CHAPTER 13 FLUID AND
ELECTROLYTES: BALANCE AND DISTURBANCE
EXAM WITH Q&A TESTED AND APPROVED!!!
You are performing an admission assessment on an older adult patient newly admitted for
end-stage liver disease. What principle should guide your assessment of the patients skin
turgor?
A) Overhydration is common among healthy older adults.
B) Dehydration causes the skin to appear spongy.
C) Inelastic skin turgor is a normal part of aging.
D) Skin turgor cannot be assessed in patients over 70. -- ANSWER--Answer: C
Inelastic skin is a normal change of aging. However, this does not mean that skin turgor
cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin
with tenting. Overhydration, not dehydration, causes the skin to appear edematous and
spongy.
The physician has ordered a peripheral IV to be inserted before the patient goes for computed
tomography. What should the nurse do when selecting a site on the hand or arm for insertion
of an IV catheter?
A) Choose a hairless site if available.
B) Consider potential effects on the patients mobility when selecting a site.
C) Have the patient briefly hold his arm over his head before insertion.
Page 1 of 50
,D) Leave the tourniquet on for at least 3 minutes. -- ANSWER--Answer: B Ideally, both
arms and hands are carefully inspected before choosing a specific venipuncture site that does
not interfere with mobility. Instruct the patient to hold his arm in a dependent position to
increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does
not necessarily need to be devoid of hair.
A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with
increased intracranial pressure. This solution will increase the number of dissolved particles
in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and
increase the blood volume. This process is best described as which of the following?
A) Hydrostatic pressure
B) Osmosis and osmolality
C) Diffusion
D) Active transport -- ANSWER--Answer: B
Osmosis is the movement of fluid from a region of low solute concentration to a region of
high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to
changes in water or volume related to water pressure. Diffusion is the movement of solutes
from an area of greater concentration to lesser concentration; the solutes in an intact vascular
system are unable to move so diffusion normally should not be taking place. Active transport
is the movement of molecules against the concentration gradient and requires adenosine
triphosphate (ATP) as an energy source; this process typically takes place at the cellular level
and is not involved in vascular volume changes.
You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic
hormone secretion (SIADH). Your patients 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
patients health?
Page 2 of 50
,A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status -- ANSWER--Answer: 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.
You are caring for a patient admitted with a diagnosis of acute kidney injury. When you
review your patients most recent laboratory reports, you note that the patients 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 -- ANSWER--Answer: A
To gauge a patients 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.
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
Page 3 of 50
, B) Hypermagnesemia
C) Hypercalcemia
D) Hypovolemia -- ANSWER--Answer: 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.
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 acidbase
imbalance?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Increased PaCO2
D) CNS disturbances -- ANSWER--Answer: 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.
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?
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ELECTROLYTES: BALANCE AND DISTURBANCE
EXAM WITH Q&A TESTED AND APPROVED!!!
You are performing an admission assessment on an older adult patient newly admitted for
end-stage liver disease. What principle should guide your assessment of the patients skin
turgor?
A) Overhydration is common among healthy older adults.
B) Dehydration causes the skin to appear spongy.
C) Inelastic skin turgor is a normal part of aging.
D) Skin turgor cannot be assessed in patients over 70. -- ANSWER--Answer: C
Inelastic skin is a normal change of aging. However, this does not mean that skin turgor
cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin
with tenting. Overhydration, not dehydration, causes the skin to appear edematous and
spongy.
The physician has ordered a peripheral IV to be inserted before the patient goes for computed
tomography. What should the nurse do when selecting a site on the hand or arm for insertion
of an IV catheter?
A) Choose a hairless site if available.
B) Consider potential effects on the patients mobility when selecting a site.
C) Have the patient briefly hold his arm over his head before insertion.
Page 1 of 50
,D) Leave the tourniquet on for at least 3 minutes. -- ANSWER--Answer: B Ideally, both
arms and hands are carefully inspected before choosing a specific venipuncture site that does
not interfere with mobility. Instruct the patient to hold his arm in a dependent position to
increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does
not necessarily need to be devoid of hair.
A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with
increased intracranial pressure. This solution will increase the number of dissolved particles
in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and
increase the blood volume. This process is best described as which of the following?
A) Hydrostatic pressure
B) Osmosis and osmolality
C) Diffusion
D) Active transport -- ANSWER--Answer: B
Osmosis is the movement of fluid from a region of low solute concentration to a region of
high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to
changes in water or volume related to water pressure. Diffusion is the movement of solutes
from an area of greater concentration to lesser concentration; the solutes in an intact vascular
system are unable to move so diffusion normally should not be taking place. Active transport
is the movement of molecules against the concentration gradient and requires adenosine
triphosphate (ATP) as an energy source; this process typically takes place at the cellular level
and is not involved in vascular volume changes.
You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic
hormone secretion (SIADH). Your patients 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
patients health?
Page 2 of 50
,A) Nutritional status
B) Potassium balance
C) Calcium balance
D) Fluid volume status -- ANSWER--Answer: 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.
You are caring for a patient admitted with a diagnosis of acute kidney injury. When you
review your patients most recent laboratory reports, you note that the patients 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 -- ANSWER--Answer: A
To gauge a patients 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.
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
Page 3 of 50
, B) Hypermagnesemia
C) Hypercalcemia
D) Hypovolemia -- ANSWER--Answer: 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.
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 acidbase
imbalance?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Increased PaCO2
D) CNS disturbances -- ANSWER--Answer: 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.
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?
Page 4 of 50
