Chapter 13: Fluid and Electrolytes- Balance and Disturbance
Hinkle: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th Edition
MULTIPLE CHOICE
1. You are caring for a patient who has a diagnosis of syndrome of inappropriate
antidiuretic hormone secretion (SIADH). Your patient's plan of care includes
assessment of specific gravity every 4 hours. The results of this test will allow
the nurse to assess what aspect of the patient's health?
A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status
ANS: D
A specific gravity will detect if the patient has a fluid volume deficit or fluid volume
excess. Nutrition, potassium, and calcium levels are not directly indicated.
2. You are caring for a patient admitted with a diagnosis of acute kidney injury.
When you review your patient's most recent laboratory reports, you note that
the patient's magnesium levels are high. You should prioritize assessment for
which of the following health problems?
A) Diminished deep tendon reflexes
B) Tachycardia
C) Cool, clammy skin
D) Acute flank pain
ANS: A
To gauge a patient's magnesium status, the nurse should check deep tendon
reflexes. If the reflex is absent, this may indicate high serum magnesium.
Tachycardia, flank pain, and cool, clammy skin are not typically associated with
hypermagnesemia.
3. You are working on a burns unit and one of your acutely ill patients is
, exhibiting signs and symptoms of third spacing. Based on this change in status,
you should expect the patient to exhibit signs and symptoms of what
imbalance?
A) Metabolic alkalosis
B) Hypermagnesemia
C) Hypercalcemia
D) Hypovolemia
ANS: D
Third-spacing fluid shift, which occurs when fluid moves out of the intravascular
space but not into the intracellular space, can cause hypovolemia. Increased
calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns
typically cause acidosis, not alkalosis.
4. A patient with a longstanding diagnosis of generalized anxiety disorder
presents to the emergency room. The triage nurse notes upon assessment that
the patient is hyperventilating. The triage nurse is aware that hyperventilation
is the most common cause of which acid-base imbalance?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Increased PaCO2
D) CNS
disturbances
ANS: B
, The most common cause of acute respiratory alkalosis is hyperventilation.
Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs
in emergency situations, such as pulmonary edema, and is exhibited by
hypoventilation and decreased PaCO2. CNS disturbances are found in extreme
hyponatremia and fluid overload.
5. You are an emergency-room nurse caring for a trauma patient. Your patient has
the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L.
How would you interpret these results?
A) Respiratory acidosis with no compensation
B) Metabolic alkalosis with a compensatory alkalosis
C) Metabolic acidosis with no compensation
D) Metabolic acidosis with a compensatory respiratory alkalosis
ANS: D
A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also
low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The
pH bicarbonate more closely corresponds with a decrease in pH, making the
metabolic component the primary problem.
6. You are making initial shift assessments on your patients. While assessing one
patient's peripheral IV site, you note edema around the insertion site. How should
you document this complication related to IV therapy?
A) Air emboli
B) Phlebitis
C) Infiltration
D) Fluid overload
ANS: C
Infiltration is the administration of nonvesicant solution or medication into the
surrounding tissue. This can occur when the IV cannula dislodges or perforates
the wall of the vein. Infiltration is characterized by edema around the insertion
Hinkle: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th Edition
MULTIPLE CHOICE
1. You are caring for a patient who has a diagnosis of syndrome of inappropriate
antidiuretic hormone secretion (SIADH). Your patient's plan of care includes
assessment of specific gravity every 4 hours. The results of this test will allow
the nurse to assess what aspect of the patient's health?
A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status
ANS: D
A specific gravity will detect if the patient has a fluid volume deficit or fluid volume
excess. Nutrition, potassium, and calcium levels are not directly indicated.
2. You are caring for a patient admitted with a diagnosis of acute kidney injury.
When you review your patient's most recent laboratory reports, you note that
the patient's magnesium levels are high. You should prioritize assessment for
which of the following health problems?
A) Diminished deep tendon reflexes
B) Tachycardia
C) Cool, clammy skin
D) Acute flank pain
ANS: A
To gauge a patient's magnesium status, the nurse should check deep tendon
reflexes. If the reflex is absent, this may indicate high serum magnesium.
Tachycardia, flank pain, and cool, clammy skin are not typically associated with
hypermagnesemia.
3. You are working on a burns unit and one of your acutely ill patients is
, exhibiting signs and symptoms of third spacing. Based on this change in status,
you should expect the patient to exhibit signs and symptoms of what
imbalance?
A) Metabolic alkalosis
B) Hypermagnesemia
C) Hypercalcemia
D) Hypovolemia
ANS: D
Third-spacing fluid shift, which occurs when fluid moves out of the intravascular
space but not into the intracellular space, can cause hypovolemia. Increased
calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns
typically cause acidosis, not alkalosis.
4. A patient with a longstanding diagnosis of generalized anxiety disorder
presents to the emergency room. The triage nurse notes upon assessment that
the patient is hyperventilating. The triage nurse is aware that hyperventilation
is the most common cause of which acid-base imbalance?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Increased PaCO2
D) CNS
disturbances
ANS: B
, The most common cause of acute respiratory alkalosis is hyperventilation.
Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs
in emergency situations, such as pulmonary edema, and is exhibited by
hypoventilation and decreased PaCO2. CNS disturbances are found in extreme
hyponatremia and fluid overload.
5. You are an emergency-room nurse caring for a trauma patient. Your patient has
the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L.
How would you interpret these results?
A) Respiratory acidosis with no compensation
B) Metabolic alkalosis with a compensatory alkalosis
C) Metabolic acidosis with no compensation
D) Metabolic acidosis with a compensatory respiratory alkalosis
ANS: D
A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also
low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The
pH bicarbonate more closely corresponds with a decrease in pH, making the
metabolic component the primary problem.
6. You are making initial shift assessments on your patients. While assessing one
patient's peripheral IV site, you note edema around the insertion site. How should
you document this complication related to IV therapy?
A) Air emboli
B) Phlebitis
C) Infiltration
D) Fluid overload
ANS: C
Infiltration is the administration of nonvesicant solution or medication into the
surrounding tissue. This can occur when the IV cannula dislodges or perforates
the wall of the vein. Infiltration is characterized by edema around the insertion
