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Chapter 03: Fluid, Electrolytes, Acid-Base Balance, and Intravenous Therapy
deWit: Medical-Surgical Nursing: Concepts & Practice, 3rd Edition
MULTIPLE CHOICE
1. The nurse uses a diagram to demonstrate how in dehydration the water is drawn into the
plasma from the cells by which process?
a. Distillation
b. Diffusion
c. Filtration
d. Osmosis
ANS: D
The process of osmosis accomplishes the movement of water from the cells into the plasma,
causing dehydration.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 32 OBJ: 3 (theory) TOP: Dehydration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse assessing a patient with vomiting and diarrhea observes that the urine is scant and
concentrated. Which controlling factor is responsible for compensatory reabsorption of water?
a. Osmoreceptors in the hypothalamus
b. Antidiuretic hormone in the posterior pituitary
c. Baroreceptors in the carotid sinus
d. Insulin from the pancreas
ANS: B
The antidiuretic hormone controls how much water leaves the body by reabsorbing water in
the renal tubules.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 30 OBJ: 2 (theory) TOP: Regulation of Body Fluids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. The nurse uses a picture to show how ions equalize their concentration by which passive
transport process?
a. Osmosis
b. Filtration
c. Titration
d. Diffusion
ANS: D
Diffusion is the process by which substances move back and forth across compartment
membranes until they are equally divided.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 31 OBJ: 2 (theory) TOP: Diffusion KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. Which term describes the active transport process that moves sodium and potassium into or
out of cells?
a. Filtration
b. Sodium pump
c. Diffusion
d. Osmosis
ANS: B
The sodium pump is the mechanism by which sodium and potassium are moved into or out of
cells regardless of the concentration.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 32 OBJ: 2 (theory) TOP: Active Transport KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. The patient taking furosemide (Lasix) to correct excess edema shows a weight loss of 5.
pounds in 24 hours. The nurse calculates that this weight loss is equivalent to how many liters
(L) of fluid?
a. 1 L
b. 1.5 L
c. 2.0 L
d. 2.5 L
ANS: D
Each kilogram (2.2 pounds) of weight loss is equivalent to 1 liter of fluid. Therefore, 5.
pounds ÷ 2.2 pounds = 2.5 liters.
PTS: 1 DIF: Cognitive Level: Application REF: 33, Clinical Cues OBJ: 1 (clinical) TOP: Fluid Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. The nurse is caring for a patient with a potassium level of 2.9 mEq/L. The nurse should
carefully monitor the patient for which potential problem?
a. Excessive urinary output
b. Abdominal distention
c. Increased reflexes
d. Hyperactive bowel sounds
ANS: B
A potassium level lower than 3.5 mEq/L results in reduced urine output, cardiac dysrhythmia,
muscle weakness, abdominal pain and distention, paralytic ileus, lethargy, and confusion.
PTS: 1 DIF: Cognitive Level: Application REF: 41, Table 3- OBJ: 15 (clinical) TOP: Hypokalemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
10. The nurse is caring for an 80-year-old patient. Which finding is the best early indicator of
dehydration in this patient?
a. Reduced skin turgor
b. Constipation
c. Increased temperature
d. Thirst
ANS: B
The nurse understands that this patient’s age places him at greater risk for dehydration.
Constipation is the best early indicator of dehydration in the older adult. Older adults have age-
related poor skin turgor. Increased temperature and thirst are later signs of dehydration.
PTS: 1 DIF: Cognitive Level: Analysis REF: 33- OBJ: 5 (theory) TOP: Dehydration in the Older Adult KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
11. The patient with long-term obstructive pulmonary disease has a pH of 7, HCO 3 –^ of 18 mEq/L,
and a PaCO 2 of 40 mm Hg. These laboratory values are consistent with which acid-base
imbalance?
a. Respiratory alkalosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Metabolic acidosis
ANS: D
These results are indicative of metabolic acidosis.
PTS: 1 DIF: Cognitive Level: Application REF: 46 OBJ: 15 (clinical) TOP: Respiratory Acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
12. The nurse is caring for a young patient with asthma. Which activity should the nurse
encourage in order to help prevent respiratory acidosis?
a. Engage in deep-breathing exercises every 2 hours.
b. Drink 8 ounces of fluid every 4 hours.
c. Ambulate for 15 minutes twice a day.
d. Sleep with the head of the bed elevated 45 degrees.
ANS: A
Deep breathing blows off CO 2 , which reduces the acid ions, thus preventing respiratory
acidosis. Drinking fluids prevents dehydration and keeps secretions moist and thin, and
sleeping with the head of the bed elevated will ease breathing and improve gas exchange.
Ambulating 15 minutes twice a day does not have an impact on respiratory acidosis.
PTS: 1 DIF: Cognitive Level: Analysis REF: 46 OBJ: 8 (theory) TOP: Respiratory Acidosis
KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. The patient who has had diarrhea for the last 3 days has blood gases of pH of 7.1, HCO 3 -^ of 20
mEq/L, and PCO 2 of 36 mm Hg. These laboratory values are consistent with which acid-base
imbalance?
a. Respiratory alkalosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Metabolic acidosis
ANS: D
Metabolic acidosis shows a low pH, low HCO 3 - , and normal CO 2.
PTS: 1 DIF: Cognitive Level: Application REF: 46 OBJ: 8 (theory) TOP: Metabolic Acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
14. The nurse is caring for a patient with metabolic acidosis. Which assessment finding reveals
that the compensatory mechanism to correct this imbalance is in effect?
a. Increased urinary output
b. Reduced abdominal distention
c. Kussmaul respirations
d. Decreased blood pressure
ANS: C
Kussmaul respirations, or deep and rapid respirations, are blowing off carbon dioxide to reduce
an acidotic state.
PTS: 1 DIF: Cognitive Level: Application REF: 47 OBJ: 7 (theory) TOP: Metabolic Acidosis KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. The nurse assesses the patient’s IV insertion site and observes that the vein is hard, the skin is
red and tender, and a blood return in the IV line. After removing the IV catheter, which action
should the nurse take next?
a. Obtain an arm board to properly secure the IV.
b. Elevate the arm above the level of the heart.
c. Clean the site with alcohol and apply cool compresses.
d. Apply a warm moist pack.
ANS: D
These are signs and symptoms of phlebitis and should be treated with a warm moist pack to
increase blood flow to the area. The IV has been discontinued, so an arm board for
stabilization is unnecessary. Elevation of the arm would be helpful to reduce swelling. A cool
compress would be indicated for other issues related to IV infusion problems, such as
extravasation.
PTS: 1 DIF: Cognitive Level: Application REF: 51
KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
19. The nurse is caring for a patient who has been on total parenteral nutrition (TPN) for 48 hours.
Which action demonstrates effective nursing care?
a. Checking the patient’s blood glucose level according to facility protocol.
b. Increasing the infusion rate if the prescribed intake falls behind.
c. Informing the patient that TPN can only be administered via a central line for 1
week.
d. Monitoring the peripheral IV site of TPN infusion for signs of infiltration at least
every 8 hours.
ANS: A
The hypertonic solution causes difficulty with glucose tolerance, so monitoring of blood
glucose level is imperative. The infusion rate should never be increased to “catch up” because
of the likelihood of fluid overload caused by the hypertonicity of the TPN. TPN can be
administered for more than 1 week and it is almost always administered via a central line
rather than a peripheral line.
PTS: 1 DIF: Cognitive Level: Application REF: 55 OBJ: 19 (clinical) TOP: TPN KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
20. The nurse is assessing a patient with renal failure and notes fatigue, muscle cramps, confusion,
and headache. Which laboratory abnormality corresponds with these findings?
a. Potassium of 3.3 mEq/L
b. Sodium of 129 mEq/L
c. Calcium of 8.2 mg/dL
d. Chloride of 105 mEq/L
ANS: B
The patient is demonstrating signs and symptoms of hyponatremia; therefore, the nurse should
assess the patient’s sodium level.
PTS: 1 DIF: Cognitive Level: Application REF: 40, Table 3- OBJ: 15 (clinical) TOP: Hyponatremia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Management of Care MULTIPLE RESPONSE
21. The nurse is assessing the hydration status of the patient. Which action(s) demonstrates
knowledge of proper assessment? ( Select all that apply .)
a. Monitoring the patient’s daily weight.
b. Assessing the patient’s skin turgor on the back of the hand.
c. Checking the patient’s blood glucose level four times a day.
d. Assessing for skin tenting on the patient’s forehead.
e. Asking the patient if he is experiencing thirst.
ANS: A, D, E
The skin of the abdomen, forearm, sternum, forehead, and thigh can be “tented” as a test for
skin turgor by gently pinching up a fold of skin and observing the delay in return to normal.
Assessment of skin turgor is not reliable on the back of the hand. Weight and experiencing
thirst can be indicators of hydration status, along with further assessment. The patient’s blood
glucose level is not an assessment parameter for hydration status.
PTS: 1 DIF: Cognitive Level: Application REF: 33 OBJ: 13 (clinical) TOP: Assessment Data: Skin Turgor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
22. The nurse is caring for a patient that has a potassium level of 5.0. The nurse should carefully
monitor the patient for which signs and symptoms? ( Select all that apply .)
a. Muscle weakness
b. Cardiac dysrhythmias
c. Decreased reflexes
d. Urinary retention
e. Hypotension
ANS: A, B, E
Normal potassium level is 3.5 to 5.0 mEq/L. Because the patient is on the highest end of
normal, the nurse should monitor for signs of hyperkalemia. Muscle weakness, cardiac
dysrhythmias, and hypotension are signs of hyperkalemia. Decreased reflexes and urinary
retention are signs of hypokalemia.
PTS: 1 DIF: Cognitive Level: Application REF: 43 OBJ: 15 (clinical) TOP: Hyperkalemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance
23. The primary care provider writes an order for the patient to receive an IV of a solution that has
the same osmotic pressure as intracellular fluid. The nurse would correctly question which IV
order(s)? ( Select all that apply .)
a. 5% dextrose in water
b. 0.45% sodium chloride
c. 5% dextrose in 0.9% sodium chloride
d. Lactated Ringer solution
e. 0.9% sodium chloride
ANS: B, C
The solution being prescribed is an isotonic solution. 5% dextrose in water, lactated Ringer
solution, and 0.9% sodium chloride are all isotonic solutions, whereas 0.45% sodium chloride
is a hypotonic solution, and 5% dextrose in 0.9% sodium chloride is a hypertonic solution.
PTS: 1 DIF: Cognitive Level: Analysis REF: 48- OBJ: 11 (theory) TOP: Isotonic Solutions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27. The nurse reminds the patient that the three body mechanisms that attempt to compensate to
correct acid-base imbalances are the __________ system, the __________ system, and the
__________.
ANS:
buffer; respiratory; kidneys
buffer; kidneys; respiratory
respiratory; buffer; kidneys
respiratory; kidneys; buffer
kidneys; respiratory; buffer
kidneys; buffer; respiratory
The buffer system, the respiratory system, and the kidneys contribute unique compensations to
correct an acid-base imbalance.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 44 OBJ: 8 (theory) TOP: Acid-Base Compensatory Mechanisms KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MATCHING
The nurse explains that the chain of events that results in hypocalcemia for the patient in early
renal failure occurs in which order? (Match the events to the proper sequence.)
a. Loss of calcium ions
b. Vitamin D not activated
c. Bone loss
d. Retention of phosphates
e. Loss of absorption of calcium from the gastrointestinal tract
28. Step 1
29. Step 2
30. Step 3
31. Step 4
32. Step 5
- ANS: D PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ANS: A PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ANS: B PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ANS: E PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
- ANS: C PTS: 1 DIF: Cognitive Level: Analysis REF: 43 OBJ: 4 (theory) TOP: Hypocalcemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation
