Chapter 8 Fluid/Electrolyte
A patient presents in the emergency department (ED) with fever, nausea, and vomiting over the
past 2 days. The nurse monitors for which laboratory result in this patient?
1. Urine specific gravity of 1.040
2. Serum potassium of 4.8 mEq/L
3. Serum sodium of 135 mEq/L
4. Urine positive for glucose and ketones
1. Urine specific gravity of 1.040
The nurse is providing care to an older adult patient who is receiving intravenous (IV) fluids at 150
mL/hour. It is important that the nurse assess for which clinical manifestations that could indicate
fluid volume excess in this patient?
1. Flattened neck veins
2. Elevated blood pressure
3. Bradycardia
4. Skin tenting
2. Elevated blood pressure
The nurse is caring for a patient with a potassium level of 5.9 mEq/L. The healthcare provider
prescribes both glucose and insulin for the patient. The patient’s spouse asks, “Why is insulin
needed?” Which response by the nurse is the most appropriate?
1. “The insulin will help his kidneys excrete the extra potassium.”
2. “The insulin is safer than other medications that can lower potassium levels.”
3. “The insulin lowers his blood sugar levels, and this is how the extra potassium is
excreted.”
4. “The insulin will cause his extra potassium to move into his cells, which will lower
potassium in the blood.”
4. “The insulin will cause his extra potassium to move into his cells, which will lower
potassium in the blood.”
The nurse prepares the patient diagnosed with chronic obstructive pulmonary disease (COPD) for
which diagnostic test to monitor acid–base balance?
1. Pulse oximetry
2. Bronchoscopy
3. Sputum studies
4. Arterial blood gases
4. Arterial blood gases
The nurse is providing care to a patient admitted for a traumatic brain injury who has developed
respiratory acidosis. Which action by the nurse is the priority?
1. Monitoring peripheral vascular status
2. Reassuring the patient to decrease anxiety
3. Assessing respiratory rate and depth closely
4. Administering sodium bicarbonate as ordered
3. Assessing respiratory rate and depth closely
Which assessment data collected by the nurse indicate that an older adult patient is at risk for
dehydration?
1. Poor skin turgor
2. Body mass index of 20.5
3. Blood pressure of 140/98 mm Hg
4. Oral intake of 48 ounces per day
4. Oral intake of 48 ounces per day
The nurse is providing care to a patient who seeks emergency treatment for headache and nausea.
The patient works in a mill without air conditioning. The patient states, “I drink water several
times each day, but I seem to sweat more than I am able to replace.” Which suggestions does the
nurse provide to this patient?
1. Drink juices and carbonated sodas.
2. Eat something salty when drinking water.
3. Eat something sweet when drinking water.
4. Double the amount of water being ingested.
2. Eat something salty when drinking water.
The nurse provides care for a patient who is experiencing hypomagnesemia. Which food choice is
best for this patient?
1. A medium-sized banana
2. One medium-sized baked potato
3. Three ounces of cooked halibut
4. A half-cup of cooked black-eyed peas
3. Three ounces of cooked halibut
The nurse is providing care to patient with the following laboratory values: pH 7.31; PaCO2 48
mm Hg; and HCO3 24 mEq/L. The nurse correlates these values to which acid–base disorder?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
3. Respiratory acidosis
The nurse is providing care to a patient who is admitted to the hospital with sudden, severe
abdominal pain. Which arterial blood gas supports the patient’s current diagnosis of respiratory
alkalosis?
1. pH is 7.35 and PaO2 is 88.
2. pH is 7.30 and HCO3 is 30.
3. pH is 7.47 and PaCO2 is 25.
4. pH is 7.33 and PaCO2 is 36.
3. pH is 7.47 and PaCO2 is 25.
The nurse plans care for a hospitalized patient. Which data necessitate the inclusion of
interventions to address a fluid volume deficit?
1. Urine output of 30 mL/hour
2. Heart rate of 110 bpm
3. Weight gain of 10 pounds in 3 days
4. Plus-3 edema in bilateral lower extremities
2. Heart rate of 110 bpm
A nurse is reviewing the serum chemistry results on a patient who has a nasogastric tube to low
intermittent suction secondary to a gunshot to the abdomen 2 days ago. Which electrolyte value
does the nurse correlate to the NG suctioning?
1. Serum chloride of 90 mEq/L
2. Serum sodium of 148 mEq/L
3. Serum potassium of 5.2 mEq/L
4. Serum calcium of 11.3 mg/dL
1. Serum chloride of 90 mEq/L
The nurse monitors for which clinical manifestations in the patient admitted with
hypermagnesemia?
1. Elevated blood pressure
2. Bradycardia
3. Increased deep tendon reflexes
4. Hyperventilation
2. Bradycardia
The nurse assesses a patient admitted to the hospital for treatment of pneumonia. The patient’s
pulse oximetry reads 77%. After repositioning the patient and increasing oxygen per the healthcare
provider’s order, there is no change in the pulse oximeter reading. Which is the priority action for
the nurse?
1. Reassessing the patient in 1 hour
2. Obtaining an arterial blood gas analysis
3. Consulting the unit respiratory therapist
4. Documenting the findings in the medical record
2. Obtaining an arterial blood gas analysis
The patient is admitted to the emergency department (ED) with symptoms of a panic attack. Based
on this data, the nurse recognizes the patient is at risk for which acid–base disorder?
1. Metabolic alkalosis
2. Metabolic acidosis
3. Respiratory acidosis
4. Respiratory alkalosis
4. Respiratory alkalosis
The nurse is analyzing the intake and output record for a patient being treated for dehydration. The
patient weighs 176 lbs and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL. Based
on this data, which conclusion by the nurse is the most appropriate?
1. Treatment has not been effective.
2. Treatment needs to include a diuretic.
3. Treatment is effective and should continue.
4. Treatment has been effective and should end.
3. Treatment is effective and should continue.
The nurse is caring for a patient with congestive heart failure who is admitted to the
medical-surgical unit with acute hypokalemia. Which prescribed medication may have contributed
to the patient’s current hypokalemic state?
1. Cortisol
2. Oxycodone
3. Flexeril
4. Nonsteroidal anti-inflammatory drugs (NSAIDs)
1. Cortisol
The nurse provides care to a patient admitted for the treatment of vomiting. When assessing the
patient, the nurse closely monitors the patient for which clinical manifestation(s)?
1. Paresthesia
2. Respiratory distress
3. Kussmaul’s respirations
4. Muscle twitching and cramps
4. Muscle twitching and cramps
he nurse is providing care to a patient who is admitted after a morphine overdose. Which
acid–base imbalance does the nurse assess for in this patient?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
3. Respiratory acidosis
The nurse is reviewing the healthcare provider’s orders for a patient who is diagnosed with
respiratory alkalosis. Which order is appropriate for this patient’s care needs?
1. Monitor arterial blood gas results.
2. Administer oxygen via face mask.
3. Restrict fluids to 2 L per day.
4. Infuse 1 ampule of sodium bicarbonate
1. Monitor arterial blood gas results.
The nurse is planning care for the patient with acute renal failure and incorporates the nursing
diagnosis of Excess Fluid Volume. Which assessment data support this nursing diagnosis?
1. Wheezing in the lungs
2. Generalized weakness
3. Urine output of 20 mL/hour
4. Pitting edema in the lower extremities
4. Pitting edema in the lower extremities
The nurse is providing care to a patient who is prescribed furosemide for treatment of congestive
heart failure (CHF). The patient’s serum potassium level is 3.4 mEq/L. Which food should the
nurse encourage the patient to eat based on this data?
1. Peas
2. Iced tea
3. Bananas
4. Baked fish
3. Bananas
Which nursing actions are appropriate when conducting an Allen test? Select all that apply.
1. Rest the patient’s arm on the mattress.
2. Support the patient’s wrist with a rolled towel.
3. Tell the patient to relax the hand and then clench a fist.
4. Ensure that a second nurse is available to assist with the procedure.
5. Press the patient’s radial and ulnar arteries using the index and middle fingers.
1. Rest the patient’s arm on the mattress.
2. Support the patient’s wrist with a rolled towel. 5. Press the patient’s radial and ulnar arteries using the index and middle fingers.
The nurse is planning care for an older adult patient with respiratory acidosis. Which intervention
does the nurse include in this patient’s plan of care?
1. Perform chest physiotherapy.
2. Reduce environmental stimuli.
3. Administer intravenous sodium bicarbonate.
4. Administer prescribed intravenous fluids carefully.
1. Perform chest physiotherapy.
The nurse is providing care for an adult patient who is admitted to the emergency department (ED)
after losing consciousness. The patient has been fasting and currently has ketones in the urine. The
nurse monitors for which acid–base imbalance?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
1. Metabolic acidosis