NURSING: A CONCEPT-BASED APPROACH TO LEARNING,
2E (PEARSON) MODULE 6 FLUIDS AND ELECTROLYTES
EXAM QUESTIONS AND CORRECT ANSWERS
Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 6 Fluids and Electrolytes
The Concept of Fluids and Electrolytes
1) The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed
with a multisystem fluid volume deficit and documents that the client is experiencing the
following symptoms: tachycardia; pale, cool skin; and a decreased urine output. The nurse
knows that these symptoms are caused by:
A) The body's natural compensatory mechanisms.
B) Cardiac failure.
C) Pharmacological effects of a diuretic.
D) Effects of rapidly infused intravenous fluids.
Answer: A
Explanation: A) The internal vasoconstrictive compensatory reactions within the body are
responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally
specifically for the brain and heart. A diuretic would cause further fluid loss, and is
contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output.
The manifestations reported are not indicative of cardiac failure in this client.
B) The internal vasoconstrictive compensatory reactions within the body are responsible for the
symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the
brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused
intravenous fluids would not cause a decrease in urine output. The manifestations reported are
not indicative of cardiac failure in this client.
C) The internal vasoconstrictive compensatory reactions within the body are responsible for the
symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the
brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused
intravenous fluids would not cause a decrease in urine output. The manifestations reported are
not indicative of cardiac failure in this client.
D) The internal vasoconstrictive compensatory reactions within the body are responsible for the
symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the
brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused
intravenous fluids would not cause a decrease in urine output. The manifestations reported are
not indicative of cardiac failure in this client.
Page Ref: 339-340
Cognitive Level: Applying
Client Need: Physiological Integrity
1
Copyright © 2015 Pearson Education, Inc.
,Nursing Process: Implementation
Learning Outcome: 1. Summarize the physiology of the various body systems involved in the
maintenance of fluid and electrolyte balance.
2) The nurse is caring for a client who is 3 days postoperative following an emergency
appendectomy. The nurse is reviewing the client's lab values and notes that the client's calcium
levels have increased since before surgery. Which intervention should the nurse implement to
decrease the client's possibility of developing hypercalcemia?
A) Measure vital signs every 8 hours.
B) Assist the client to ambulate around the room at least three times daily.
C) Irrigate the client's Foley catheter daily.
D) Assist the client to turn, cough, and deep breathe every 2 hours.
Answer: B
Explanation: A) Hypercalcemia can occur from immobility. Ambulation of the client helps to
prevent leaching of calcium from the bones into the serum. None of the other options is related to
the development of hypercalcemia.
B) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching
of calcium from the bones into the serum. None of the other options is related to the development
of hypercalcemia.
C) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching
of calcium from the bones into the serum. None of the other options is related to the development
of hypercalcemia.
D) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching
of calcium from the bones into the serum. None of the other options is related to the development
of hypercalcemia.
Page Ref: 341
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Examine the relationship between fluid and electrolyte balance and other
concepts.
2
Copyright © 2015 Pearson Education, Inc.
,3) The nurse is reviewing the lab values for a client being cared for on the unit. The client's
phosphorus level is 2.0 mg/dL. The nurse is planning care for this client. Which nursing
intervention would address this client's phosphorus level?
A) Enforce contact precautions.
B) Encourage consumption of a high-calorie carbohydrate diet.
C) Strain all urine.
D) Encourage consumption of milk and yogurt.
Answer: D
Explanation: A) A phosphorus level of 2.0 is low, and the client will need additional dietary
phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide
that additional phosphorus. There is no indication of the need to place this client on contact
precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
B) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus.
Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that
additional phosphorus. There is no indication of the need to place this client on contact
precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
C) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus.
Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that
additional phosphorus. There is no indication of the need to place this client on contact
precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
D) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus.
Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that
additional phosphorus. There is no indication of the need to place this client on contact
precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
Page Ref: 342
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Identify commonly occurring alterations in fluid and electrolyte balance
and their related therapies.
3
Copyright © 2015 Pearson Education, Inc.
, 4) A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother
of a 3-month-old infant. The mother tells the nurse that the child has been vomiting and
experiencing diarrhea for several days. Which nurse response is most appropriate?
A) "You should bring the infant in to be seen by the doctor."
B) "Give your baby at least 2 ounces of juice every 2 hours."
C) "Give your baby 50 mL of glucose water every hour."
D) "Measure your baby's urine output for 24 hours and call back tomorrow."
Answer: A
Explanation: A) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea
in infants due to rapid fluid loss that can occur in this age group. They should also be taught the
importance of bringing an infant in this situation to healthcare providers for evaluation.
Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status,
and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the
next 24 hours would increase the potential for the infant to become dehydrated.
B) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due
to rapid fluid loss that can occur in this age group. They should also be taught the importance of
bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for
an infant who is actively vomiting will not improve fluid balance status, and juice and glucose
water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would
increase the potential for the infant to become dehydrated.
C) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due
to rapid fluid loss that can occur in this age group. They should also be taught the importance of
bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for
an infant who is actively vomiting will not improve fluid balance status, and juice and glucose
water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would
increase the potential for the infant to become dehydrated.
D) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due
to rapid fluid loss that can occur in this age group. They should also be taught the importance of
bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for
an infant who is actively vomiting will not improve fluid balance status, and juice and glucose
water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would
increase the potential for the infant to become dehydrated.
Page Ref: 344
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Differentiate common assessment procedures used to examine fluid and
electrolyte balance across the life span.
4
Copyright © 2015 Pearson Education, Inc.
2E (PEARSON) MODULE 6 FLUIDS AND ELECTROLYTES
EXAM QUESTIONS AND CORRECT ANSWERS
Nursing: A Concept-Based Approach to Learning, 2e (Pearson)
Module 6 Fluids and Electrolytes
The Concept of Fluids and Electrolytes
1) The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed
with a multisystem fluid volume deficit and documents that the client is experiencing the
following symptoms: tachycardia; pale, cool skin; and a decreased urine output. The nurse
knows that these symptoms are caused by:
A) The body's natural compensatory mechanisms.
B) Cardiac failure.
C) Pharmacological effects of a diuretic.
D) Effects of rapidly infused intravenous fluids.
Answer: A
Explanation: A) The internal vasoconstrictive compensatory reactions within the body are
responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally
specifically for the brain and heart. A diuretic would cause further fluid loss, and is
contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output.
The manifestations reported are not indicative of cardiac failure in this client.
B) The internal vasoconstrictive compensatory reactions within the body are responsible for the
symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the
brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused
intravenous fluids would not cause a decrease in urine output. The manifestations reported are
not indicative of cardiac failure in this client.
C) The internal vasoconstrictive compensatory reactions within the body are responsible for the
symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the
brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused
intravenous fluids would not cause a decrease in urine output. The manifestations reported are
not indicative of cardiac failure in this client.
D) The internal vasoconstrictive compensatory reactions within the body are responsible for the
symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the
brain and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused
intravenous fluids would not cause a decrease in urine output. The manifestations reported are
not indicative of cardiac failure in this client.
Page Ref: 339-340
Cognitive Level: Applying
Client Need: Physiological Integrity
1
Copyright © 2015 Pearson Education, Inc.
,Nursing Process: Implementation
Learning Outcome: 1. Summarize the physiology of the various body systems involved in the
maintenance of fluid and electrolyte balance.
2) The nurse is caring for a client who is 3 days postoperative following an emergency
appendectomy. The nurse is reviewing the client's lab values and notes that the client's calcium
levels have increased since before surgery. Which intervention should the nurse implement to
decrease the client's possibility of developing hypercalcemia?
A) Measure vital signs every 8 hours.
B) Assist the client to ambulate around the room at least three times daily.
C) Irrigate the client's Foley catheter daily.
D) Assist the client to turn, cough, and deep breathe every 2 hours.
Answer: B
Explanation: A) Hypercalcemia can occur from immobility. Ambulation of the client helps to
prevent leaching of calcium from the bones into the serum. None of the other options is related to
the development of hypercalcemia.
B) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching
of calcium from the bones into the serum. None of the other options is related to the development
of hypercalcemia.
C) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching
of calcium from the bones into the serum. None of the other options is related to the development
of hypercalcemia.
D) Hypercalcemia can occur from immobility. Ambulation of the client helps to prevent leaching
of calcium from the bones into the serum. None of the other options is related to the development
of hypercalcemia.
Page Ref: 341
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 2. Examine the relationship between fluid and electrolyte balance and other
concepts.
2
Copyright © 2015 Pearson Education, Inc.
,3) The nurse is reviewing the lab values for a client being cared for on the unit. The client's
phosphorus level is 2.0 mg/dL. The nurse is planning care for this client. Which nursing
intervention would address this client's phosphorus level?
A) Enforce contact precautions.
B) Encourage consumption of a high-calorie carbohydrate diet.
C) Strain all urine.
D) Encourage consumption of milk and yogurt.
Answer: D
Explanation: A) A phosphorus level of 2.0 is low, and the client will need additional dietary
phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide
that additional phosphorus. There is no indication of the need to place this client on contact
precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
B) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus.
Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that
additional phosphorus. There is no indication of the need to place this client on contact
precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
C) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus.
Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that
additional phosphorus. There is no indication of the need to place this client on contact
precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
D) A phosphorus level of 2.0 is low, and the client will need additional dietary phosphorus.
Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that
additional phosphorus. There is no indication of the need to place this client on contact
precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
Page Ref: 342
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 3. Identify commonly occurring alterations in fluid and electrolyte balance
and their related therapies.
3
Copyright © 2015 Pearson Education, Inc.
, 4) A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother
of a 3-month-old infant. The mother tells the nurse that the child has been vomiting and
experiencing diarrhea for several days. Which nurse response is most appropriate?
A) "You should bring the infant in to be seen by the doctor."
B) "Give your baby at least 2 ounces of juice every 2 hours."
C) "Give your baby 50 mL of glucose water every hour."
D) "Measure your baby's urine output for 24 hours and call back tomorrow."
Answer: A
Explanation: A) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea
in infants due to rapid fluid loss that can occur in this age group. They should also be taught the
importance of bringing an infant in this situation to healthcare providers for evaluation.
Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status,
and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the
next 24 hours would increase the potential for the infant to become dehydrated.
B) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due
to rapid fluid loss that can occur in this age group. They should also be taught the importance of
bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for
an infant who is actively vomiting will not improve fluid balance status, and juice and glucose
water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would
increase the potential for the infant to become dehydrated.
C) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due
to rapid fluid loss that can occur in this age group. They should also be taught the importance of
bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for
an infant who is actively vomiting will not improve fluid balance status, and juice and glucose
water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would
increase the potential for the infant to become dehydrated.
D) Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due
to rapid fluid loss that can occur in this age group. They should also be taught the importance of
bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for
an infant who is actively vomiting will not improve fluid balance status, and juice and glucose
water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would
increase the potential for the infant to become dehydrated.
Page Ref: 344
Cognitive Level: Applying
Client Need: Physiological Integrity
Nursing Process: Implementation
Learning Outcome: 4. Differentiate common assessment procedures used to examine fluid and
electrolyte balance across the life span.
4
Copyright © 2015 Pearson Education, Inc.
