CHAPTER 4 Fluid, electrolyte, and acid-base balance problems
1.The client’s nursing diagnosis is Deficient Fluid Volume related to excessive fluid
loss. Which action related to fluid management should be delegated to a UAP?
o 1.Administering IV fluids as prescribed by the physician
o 2.Providing straws and offering fluids between meals
o 3.Developing a plan for added fluid intake over 24 hours
o 4.Teaching family members to assist the client with fluid intake
2.The client also has the nursing diagnosis Decreased Cardiac Output related to
decreased plasma volume. Which assessment finding supports this nursing diagnosis?
o 1.Flattened neck veins when the client is in the supine position
o 2.Full and bounding pedal and post-tibial pulses
o 3.Pitting edema located in the feet, ankles, and calves
o 4.Shallow respirations with crackles on auscultation
3.The nursing care plan for the client with dehydration includes interventions for oral
health. Which interventions are within the scope of practice for an LPN/LVN being
supervised by a nurse? (Select all that apply.)
o 1.Reminding the client to avoid commercial mouthwashes
o 2.Encouraging mouth rinsing with warm saline
o 3.Observing the lips, tongue, and mucous membranes
o 4.Providing mouth care every 2 hours while the client is awake
o 5.Seeking a dietary consult to increase fluids on meal trays
4.The health care provider has written all of these orders for a client with a diagnosis
of Excess Fluid Volume. The client’s morning assessment reveals bounding peripheral
pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which
order takes priority at this time?
o 1.Weigh the client every morning.
o 2.Maintain accurate intake and output records.
o 3.Restrict fluids to 1500 mL/day.
o 4.Administer furosemide (Lasix) 40 mg IV push.
5.You have been floated to the telemetry unit for the day. The monitor watcher informs
you that the client has developed prominent U waves. Which laboratory value should you
check immediately?
o 1.Sodium
o 2.Potassium
o 3.Magnesium
o 4.Calcium
6.A client’s potassium level is 6.7 mEq/L. Which intervention should you delegate to
the first-year student nurse whom you are supervising?
o 1.Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally.
o 2.Administer spironolactone (Aldactone) 25 mg orally.
o 3.Assess the electrocardiogram (ECG) strip for tall T waves.
o 4.Administer potassium 10 mEq orally.
7.A client is admitted to the unit with a diagnosis of syndrome of inappropriate
antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would you be
sure to monitor?
o 1.Hypokalemia
o 2.Hyperkalemia
o 3.Hyponatremia
o 4.Hypernatremia
, 8.The charge nurse assigned the care of a client with acute kidney failure and
hypernatremia to you, a newly-graduated RN. Which action can you delegate to the UAP?
o 1.Providing oral care every 3 to 4 hours
o 2.Monitoring for indications of dehydration
o 3.Administering 0.45% saline by IV line
o 4.Assessing daily weights for trends
9.An experienced LPN/LVN reports to you that a client’s blood pressure and heart rate
have decreased, and when his face is assessed, one side twitches. What action should you
take at this time?
o 1.Reassess the client’s blood pressure and heart rate.
o 2.Review the client’s morning calcium level.
o 3.Request a neurologic consult today.
o 4.Check the client’s pupillary reaction to light.
10.You are preparing to discharge a client whose calcium level was low but is now just
barely within the normal range (9 to 10.5 mg/dL). Which statement by the client indicates
to you the need for additional teaching?
o 1.“I will call my doctor if I experience muscle twitching or seizures.”
o 2.“I will make sure to take my vitamin D with my calcium each day.”
o 3.“I will take my calcium citrate pill every morning before breakfast.”
o 4.“I will avoid dairy products, broccoli, and spinach when I eat.”
11.The UAP asks you why the client with a chronically low phosphorus level needs so
much assistance with activities of daily living. What is your best response?
o 1.“The client’s low phosphorus is probably due to malnutrition.”
o 2.“The client is just worn out from not getting enough rest.”
o 3.“The client’s skeletal muscles are weak because of the low phosphorus.”
o 4.“The client will do more for himself when his phosphorus level is normal.”
12.You are reviewing the client’s morning laboratory results. Which of these results is
of most concern to you?
o 1.Serum potassium level of 5.2 mEq/L
o 2.Serum sodium level of 134 mEq/L
o 3.Serum calcium level of 10.6 mg/dL
o 4.Serum magnesium level of 0.8 mEq/L
13.As the charge nurse, you would assign which client to the step-down unit nurse
floated to the intensive care unit for the day?
o 1.68-year-old on a ventilator with acute respiratory failure and respiratory
acidosis
o 2.72-year-old with chronic obstructive pulmonary disease (COPD) and normal
blood gas values who is ventilator dependent
o 3.Newly-admitted 56-year-old with diabetic ketoacidosis receiving an insulin drip
o 4.38-year-old on a ventilator with narcotic overdose and respiratory alkalosis
14.The client with respiratory failure is receiving mechanical ventilation and continues
to produce arterial blood gas results indicating respiratory acidosis. Which change in
ventilator setting should you expect to correct this problem?
o 1.Increase in ventilator rate from 6 to 10 breaths/min
o 2.Decrease in ventilator rate from 10 to 6 breaths/min
o 3.Increase in oxygen concentration from 30% to 40%
o 4.Decrease in oxygen concentration from 40% to 30%
15.Which action should you delegate to a UAP for the client with diabetic
ketoacidosis? (Select all that apply.)
o 1.Checking fingerstick glucose results every hour
o 2.Recording intake and output every hour
, o 3.Measuring vital signs every 15 minutes
o 4.Assessing for indicators of fluid imbalance
o 5.Notifying the provider of changes in glucose level
16.You are admitting an older adult client to the medical unit. Which assessment factor
alerts you that this client has a risk for acid-base imbalances?
o 1.History of myocardial infarction 1 year ago
o 2.Antacid use for occasional indigestion
o 3.Shortness of breath with extreme exertion
o 4.Chronic renal insufficiency
17.A client with lung cancer has received oxycodone (Roxicodone) 10 mg orally for
pain. When the student nurse assesses the client, which finding would you instruct the
student to report immediately?
o 1.Respiratory rate of 8 to 10 breaths/min
o 2.Decrease in pain level from 6 to 2 (on a scale of 10)
o 3.Request by the client that the room door be closed
o 4.Heart rate of 90 to 100 beats/min
18.The UAP reports to you that a client seems very anxious, and vital sign
measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance
should you suspect?
o 1.Respiratory acidosis
o 2.Respiratory alkalosis
o 3.Metabolic acidosis
o 4.Metabolic alkalosis
19.A client is admitted to your unit for chemotherapy. To prevent an acid-base
problem, which finding would you instruct the UAP to report?
o 1.Repeated episodes of nausea and vomiting
o 2.Reports of pain associated with exertion
o 3.Failure to eat all the food on the breakfast tray
o 4.Client hair loss during the morning bath
20.The client has a nasogastric (NG) tube connected to intermittent wall suction. The
student nurse asks why the client’s respiratory rate has decreased. What is your best
response?
o 1.“It’s common for clients with uncomfortable equipment such as NG tubes to
have a lower rate of breathing.”
o 2.“The client may have a metabolic alkalosis due to the NG suctioning, and the
decreased respiratory rate is a compensatory mechanism.”
o 3.“Whenever a client develops a respiratory acid-base problem, decreasing the
respiratory rate helps correct the problem.”
o 4.“The client is hypoventilating because of anxiety, and we will have to stay
alert for the development of respiratory acidosis.”
21.The client has an order for hydrochlorothiazide (HCTZ, Microzide) 10 mg orally
every day. What should you be sure to include in a teaching plan for this drug? (Select all
that apply.)
o 1.“Take this medication in the morning.”
o 2.“This medication should be taken in 2 divided doses when you get up and
when you go to bed.”
o 3.“Eat foods with extra sodium every day.”
o 4.“Inform your prescriber if you notice weight gain or increased swelling.”
o 5.“You should expect your urine output to increase.”
22.Which blood test result would you be sure to monitor for the client taking HCTZ?
o 1.Sodium level
1.The client’s nursing diagnosis is Deficient Fluid Volume related to excessive fluid
loss. Which action related to fluid management should be delegated to a UAP?
o 1.Administering IV fluids as prescribed by the physician
o 2.Providing straws and offering fluids between meals
o 3.Developing a plan for added fluid intake over 24 hours
o 4.Teaching family members to assist the client with fluid intake
2.The client also has the nursing diagnosis Decreased Cardiac Output related to
decreased plasma volume. Which assessment finding supports this nursing diagnosis?
o 1.Flattened neck veins when the client is in the supine position
o 2.Full and bounding pedal and post-tibial pulses
o 3.Pitting edema located in the feet, ankles, and calves
o 4.Shallow respirations with crackles on auscultation
3.The nursing care plan for the client with dehydration includes interventions for oral
health. Which interventions are within the scope of practice for an LPN/LVN being
supervised by a nurse? (Select all that apply.)
o 1.Reminding the client to avoid commercial mouthwashes
o 2.Encouraging mouth rinsing with warm saline
o 3.Observing the lips, tongue, and mucous membranes
o 4.Providing mouth care every 2 hours while the client is awake
o 5.Seeking a dietary consult to increase fluids on meal trays
4.The health care provider has written all of these orders for a client with a diagnosis
of Excess Fluid Volume. The client’s morning assessment reveals bounding peripheral
pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which
order takes priority at this time?
o 1.Weigh the client every morning.
o 2.Maintain accurate intake and output records.
o 3.Restrict fluids to 1500 mL/day.
o 4.Administer furosemide (Lasix) 40 mg IV push.
5.You have been floated to the telemetry unit for the day. The monitor watcher informs
you that the client has developed prominent U waves. Which laboratory value should you
check immediately?
o 1.Sodium
o 2.Potassium
o 3.Magnesium
o 4.Calcium
6.A client’s potassium level is 6.7 mEq/L. Which intervention should you delegate to
the first-year student nurse whom you are supervising?
o 1.Administer sodium polystyrene sulfonate (Kayexalate) 15 g orally.
o 2.Administer spironolactone (Aldactone) 25 mg orally.
o 3.Assess the electrocardiogram (ECG) strip for tall T waves.
o 4.Administer potassium 10 mEq orally.
7.A client is admitted to the unit with a diagnosis of syndrome of inappropriate
antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would you be
sure to monitor?
o 1.Hypokalemia
o 2.Hyperkalemia
o 3.Hyponatremia
o 4.Hypernatremia
, 8.The charge nurse assigned the care of a client with acute kidney failure and
hypernatremia to you, a newly-graduated RN. Which action can you delegate to the UAP?
o 1.Providing oral care every 3 to 4 hours
o 2.Monitoring for indications of dehydration
o 3.Administering 0.45% saline by IV line
o 4.Assessing daily weights for trends
9.An experienced LPN/LVN reports to you that a client’s blood pressure and heart rate
have decreased, and when his face is assessed, one side twitches. What action should you
take at this time?
o 1.Reassess the client’s blood pressure and heart rate.
o 2.Review the client’s morning calcium level.
o 3.Request a neurologic consult today.
o 4.Check the client’s pupillary reaction to light.
10.You are preparing to discharge a client whose calcium level was low but is now just
barely within the normal range (9 to 10.5 mg/dL). Which statement by the client indicates
to you the need for additional teaching?
o 1.“I will call my doctor if I experience muscle twitching or seizures.”
o 2.“I will make sure to take my vitamin D with my calcium each day.”
o 3.“I will take my calcium citrate pill every morning before breakfast.”
o 4.“I will avoid dairy products, broccoli, and spinach when I eat.”
11.The UAP asks you why the client with a chronically low phosphorus level needs so
much assistance with activities of daily living. What is your best response?
o 1.“The client’s low phosphorus is probably due to malnutrition.”
o 2.“The client is just worn out from not getting enough rest.”
o 3.“The client’s skeletal muscles are weak because of the low phosphorus.”
o 4.“The client will do more for himself when his phosphorus level is normal.”
12.You are reviewing the client’s morning laboratory results. Which of these results is
of most concern to you?
o 1.Serum potassium level of 5.2 mEq/L
o 2.Serum sodium level of 134 mEq/L
o 3.Serum calcium level of 10.6 mg/dL
o 4.Serum magnesium level of 0.8 mEq/L
13.As the charge nurse, you would assign which client to the step-down unit nurse
floated to the intensive care unit for the day?
o 1.68-year-old on a ventilator with acute respiratory failure and respiratory
acidosis
o 2.72-year-old with chronic obstructive pulmonary disease (COPD) and normal
blood gas values who is ventilator dependent
o 3.Newly-admitted 56-year-old with diabetic ketoacidosis receiving an insulin drip
o 4.38-year-old on a ventilator with narcotic overdose and respiratory alkalosis
14.The client with respiratory failure is receiving mechanical ventilation and continues
to produce arterial blood gas results indicating respiratory acidosis. Which change in
ventilator setting should you expect to correct this problem?
o 1.Increase in ventilator rate from 6 to 10 breaths/min
o 2.Decrease in ventilator rate from 10 to 6 breaths/min
o 3.Increase in oxygen concentration from 30% to 40%
o 4.Decrease in oxygen concentration from 40% to 30%
15.Which action should you delegate to a UAP for the client with diabetic
ketoacidosis? (Select all that apply.)
o 1.Checking fingerstick glucose results every hour
o 2.Recording intake and output every hour
, o 3.Measuring vital signs every 15 minutes
o 4.Assessing for indicators of fluid imbalance
o 5.Notifying the provider of changes in glucose level
16.You are admitting an older adult client to the medical unit. Which assessment factor
alerts you that this client has a risk for acid-base imbalances?
o 1.History of myocardial infarction 1 year ago
o 2.Antacid use for occasional indigestion
o 3.Shortness of breath with extreme exertion
o 4.Chronic renal insufficiency
17.A client with lung cancer has received oxycodone (Roxicodone) 10 mg orally for
pain. When the student nurse assesses the client, which finding would you instruct the
student to report immediately?
o 1.Respiratory rate of 8 to 10 breaths/min
o 2.Decrease in pain level from 6 to 2 (on a scale of 10)
o 3.Request by the client that the room door be closed
o 4.Heart rate of 90 to 100 beats/min
18.The UAP reports to you that a client seems very anxious, and vital sign
measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance
should you suspect?
o 1.Respiratory acidosis
o 2.Respiratory alkalosis
o 3.Metabolic acidosis
o 4.Metabolic alkalosis
19.A client is admitted to your unit for chemotherapy. To prevent an acid-base
problem, which finding would you instruct the UAP to report?
o 1.Repeated episodes of nausea and vomiting
o 2.Reports of pain associated with exertion
o 3.Failure to eat all the food on the breakfast tray
o 4.Client hair loss during the morning bath
20.The client has a nasogastric (NG) tube connected to intermittent wall suction. The
student nurse asks why the client’s respiratory rate has decreased. What is your best
response?
o 1.“It’s common for clients with uncomfortable equipment such as NG tubes to
have a lower rate of breathing.”
o 2.“The client may have a metabolic alkalosis due to the NG suctioning, and the
decreased respiratory rate is a compensatory mechanism.”
o 3.“Whenever a client develops a respiratory acid-base problem, decreasing the
respiratory rate helps correct the problem.”
o 4.“The client is hypoventilating because of anxiety, and we will have to stay
alert for the development of respiratory acidosis.”
21.The client has an order for hydrochlorothiazide (HCTZ, Microzide) 10 mg orally
every day. What should you be sure to include in a teaching plan for this drug? (Select all
that apply.)
o 1.“Take this medication in the morning.”
o 2.“This medication should be taken in 2 divided doses when you get up and
when you go to bed.”
o 3.“Eat foods with extra sodium every day.”
o 4.“Inform your prescriber if you notice weight gain or increased swelling.”
o 5.“You should expect your urine output to increase.”
22.Which blood test result would you be sure to monitor for the client taking HCTZ?
o 1.Sodium level
