الجزء الثالث اسئلة اختيارى على fluid and electrolyte balance

 (23)تكملة اسئلة ال mcq على fluid and electrolyte balance

ملاحظة:فيه اسئلة مش تبعنا فى المنهج

(1)An elderly patient was hydrated with lactated Ringer's solution in the emergency room for the last hour. During the most recent evaluation of the patient by the nurse, a finding of a rapid bounding pulse and shortness of breath were noted. Reporting this episode to the physician, the nurse suspects that the patient now shows signs of:
A. Hypovolemia, and needs more fluids
B. Hypervolemia, and needs the fluids adjusted
C. An acid-base disturbance
D. Needing no adjustment in fluid administration

 (2)A client taking lasix (furosemide) for congestive heart failure is seeing the physician for a potassium value of 3.0. An order for oral potassium taken daily is written and discussed with the client. In addition, potassium-rich foods should be eaten. The nurse educator meets with this client and has the client identify all of the following foods as potassium-rich except:
A. Baked potato
B. White bread
C. Apricot
D. Orange juice

.

(3)Edema that forms in clients with kidney disease is due to:
A. Reduced plasma oncotic pressure, so that fluid is not drawn into the capillaries from interstitial tissues
B. Decreased capillary hydrostatic pressures pushing fluid into the interstitial tissues
C. Capillaries becoming less permeable, allowing fluid to escape into interstitial tissues
D. Obstructed lymph flow that assists the movement of fluid from the interstitial tissues back into the vascular compartment

 (4)A client suffering from a narcotic overdose is seen in the Emergency Department. The client is confused, with warm, flushed skin, headache, and weakness. Vital signs of noted are T 102.6, HR 128, R 24, and BP 130/86. A blood gas analysis sample was drawn on room air, and the results are as follows: pH 7.33, PaCO2 53, PaO2 72, HCO3 24. This client is at risk for:
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

 (5)Measurements related to fluid balance of clients that a nurse can initiate without a physician's order include:
A. Daily weights, vital signs, and fluid intake and output
B. Daily weights, diuretics, and waist measurement
C. Monitoring temperature, fluid intake and output, and calorie count
D. Auscultating lung sounds, monitoring color of urine, and placing a Foley catheter into the client

(6)The nurse has been invited to discuss "the importance of promoting a good fluid and electrolyte balance in children" for a group of parents at the local school parents club meeting. Of the following actions, which is not representative of this topic?
A. Recognizing possible risk factors for fluid and electrolyte balance, such as prolonged or repeated vomiting, frequent watery stools, or inability to consume fluids
B. Increasing fluid intake before, during, and after strenuous exercise, particularly when the environmental temperature is high, and replacing lost electrolytes from excessive perspiration as needed with commercial electrolyte solutions
C. Consuming six to eight glasses of water daily
D. Encouraging excessive amounts of foods or fluids high in salt or caffeine

 (7)The nurse is admitting a new client, 80 years old, with congestive heart failure into your home health agency. The following assessment findings have been determined after meeting the client: overweight but no gain since the client left the hospital two days ago; VS: T 99.0, HR 100, R 22, BP 130/86. Foods eaten include canned soup at each meal, ham, and cheese. When completing the care plan for this client, the nurse should include which of the following nursing diagnosis:
A. Improved Gas Exchange
B. Risk for Fluid Volume Deficit
C. Risk for Fluid Volume Imbalance
D. Impaired Skin Integrity

 (8)Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period that blood:
A. Hanging for a longer four hours creates an increased risk of sepsis
B. May clot in the bag
C. May evaporate
D. May not clot in the recipient after this time period

 (9)A patient who is comatose is admitted to the hospital with an unknown history. Respirations are deep and rapid. Arterial blood gas levels on admission are pH, 7.20; PaCO2, 21 mm Hg; PaO2, 92 mm Hg; and HCO3-, 8. You interpret these laboratory values to indicate:
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis

(10)A patient with a cardiac history is taking the diuretic furosemide (Lasix) and is seen in the emergency department for muscle weakness. Which laboratory value do you assess first?
A. Serum albumin
B. Serum sodium
C. Hematocrit
D. Serum potassium

 (11)Which of these patients do you expect will need teaching regarding dietary sodium restriction?
A. An 88-year-old with a fractured femur scheduled for surgery
B. A 65-year-old recently diagnosed with heart failure
C. A 50-year-old recently diagnosed with asthma and diabetes
D. A 20-year-old with vomiting and diarrhea from gastroenteritis

 (12)You teach patients to replace sweat, vomiting, or diarrhea fluid losses with which type of fluid?
A. Tap water or bottled water
B. Fluid that has sodium (salt) in it
C. Fluid that has K+ and HCO3- in it
D. Coffee or tea, whichever they prefer

.

(13)You assess four patients. Which patient is at greatest risk for the development of hypocalcemia?
A. 56-year-old with acute kidney renal failure
B. 40-year-old with appendicitis
C. 28-year-old who has acute pancreatitis
D. 65-year-old with hypertension and asthma

 (14)Which of the following activities can you delegate to nursing assistive personnel (NAP)? (Select all that apply.)
A. Measuring oral intake and urine output
B. Preparing intravenous (IV) tubing for routine change
C. Reporting an IV container that is low in fluid
D. Changing an IV fluid container

 (15)Assessment findings consistent with intravenous (IV) fluid infiltration include: (Select all that apply.)
A. Edema and pain
B. Streak formation
C. Pain and erythema
D. Pallor and coolness
E. Numbness and pain
Rationale
Inadvertent fluid leakage into the interstitial compartment around an IV site can cause swelling, pain from the pressure, pale color, and coolness of the infiltrated area.

 (16)Which of the following defining characteristics is consistent with fluid volume deficit?
A. A 1-lb (0.5 kg) weight loss, pale yellow urine
B. Engorged neck veins when upright, bradycardia
C. Dry mucous membranes, thready pulse, tachycardia
D. Bounding radial pulse, fl at neck veins when supine

 (17)Which of the following assessments do you perform routinely when an older adult patient is receiving intravenous 0.9% NaCl?
A. Auscultate dependent portions of lungs
B. Check color of urine
C. Assess muscle strength
D. Check skin turgor over sternum or shin

 (18)While receiving a blood transfusion, your patient develops chills, tachycardia, and flushing. What is your priority action?
A. Notify a health care provider
B. Insert an indwelling catheter
C. Alert the blood bank
D. Stop the transfusion

 (19)The health care provider's order is 1000 mL 0.9% NaCl with 20 mEq K+ intravenously over 8 hours. Which assessment finding causes you to clarify the order with the health care provider before hanging this fluid?
A. Flat neck veins
B. Tachycardia
C. Hypotension
D. Oliguria

 (20)Your patient who has diabetic ketoacidosis is breathing rapidly and deeply. Intravenous (IV) fluids and other treatments have just been started. What should you do about this patient's breathing?
A. Notify her health care provider that she is hyperventilating
B. Provide frequent oral care to keep her mucous membranes moist
C. Ask her to breathe slower and help her to calm down and relax
D. Assess her for pain and request anour patient had 200 mL of ice (21)chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record?
A. 700 mL
B. 900 mL
C. 1000 mL
D. 1100 mL
order for a sedative

B. Provide frequent oral care to keep her mucous membranes moist
Rationale
Hyperventilation is a compensatory mechanism for metabolic acidosis and should be allowed to continue. Rapid breathing can make oral mucous membranes dry and cracked

(22)Your patient had 200 mL of ice chips and 900 mL intravenous (IV) fluid during your shift. Which total intake should you record?
A. 700 mL
B. 900 mL
C. 1000 mL
D. 1100 mL

C. 1000 mL
Rationale
Add one half the volume of ice chips to other intake to calculate total intake.

(23)The health care provider's order is 1000 mL 0.9% NaCl IV over 6 hours. Which rate do you program into the infusion pump?
A. 125 mL/hr
B. 167 mL/hr
C. 200 mL/hr
D. 1000 mL/hr

B. 167 mL/hr
Rationale
1000 mL divided by 6 hours is 166.7 mL/hr, which rounds to 167 mL/hr (if infusion pump accepts decimals, program it to 166.7 mL/hr)

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