Fluid Volume Imbalances
A nurse is assessing a patient with suspected isotonic fluid volume deficit. Which of the following findings is most consistent with this condition?
A. Weight gain, bradycardia, and hypertension
B. Increased urine output, tachypnea, and hyperthermia
C. Thirst, weak pulse, and decreased skin turgor
D. Pulmonary edema, crackles, and jugular vein distension
Answer: C. Thirst, weak pulse, and decreased skin turgor
Rationale: Isotonic fluid volume deficit (hypovolemia) occurs when there is an equal loss of water and electrolytes, leading to dehydration and hypovolemia. Symptoms include thirst, hypotension, tachycardia, dry mucous membranes, and poor skin turgor. The other choices are associated with fluid volume excess.
A trauma patient with severe burn injuries is in hypovolemic shock. The nurse anticipates which early physiological response?
A. Bradycardia and hypotension
B. Decreased urine output and tachycardia
C. Widened pulse pressure and warm, flushed skin
D. Increased central venous pressure (CVP)
Answer: A. Dry mouth and excessive thirst
Rationale: Hypernatremia occurs when there is too little water in the body, leading to cellular dehydration. The body responds by triggering thirst to increase water intake. Dry mouth, restlessness, and confusion are common symptoms. Swelling is associated with fluid retention, not dehydration, and muscle spasms are more common in calcium imbalances.
A nurse is assessing a patient with low potassium levels. Which symptom is most commonly associated with hypokalemia?
A. Muscle weakness and leg cramps
B. Increased reflexes and tremors
C. High blood pressure and flushed skin
D. Slow, bounding pulse
Answer: A. Muscle weakness and leg cramps
Rationale: Potassium is essential for muscle contraction and nerve function. Hypokalemia causes muscle weakness, cramps, fatigue, and constipation due to decreased neuromuscular excitability. Increased reflexes and tremors are more common with hyperkalemia, while blood pressure changes and a bounding pulse are unrelated.
A nurse is assessing a patient with low calcium levels. Which symptom is most commonly associated with hypocalcemia?
A. Numbness and tingling in the fingers
B. High blood pressure and flushed skin
C. Weak pulse and warm extremities
D. Slow reflexes and confusion
Answer: A. Numbness and tingling in the fingers
Rationale: Calcium plays a key role in nerve and muscle function. Hypocalcemia can cause neuromuscular excitability, tingling (paresthesia), muscle cramps, and tetany. Slow reflexes and confusion are more common in hypercalcemia.
A nurse is assessing a patient with severe diarrhea. The nurse understands this patient is at risk for which acid-base imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: A. Metabolic acidosis
Rationale: Severe diarrhea causes excessive loss of bicarbonate (HCO₃⁻), leading to metabolic acidosis. The body compensates with increased respiratory rate (Kussmaul breathing) to remove CO₂.
A patient with heart failure is experiencing fluid volume excess. Which assessment finding requires immediate intervention?
A. 2+ pitting edema in the lower extremities
B. Weight gain of 2 kg (4.4 lbs) in 2 days
C. Crackles in the lungs and shortness of breath
D. Elevated blood pressure of 145/90 mmHg
Answer: C. Crackles in the lungs and shortness of breath
Rationale: Pulmonary congestion (evidenced by crackles and dyspnea) indicates fluid overload in the lungs, which can progress to pulmonary edema, a life-threatening condition requiring immediate intervention. Weight gain and edema are expected but are not immediately life-threatening.
A nurse is caring for a patient with hyponatremia. Which symptom should the nurse expect?
A. Increased thirst
B. Muscle cramps and confusion
C. Warm, flushed skin
D. Slow heart rate and high blood pressure
Answer: B. Muscle cramps and confusion
Rationale: Hyponatremia causes neurological symptoms (confusion, headache, seizures) due to cell swelling, as well as muscle weakness and cramps. Increased thirst is a sign of hypernatremia, while flushed skin and high blood pressure are unrelated.
A patient is taking a diuretic (furosemide). Which potassium imbalance is the patient most at risk for?
A. Hypokalemia
B. Hyperkalemia
C. Hyponatremia
D. Hypercalcemia
Answer: A. Hypokalemia
Rationale: Diuretics like furosemide (Lasix) cause potassium loss through increased urination, leading to hypokalemia. Patients may develop fatigue, weakness, and irregular heart rhythms if potassium levels drop too low.
A patient with hypoparathyroidism is at risk for which calcium imbalance?
A. Hypercalcemia
B. Hypocalcemia
C. Hyperkalemia
D. Hyponatremia
Answer: B. Hypocalcemia
Rationale: The parathyroid glands regulate calcium levels. Hypoparathyroidism causes a decrease in parathyroid hormone (PTH), leading to low calcium levels (hypocalcemia). This results in muscle cramps, tetany, and neurological symptoms.
A patient who has been vomiting frequently for the past 24 hours is at risk for which acid-base imbalance?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
Answer: B. Metabolic alkalosis
Rationale: Vomiting causes loss of stomach acid (HCl), leading to an increase in bicarbonate (HCO₃⁻), resulting in metabolic alkalosis. Symptoms include muscle cramps, dizziness, and shallow breathing as the body tries to retain CO₂.
A patient receiving diuretics for hypertension reports dizziness upon standing. The nurse notes a BP drop of 20 mmHg when changing positions. What is the most likely cause?
A. Hyponatremia
B. Fluid volume deficit
C. Hyperkalemia
D. Fluid volume excess
Answer: B. Fluid volume deficit
Rationale: Diuretics (e.g., furosemide) cause excessive fluid loss, leading to hypovolemia and orthostatic hypotension. Patients may experience dizziness, weakness, and syncope when changing positions. Hyperkalemia is more common with potassium-sparing diuretics, while hyponatremia alone does not cause severe volume depletion.
A patient with diarrhea and excessive sweating is admitted for dehydration. Which assessment finding suggests hyponatremia?
A. Dry mucous membranes
B. Edema in the lower extremities
C. Confusion and dizziness
D. Increased urine output
Answer: C. Confusion and dizziness
Rationale: Sodium plays a key role in nerve and brain function. Low sodium levels from fluid loss can cause confusion, dizziness, and weakness. Dry mucous membranes are common in dehydration, but not specific to hyponatremia.
A nurse is caring for a patient with severe vomiting and diarrhea. What potassium-related complication is most concerning?
A. Hypokalemia leading to cardiac arrhythmias
B. Hyperkalemia causing excessive sweating
C. Hypokalemia leading to fluid overload
D. Hyperkalemia causing muscle weakness
Answer: A. Hypokalemia leading to cardiac arrhythmias
Rationale: Potassium is lost through the gastrointestinal tract. Severe vomiting and diarrhea can cause hypokalemia, increasing the risk of irregular heart rhythms (arrhythmias), which can be life-threatening. Fluid overload and excessive sweating are unrelated to potassium imbalances.
A nurse is caring for a patient with hypercalcemia. Which symptom is the patient most likely to report?
A. Muscle spasms and increased reflexes
B. Nausea, constipation, and weakness
C. Tingling in the fingers and facial twitching
D. Increased urination and excessive thirst
Answer: B. Nausea, constipation, and weakness
Rationale: Hypercalcemia decreases neuromuscular excitability, leading to muscle weakness, fatigue, nausea, and constipation. Increased reflexes and tingling occur with hypocalcemia, not hypercalcemia.
A patient with chronic obstructive pulmonary disease (COPD) is experiencing confusion and drowsiness. The nurse suspects which acid-base imbalance?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis
Answer: C. Respiratory acidosis
Rationale: COPD causes poor gas exchange, leading to CO₂ retention. This increases carbonic acid (H₂CO₃) in the blood, leading to respiratory acidosis. Symptoms include confusion, drowsiness, and headache due to CO₂ buildup.
A patient with sepsis has developed third-spacing of fluids. Which assessment finding is most concerning?
A. Generalized edema
B. Urine output of 10 mL/hr
C. Serum albumin of 4.0 g/dL
D. Blood pressure of 130/80 mmHg
Answer: B. Urine output of 10 mL/hr
Rationale: Third-spacing (fluid shifting into interstitial spaces) reduces effective circulating volume, leading to hypoperfusion and decreased urine output (< 30 mL/hr). This indicates acute kidney injury (AKI) and requires immediate intervention. Edema is expected, and normal albumin levels (3.5–5 g/dL) do not indicate a worsening condition.
A patient with excessive water intake is at risk for which sodium imbalance?
A. Hypernatremia
B. Hyponatremia
C. Hypokalemia
D. Hypercalcemia
Answer: B. Hyponatremia
Rationale: Drinking too much water dilutes sodium levels, leading to hyponatremia. This can cause headaches, confusion, and seizures due to fluid shifting into brain cells. Hypernatremia is caused by water loss or excessive sodium intake.
A patient with kidney failure is at risk for which potassium imbalance?
A. Hypokalemia
B. Hyperkalemia
C. Hypocalcemia
D. Hyponatremia
Answer: B. Hyperkalemia
Rationale: The kidneys regulate potassium balance by excreting excess potassium in urine. If the kidneys fail, potassium builds up in the body, leading to hyperkalemia, which can cause muscle weakness, numbness, and dangerous heart arrhythmias.
A patient with cancer is experiencing hypercalcemia. What is the most likely cause?
A. Excessive dietary calcium intake
B. Kidney disease
C. Bone breakdown and calcium release
D. Increased parathyroid hormone (PTH)
Answer: C. Bone breakdown and calcium release
Rationale: Certain cancers (e.g., bone metastases, multiple myeloma) cause bone destruction, releasing calcium into the bloodstream, leading to hypercalcemia. Kidney disease and diet rarely cause severe hypercalcemia.
A nurse is caring for a patient who is hyperventilating due to anxiety. What acid-base imbalance is this patient at risk for?
A. Respiratory acidosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
Answer: C. Respiratory alkalosis
Rationale: Hyperventilation causes excessive CO₂ loss, leading to respiratory alkalosis. Symptoms include lightheadedness, tingling in the fingers (paresthesia), and dizziness due to low CO₂ levels.
A patient with heart failure is experiencing shortness of breath, edema, and weight gain. What is the most likely cause of these symptoms?
A. Fluid volume deficit
B. Third-spacing of fluids
C. Fluid volume excess
D. Dehydration
Answer: C. Fluid volume excess
Rationale: Heart failure reduces the heart’s ability to pump effectively, leading to fluid retention, pulmonary congestion (shortness of breath), and peripheral edema. Weight gain is a common sign of fluid overload.
A nurse is caring for a patient with hypernatremia due to dehydration. Which intervention is most appropriate?
A. Encourage frequent sips of water
B. Restrict fluids and provide a low-sodium diet
C. Give a diuretic to remove excess sodium
D. Increase salt intake to balance sodium levels
Answer: A. Encourage frequent sips of water
Rationale: Hypernatremia occurs when there is too little water in the body. Encouraging fluid intake helps dilute sodium levels and restore balance. Diuretics are only used in cases of fluid overload, not dehydration.
A patient reports numbness, tingling, and muscle twitching. The nurse suspects hyperkalemia. Which additional symptom would confirm this suspicion?
A. Slow, thready pulse
B. Increased deep tendon reflexes
C. Irregular heart rhythm
D. Constipation and bloating
Answer: C. Irregular heart rhythm
Rationale: Hyperkalemia affects heart conduction, leading to dangerous arrhythmias, palpitations, and bradycardia. While muscle twitching and numbness occur early, cardiac changes are the most serious concern. Constipation is linked to hypokalemia, not hyperkalemia.
A nurse is caring for a patient with hypocalcemia after thyroid surgery. Which intervention should the nurse anticipate?
A. Encouraging a low-calcium diet
B. Administering calcium supplements
C. Restricting fluids
D. Encouraging high-sodium foods
Answer: B. Administering calcium supplements
Rationale: Thyroid or parathyroid surgery can disrupt calcium regulation, leading to hypocalcemia. The priority intervention is to administer calcium supplements. A low-calcium diet would worsen the condition, and fluid or sodium intake does not directly affect calcium levels.
A patient with severe kidney disease is at risk for which acid-base imbalance?
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
Answer: B. Metabolic acidosis
Rationale: The kidneys normally excrete hydrogen ions (H⁺) and reabsorb bicarbonate (HCO₃⁻). In kidney disease, the body retains acid, leading to metabolic acidosis. Symptoms include weakness, confusion, and deep rapid breathing (Kussmaul respirations) as compensation.