Fundamentals Concepts And Skills For Nurses Ch 25

Question 1

1.A 10-month old infant has had watery green stool for 2 days and refuses the bottle. The nurse is aware that the primary concern for this baby is:

a. metabolic acidosis.
b. metabolic alkalosis.
c. weight loss.
d. diaper rash

Answer 1

A. Metabolic acidosis

Question 2

2. The patient who was admitted after vomiting for 3 days would show an abnormally low blood pressure because of a fluid shift from:
   a. intracellular to the extracellular.
   b. interstitial to intravascular.
   c. intravascular to the interstitial.
   d. interstitial to the intracellular

Answer 2

c. intravascular to the interstitial.

Question 3

3. An isotonic state exists within a patient’s body fluids when the solute
   concentration of:
   a. interstitial fluid is less than the transcellular.
   b. intracellular and extracellular fluid is equal.
   c. intracellular fluid is greater than extracellular fluid.
   d. extracellular fluid is lesser than intracellular fluid.

Answer 3

b. intracellular and extracellular fluid is equal.

Question 4

4. The nurse is aware that an infant is more at risk for dehydration because
   the infant:
   a. has kidneys that reabsorb water from the intravascular space.
   b. has a larger body surface compared with body weight.
   c. urinates more frequently.
   d. has fat that absorbs water.

Answer 4

b. has a larger body surface compared with body weight.

Question 5

5. The nurse points out that nonelectrolyte products of metabolism are as important to health as electrolytes. Nonelectrolytes include:
   a. magnesium.
   b. amino acids.
   c. calcium.
   d. phosphates

Answer 5

b. amino acids.

Question 6

6. The nurse assesses that the patient has developed abdominal pain, urinary retention, and confusion. The nurse concludes these signs are the results of an inadequate supply of:
   a. calcium (Ca2+).
   b. sodium (NA+).
   c. phosphates (PO 3).
   d. potassium (K+).

Answer 6

d. potassium (K+).

Question 7

7. A nurse gets a positive Chvostek’s sign on a young woman with bulimia
   who has been giving herself frequent enemas containing phosphate. The
   nurse anticipates a laboratory finding of:
   a. sodium 140 mEq/L.
   b. potassium 4.5 mEq/L.
   c. magnesium 1.6 mEq/L.
   d. calcium 6.5 mEq/L

Answer 7

d.calcium 6.5 mEq/L.

Question 8

8. A patient has been identified as having a dietary deficiency of
   vitamin D. The nurse understands that this patient is also at risk
   for having a deficiency of:
   a. calcium.
   b. magnesium.
   c. sodium.
   d. potassium.

Answer 8

A. Calcium.

Question 9

9. The nurse explains that the dehydrated patient’s urine is concentrated because:
   a. renal tubules reabsorb more water and reduce urine output.
   b. kidneys cease to function.
   c. blood pressure drops.
   d. the colon retains more fluid from the fecal waste.

Answer 9

a. renal tubules reabsorb more water and reduce urine output.

Question 10

10. The nurse is aware that small ions such as glucose, oxygen, and carbon
    dioxide redistribute themselves through semipermeable membranes by a process called:
    a. diffusion.
    b. osmosis.
    c. blood pressure.
    d. rehydration

Answer 10

A. Diffusion

Question 11

11. A patient with healthy kidneys experiences metabolic alkalosis resulting from episodes of vomiting. The nurse takes into consideration that the kidneys can clear the alkaline substances and fully stabilize the patient’s pH in approximately:
    a. 3 to 5 minutes.
    b. 12 to 24 hours.
    c. 3 days.
    d. 1 week.

Answer 11

C. 3 days.

Question 12

12. A patient with a history of severe chronic obstructive pulmonary
    disease (COPD) is most likely to have:
    a. respiratory alkalosis.
    b. respiratory acidosis.
    c. metabolic alkalosis.
    d. metabolic acidosis.

Answer 12

B. Respiratory acidosis.

Question 13

13. A patient who is experiencing severe diarrhea is losing excessive
    bicarbonate ions. This patient is at risk for developing:
    a. respiratory alkalosis.
    b. respiratory acidosis.
    c. metabolic alkalosis.
    d. metabolic acidosis

Answer 13

D. Metabolic acidosis

Question 14

14. An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse coulddo is to instruct the patient to:
    a. sit up.
    b. lie down.
    c. breathe through a re-breather mask.
    d. pant with mouth open.

Answer 14

C. Breathe through a re-breather mask.

Question 15

15. The nurse is aware that a more dynamic process that moves molecules into cells regardless of their electrical charge or concentration in the cell
    is:
    a. filtration.
    b. osmosis.
    c. active transport.
    d. hydrostatic pressures.

Answer 15

C. Active transport.

Question 16

16. For the accurate measurement to detect fluid retention, the nurse
    instructs the nursing assistants to measure the weight with the
    same scale:
    a. each morning before breakfast after the patient has voided.
    b. each day at noon before lunch, dressed in light clothing.
    c. in between meals, dressed in light clothing after voiding.
    d. just before bedtime, while the patient is in a hospital gown or pajamas.

Answer 16

A. Each morning before breakfast after the patient has voided.

Question 17

17. A patient with heart failure has gained 1.1 pounds over the last 24
    hours. The nurse is aware that this weight gain represents a fluid
    retention of:
    a. 0.25 L.
    b. 0.5 L.
    c. 1.0 L.
    d. 2.0 L

Answer 17

B.0.5 L

Question 18

18. The nurse is comparing sitting and standing vital signs for a patient who

has been diagnosed with dehydration. The pulse rate has increased by 10 beats/min at 1 minute. The nurse then anticipates the blood pressure
to show a(n):
a. increase of 5 mm Hg.
b. drop of 40 mm Hg.
c. drop of 20 mm Hg.
d. increase of 10 mm Hg

Answer 18

C. Drop of 20 mm Hg.

Question 19

19. A patient drank a cup of coffee, a half glass of orange juice, and half a
    carton of milk with breakfast. Using common equivalents of food
    containers as a guide, the nurse notes on the intake column of the
    intake and output sheet that the patient consumed:
    a. 360 mL.
    b. 400 mL.
    c. 420 mL.
    d. 600 mL

Answer 19

C. 420 mL

Question 20

20. At the beginning of the shift, a patient’s IV bag has 960 mL remaining. The IV fluid is running at 75 mL/hr. In 8 hours, there should be how many milliliters remaining in the IV bag?
    a. 150
    b. 360
    c. 450
    d. 600

Answer 20

B. 360
75x8=600 960-600=360

Question 21

21. The primary care provider orders fluid restriction for a patient with severe fluid volume excess. When a patient is placed on a fluid restriction, the allowance of fluids should be:
    a. greatest during the day shift.
    b. greatest during the evening shift.
    c. greatest during the night shift.
    d. spaced in equal increments for all shifts.

Answer 21

A. Greatest during the day shift.

Question 22

22. The nurse is aware that the patient who suffered a brain injury with cerebral edema will most likely receive a fluid that is:
    a. isotonic.
    b. hypertonic.
    c. hypotonic.
    d. enhanced with vitamin B

Answer 22

B. Hypertonic

Question 23

23. The patient who is prescribed a diuretic for fluid volume excess is discharged home. The patient verbalizes understanding of his diseaseprocess when he says:
    a. “I can put catsup on my scrambled eggs.”
    b. “I can snack on salted popcorn.”
    c. “I will snack on raisins.”
    d. “I will avoid apricots.

Answer 23

C.“I will snack on raisins.”

Question 24

24. The nurse is caring for a patient for whom a dose of IV potassium has been ordered. Prior to hanging the potassium, the nurse should:
    a. check urine output to be above 60 mL/hr.
    b. check the dose with another licensed person.
    c. confirm the IV fluid running is compatible with potassium.
    d. start potassium with another venipuncture.

Answer 24

c. confirm the IV fluid running is compatible with potassium

Question 25

25. The nurse caring for a frail 92-year-old dehydrated patient should add to the plan of care:
    a. potential for over-hydration related to excessive thirst.
    b. potential for diarrhea related to dehydration.
    c. potential for pulmonary congestion related to excessive fluid intake.
    d. potential for fall related to confusion

Answer 25

d. potential for fall related to confusion

Question 26

26. The nurse is determining if I&O are within normal limits. Which of
    the following is an indication of a fluid imbalance?
    a. Twenty-four hour I&O totals show 2 L negative output. Compare daily weight to see if there is a weight gain of 2 kg.
    b. Shift I&O totals show a 2 L positive output. Compare the daily weights to see if there is a weight gain of 2 kg.
    c. Shift I&O totals show a 4 L negative output. Compare daily weights to see if there is a zero weight loss.
    d. Twenty-four hour I&O totals are equal. Compare daily weight to
    see if there is a negative weight loss.

Answer 26

a. Twenty-four hour I&O totals show 2 L negative output. Comparedaily weight to see if there is a weight gain of 2 kg

Question 27

1. The nurse clarifies that the electrolytes include: (Select all that apply.)
   a. sodium.
   b. fatty acids
   c. potassium
   d. magnesium.
   e. amino acids.
   f. glucose

Answer 27

A,C,D
A. Sodium
C. Potassium
D. Magnesium

Question 28

2. Based on the information provided, which of these measurements shouldbe recorded on the output sheet? (Select all that apply.)
   a. 250 mL nasogastric secretions
   b. 200 mL diarrhea stoolc. 900 mL IV therapy
   d. 650 mL urine from Foley cathetere. e. 50 mL chest tube drainage
   f. 240 mL milk

Answer 28

A,B,D,E
a. 250 mL nasogastric secretions
b. 200 mL diarrhea stool.
d. 650 mL urine from Foley cathetere. e. 50 mL chest tube drainage

Question 29

3. The nurse assessing a newly admitted patient with marked edema fromsevere heart failure would anticipate that the patient would exhibit: (Select all that apply.)
   a. a thready pulse.
   b. concentrated urine.
   c. hypertension.
   d. weight gain.
   e. crackles heard on auscultation

Answer 29

C,D,E
c. hypertension.
d. weight gain.
e. crackles heard on auscultation

Question 30

4. The nurse explains that water as a constituent of the body has the functions of: (Select all that apply.)
   a. transportation of nutrients
   b. blood pressure regulation.
   c. heat regulation.
   d. removing waste from the cells.
   e. assists with digestion of protein

Answer 30

A,C,D
a. transportation of nutrients
c. heat regulation.
d. removing waste from the cells

Question 31

1. A patient with a serum potassium value of less than 3.5 mEq/L is

Answer 31

Hypokalemic

Question 32

2. The nurse clarifies that when electrolytes are in solution, they break up and become ______

Answer 32

Ions