Chapter 15: Fluid and Chemical Balance
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. 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) _____ mm Hg.
a. increase of 5
b. drop of 40
c. drop of 20
d. increase of 10
ANS: C
A drop in systolic blood pressure by at least 20 mm Hg accompanied by a pulse rate
increase of at least 10 beats/min at 1 minute following position change is suggestive
of fluid-volume deficit.
DIF: Cognitive Level: Analysis REF: d 444, Clinical cues OBJ:
Clinical Practice #1 TOP: Assessment: Fluid and Electrolytes KEY:
Nursing Process Step: Assessment MSC: NCLEX: Physiological
Integrity: physiological adaptation
2. 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 _____ mL.
a. 360
b. 400
c. 420
d. 600
ANS: C
A coffee cup is generally equivalent to 240 mL, a half glass of juice is 60 mL, and
half a carton of milk is 120 mL.
DIF: Cognitive Level: Analysis REF: d 446, Table 25-8 OBJ:
Clinical Practice #1 TOP: Intake and Output KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic care and
comfort
3. At the beginning of the shift, a patients 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
ANS: B
75 mL/hr 8 hours = 600; 960 600 = 360.
DIF: Cognitive Level: Analysis REF: d 446 OBJ: Clinical Practice #1
, TOP: Intake and Output KEY: Nursing Process Step:
Assessment MSC: NCLEX: Physiological Integrity: pharmacological and
parenteral therapies
4. The physician 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.
ANS: A
The greatest amount of fluid is given during the day shift, followed by the evening
shift. The least amount of fluid is given at night, when the patient should be sleeping.
DIF: Cognitive Level: Comprehension REF: d 447 OBJ: Clinical
Practice #1 TOP: Intake and Output KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological Integrity: basic
care and comfort
5. 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.
ANS: B
Hypertonic fluids draw fluid from the intracellular space and reduce edema.
DIF: Cognitive Level: Comprehension REF: d 446, Table 25-6
OBJ: Clinical Practice #4 TOP: Hypertonic Solutions KEY:
Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity:
basic care and comfort
6. The patient who is prescribed a diuretic for fluid-volume excess is discharged home. The
patient verbalizes understanding of his disease process 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.
ANS: C
The patient will lose electrolytes, especially potassium, because he is on a diuretic;
snacks such as raisins and apricots are rich in potassium.
DIF: Cognitive Level: Analysis REF: d 437, Patient Teaching
OBJ: Clinical Practice #3 TOP: Teaching Plan for Sodium
Restriction KEY: Nursing Process Step: Evaluation MSC:
NCLEX: Health Promotion and Maintenance: prevention and early detection
of disease
7. The nurse is caring for a patient for whom a dose of IV potassium has been ordered. Prior
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. 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) _____ mm Hg.
a. increase of 5
b. drop of 40
c. drop of 20
d. increase of 10
ANS: C
A drop in systolic blood pressure by at least 20 mm Hg accompanied by a pulse rate
increase of at least 10 beats/min at 1 minute following position change is suggestive
of fluid-volume deficit.
DIF: Cognitive Level: Analysis REF: d 444, Clinical cues OBJ:
Clinical Practice #1 TOP: Assessment: Fluid and Electrolytes KEY:
Nursing Process Step: Assessment MSC: NCLEX: Physiological
Integrity: physiological adaptation
2. 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 _____ mL.
a. 360
b. 400
c. 420
d. 600
ANS: C
A coffee cup is generally equivalent to 240 mL, a half glass of juice is 60 mL, and
half a carton of milk is 120 mL.
DIF: Cognitive Level: Analysis REF: d 446, Table 25-8 OBJ:
Clinical Practice #1 TOP: Intake and Output KEY: Nursing Process
Step: Assessment MSC: NCLEX: Physiological Integrity: basic care and
comfort
3. At the beginning of the shift, a patients 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
ANS: B
75 mL/hr 8 hours = 600; 960 600 = 360.
DIF: Cognitive Level: Analysis REF: d 446 OBJ: Clinical Practice #1
, TOP: Intake and Output KEY: Nursing Process Step:
Assessment MSC: NCLEX: Physiological Integrity: pharmacological and
parenteral therapies
4. The physician 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.
ANS: A
The greatest amount of fluid is given during the day shift, followed by the evening
shift. The least amount of fluid is given at night, when the patient should be sleeping.
DIF: Cognitive Level: Comprehension REF: d 447 OBJ: Clinical
Practice #1 TOP: Intake and Output KEY: Nursing Process
Step: Planning MSC: NCLEX: Physiological Integrity: basic
care and comfort
5. 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.
ANS: B
Hypertonic fluids draw fluid from the intracellular space and reduce edema.
DIF: Cognitive Level: Comprehension REF: d 446, Table 25-6
OBJ: Clinical Practice #4 TOP: Hypertonic Solutions KEY:
Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity:
basic care and comfort
6. The patient who is prescribed a diuretic for fluid-volume excess is discharged home. The
patient verbalizes understanding of his disease process 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.
ANS: C
The patient will lose electrolytes, especially potassium, because he is on a diuretic;
snacks such as raisins and apricots are rich in potassium.
DIF: Cognitive Level: Analysis REF: d 437, Patient Teaching
OBJ: Clinical Practice #3 TOP: Teaching Plan for Sodium
Restriction KEY: Nursing Process Step: Evaluation MSC:
NCLEX: Health Promotion and Maintenance: prevention and early detection
of disease
7. The nurse is caring for a patient for whom a dose of IV potassium has been ordered. Prior
