Chapter 38 Fluids, Electrolytes, & Acid–Base Balance

Chapter 38  Fluids, Electrolytes, & Acid–Base Balance

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. After morning care, the nurse lowered the height of the IV container infusing via gravity flow, at the patient’s request. What is the nurse’s next best action?
a)
Calculate the new infusion rate.
b)
Readjust the infusion rate, as needed.
c)
Change the IV site and move it to the other arm.
d)
Instruct the client to call when the IV bag is empty.

ANS: B
The rate of an IV infusing via gravity draining will be altered by raising or lowering the IV solution. Thus, if the IV pole is lowered, the rate will need to be verified and adjusted as needed. The drip rate is based on the administration set and prescribed rate and is not affected by the height of the IV solution. The IV site will need to be changed only when clinically indicated. The nurse should not rely on the patient, but should monitor the infusion amount.

Difficulty: Easy
Nursing Process: NA
Client Need: HPM
Cognitive Level: Application

PTS: 1

2. The nurse has started to infuse the first of two units of packed red blood cells (prbc) on her patient. What is the nurse’s next best action?
a)
Delegate to the NAP to take vital signs every 15 minutes for 1 hour.
b)
Infuse the blood at a rate of 100 mL/hr so it will infuse in 4 hours.
c)
Infuse an IV solution of lactated Ringer’s with the blood.
d)
Remain with the patient for the first 15 minutes of the infusion.

ANS: D
The nurse’s next best action is to stay with the patient and assess for a transfusion reaction, which is more likely with the first 50 mL of the blood. The nurse should not delegate the initial vital sign to the NAP. The only compatible IV solution that can infuse with blood is normal saline (0.9% NS).

Difficulty: Moderate
Nursing Process: NA
Client Need: PHSI
Cognitive Level: Application

PTS: 1

3. What is the recommended position for a patient who is experiencing an air embolus because of failure to prime the IV tubing?
a)
High-Fowler’s
b)
Supine
c)
Trendelenburg, on the left side
d)
Prone, on the right side

ANS: C
The patient should be put in the Trendelenburg position to prevent air from traveling through the right side of the heart into the pulmonary artery, which could create a blockage in ventricular outflow.

Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1

4. A patient receiving a unit of whole blood begins to complain of “feeling funny” and having chills. The nurse assesses that the patient has dyspnea, hypotension, and tachycardia. Which blood transfusion reaction should the nurse suspect?
a)
Febrile
b)
Circulatory overload
c)
Hemolytic
d)
Allergic

ANS: C
These are the signs and symptoms of a hemolytic reaction, which includes fever, chills, dyspnea, tachycardia, chest pains, and hypotension. The blood should be stopped immediately, as this can be a fatal reaction. Fever, chills, and flushed skin are signs of a febrile reaction. A patient experiencing an allergic reaction will complain of flushing, wheezing, itching, and hives. A patient with fluid overload will have distended neck veins and difficulty breathing, and crackles can be auscultated.

Difficulty: Moderate
Nursing Process: NA
Client Need: HPM
Cognitive Level: Application

PTS: 1

5. A client is admitted to the emergency department (ED) in respiratory distress. The results of his arterial blood gases are the following: pH = 7.30; PCO2 = 40; HCO3 = 19 mEq/L; PO2 = 80. The nurse interprets the findings as which of the following?
a)
Respiratory acidosis with normal oxygen levels
b)
Respiratory alkalosis with hypoxia
c)
Metabolic acidosis with normal oxygen levels
d)
Metabolic alkalosis with hypoxia

ANS: C
The pH is acidotic. The HCO3 of 19 mEq/L is low and has moved in the same direction as the pH, indicating a metabolic disorder. The PCO2 is within normal range with no signs of compensation. The PO2 level is normal.

Difficulty: Difficult
Nursing Process: Diagnosis
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1