loss. The 60-year-old
client with pneumonia and a fever should be monitored for a fluid deficit, but he
is not as likely to develop one as a client who is actively losing fluids through
diarrhoea.
During a follow-up visit to the physician, a client with hyperparathyroidism
asks the nurse to explain the physiology of the parathyroid glands. The nurse
states that these glands produce parathyroid hormone (PTH). PTH maintains the
balance between calcium and - ANSWER phosphorus.
PTH increases the serum calcium level and decreases the serum phosphate
level. PTH doesn't affect sodium, potassium, or magnesium regulation.
,A client has vomited several times over the past 12 hours. The nurse should
recognize the risk of what complication? - ANSWER metabolic alkalosis
Vomiting results in loss of hydrochloric acid (HCl) and potassium from the
stomach, leading to a reduction of chlorides and potassium in the blood and to
metabolic alkalosis.
A child is brought to the emergency department with a full-thickness burn
involving the epidermis, dermis, and underlying subcutaneous tissue, but does
not report pain at this time. Which statements by the nurse are correct about this
type of burn? Select all that apply. - ANSWER This is a severe burn and nerve
endings have been destroyed.
The child must be monitored for signs of fluid shift.
Rehabilitation and skin grafting will be necessary.
This is an example of a third-degree burn, which is very serious. This child must
be carefully monitored for complications. The fact that there is no pain is due to
the destruction of the nerve endings. Fluid shift can occur and result in shock. A
burn of this degree will also require a long rehabilitation with skin grafting. Oral
pain medication would not be administered as the child would be NPO and oral
medication would not be effective. This burn is not superficial.
A client has a nursing diagnosis of fluid volume deficit. Which nursing
assessment finding would support this diagnosis? - ANSWER orthostatic
blood pressure changes
Fluid volume deficit is characterized by hypotension, tachycardia, increased
body temperature, and weakness. Leathery, pliable skin may not demonstrate
fluid deficit; it may reflect diabetes. Pitting edema and pedal pulses of 4+
demonstrate localized edema and potential fluid excess.
,During a clinic visit, the mother of an infant with hydrocele states that the
infant's scrotum is smaller now than when he was born. After teaching the
mother about the infant's condition, which statement by the mother indicates
that the teaching has been effective? - ANSWER "It seems like the fluid is
being reabsorbed."
A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along
the spermatic cord that results from a patent processus vaginalis. As fluid is
being absorbed, scrotal size decreases. Elevation of the infant's bottom,
massage, or keeping the infant quiet or in an infant seat would have no effect in
promoting fluid reabsorption in hydrocele.
The nurse determines that interventions for decreasing fluid retention have been
effective when the nurse makes which assessment in child with nephrotic
syndrome? - ANSWER decreased abdominal girth
Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic
pressure changes. Increased abdominal fluid is evidenced by an increase in
abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid
in the third spaces and tissues. When fluid accumulates in the abdomen and
interstitial spaces, the child does not feel hungry and does not eat well.
Although increased caloric intake may indicate decreased intestinal edema, it is
not the best and most accurate indicator of fluid retention. Increased respiratory
rate may be an indication of increasing fluid in the abdomen (ascites) causing
pressure on the diaphragm. Heart rate usually stays in the normal range even
with excessive fluid volume.
A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of
100 mg/dL, serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and
lethargy. What is the priority nursing assessment? - ANSWER cardiac rhythm
, Manifestations of CKD result from loss of the renal regulatory functions of
filtering metabolic waste products and maintaining fluid and electrolyte balance.
These laboratory results indicate CKD, but the most significant result is the
potassium level. The normal range of potassium is between 3.5 and 5.0 mEq/L.
A potassium level greater than 7 mEq/L may produce fatal cardiac
dysrhythmias. Normal BUN level ranges from 8 to 23 mg/dL; normal serum
creatinine level ranges from 0.7 to 1.5 mg/dL.
A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol
solution intravenously over 5 minutes. The client weighs 132 lb (60 kg). How
many grams would the nurse administer? Record your answer as a whole
number. - ANSWER 12
First, convert the client's weight from pounds to kilograms:132 lb ÷ 2.2 lb/kg =
60 kg.Then, to calculate the number of grams to administer, multiply the
ordered number of grams by the client's weight in kilograms:0.2g/kg X 60 kg =
12 g.
The nurse is caring for assigned clients on the oncology unit. Which client is at
greatest risk for dehydration? - ANSWER a 48-year-old having intracavitary
radiation for cancer of the cervix
Dehydration can occur from fluid loss secondary to tissue destruction at the site
of irradiation at any age. After radical vulvectomy, wound drains are generally
removed by postoperative day four or five, and don't create a significant risk of
dehydration. Tamoxifen therapy is unrelated to dehydration. Although urine
may escape through the vagina as a result of a vesicovaginal fistula, it does not
cause the loss of an unusual amount of urine or other fluid.
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