Fluid and Electrolyte Imbalances

Quiz 1

• Excess fluid volume in heart failure presents as increased blood pressure and respirations.
• Potassium deficit risk is determined when a client requires nasogastric suction.
• Suspected hypocalcemia presents as twitching.
• Diuretics can cause a sodium level of 130 mEq/L (130 mmol/L).
• Hyponatremia signs expect hyperactive bowel sounds.
• Malnutrition likely causes a serum phosphorus level of 1.8 mg/dL (0.45) mmol/L.
• Insensible fluid loss occurs through the gastrointestinal tract
• A client with an ileostomy is most likely at risk for a fluid volume deficit.
• Intravenous (IV) diuretics can cause fluid volume deficit showing weight loss and poor skin turgor

Quiz 1 Continued

• Increased respirations and increased blood pressure are sings for fluid volume excess
• Kidney disease and a 12-year history of diabetes mellitus are risk factors for fluid volume excess.
• A traumatic burn leads to the development of a potassium level of 5.5 mEq/L (5.5 mmol/L).
• A solution of 0.45% sodium chloride is categorized as hypotonic
• Extracellular fluid volume excess presents as distended jugular veins.
• Diarrhea can cause a decrease in tissue turgor.
• Vomiting and diarrhea will cause a loss of body weight which indicates fluid deficit.
• In intracellular fluid, potassium is the most important electrolyte
• Acute kidney failure causes diminished acid-base balance of the body
• Clear breath sounds indicate successful treatment for excessive fluid volume.
• For a serum potassium level has increased to 5.8 mEq/L, take vital signs and notify the health care provider.
• Causes of ascites: Diminished plasma protein level

Quiz 1 Arterial Blood Gas & IV Infusion

• Arterial blood gas with pH of 7.52, PCO2 of 32 mm Hg, and HCO3 of 24 mEq/L indicates excessive mechanical ventilation.
• Using serum albumin maintains oncotic pressure
• For an IV infiltration, discontinue the infusion.
• If IV containing potassium infuses too rapidly, insulin is added to a 10% dextrose in water solution to move potassium into body cells with glucose and insulin.

Quiz 1 Nursing Responses & Clinical Indicators

• "You are concerned about your diagnosis" is the best response if a client appears anxious and says, "The doctor told me I have lung cancer. My father died from cancer. I wish I had never smoked."
• Muscle spasms can indicate hypokalemia.
• The most likely cause of IV infiltration is failure to secure the catheter adequately
• For a client with ascites receiving albumin, slow IV rate and restricted fluid intake provide greatest therapeutic effect
• Clinical indicators to expect with hyperkalemia include weakness and dysrhythmias
• An addition of 20 mEq of potassium chloride to IV solution of a client with diabetic ketoacidosis replaces excessive losses.

CA Quiz 3 The Nurse Prioritizes Assessments

• The nurse should prioritize assessing shortness of breath for a patient who has a pleural effusion and who underwent a thoracoscopic procedure earlier in the morning.
• Criteria that will determine when to give fluids, is a positive cough and gag reflex for a post bronchoscopy patient
• The best time to collect a sputum sample is first thing in the morning.
• Continuous wheezes suggest asthma during inspiration and expiration on a teenage girl who presented with acute shortness of breath

CA Quiz Assessment of Emphysema

• Assessment when preparing to auscultate for a patient experiencing an exacerbation of her emphysema symptoms, anticipate faint breath sounds with prolonged expiration
• Upon assessment, crackles will indicate heart failure
• Confusion and lethargy are complications related to the administration of large doses of lidocaine in the elderly.
• TB skin test doesn't differentiate between active and dormant TB infection
• A lower respiratory tract infection most often causes impaired gas exchange

CA Quiz, Acute Exacerbation

• The accurate measurement of the concentration of oxygen is an arterial blood gas (ABG) study when a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease, has increased dyspnea.
• Sputum that is greenish and in large quantity can indicate an infection.
• A COPD and cor pulmonale patient in discharge needs to weigh themselves and report a gain of 2 lb in a day.
• Pleural fluid lubricates the movement of the thorax and lungs.

CA Quiz, Pulmonary Conditions

• During which condition would lead to an increase in lung compliance? Emphysema
• If the chest drainage system is disconnected, place the end of the chest tube in a container of sterile saline.
• Tidal volume denotes the volume of air inspired and expired with a normal breath.
• The nurse should be alert for seizures in a client with respiratory acidosis
• Tonsils help to guard the body from invasion of organisms.
• Assessing four normal breaths followed by an episode of apnea lasting 20 seconds indicate Biots respiration
• Dyspnea and wheezing throughout lung fields can mean the patient has a narrowed airway.

Quiz 4: The Nurse is Preparing to Suction

• Limit suctioning time to a maximum of 10 seconds
• Home care instructions for tuberculosis: resume activities gradually, cover mouth and noise and put used tissues in plastic bags
• Pursed-lip breathing is to promote carbon dioxide elimination
• Report shortness of breath as an early sign of exacerbation for a client with pulmonary sarcoidosis
• The nurse should expect to note pain, especially with inspiration for a client with a fractured rib

Quiz 4: Findings After Bronchoscopy and the Alarms

• The nurse should immediately report blood-streaked sputum to the health care provider.
• The nurse should ventilate the client manually
• The nurse should prepare a Venturi mask.
• Confirm tuberculosis with a sputum culture
• Sitting up and leaning on an overbed table enhances breathing during dyspneic periods.
• The most distinctive sign of flail chest is paradoxical chest movement

Quiz 4: AIDS and HIV

• Client who has human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST), a 7-mm area of induration at the site of the skin test means a positive result
• Percussion and vibration will help the client after they are positioned for postural drainage.
• Assess for Increased respiratory rate as the earliest sign of acute respiratory distress syndrome.
• The nurse can indicate that a pneumothorax is present with Diminished breath sounds
• Stop the procedure and reoxygenate the client if heart rate is decreasing during suctioning.

Quiz 4: Bed Baths and Chest Trauma

• When giving a bed bath the nurse should wear a particulate respirator, gown, and gloves for TB
• With chest trauma, if the high-pressure alarm goes off on the ventilator, and you note absences of breath sounds, means to check for the other signs of a right pneumothorax.
• Expect a client with acute exacerbation of chronic obstructive pulmonary disease to have decreased oxygen saturation with mild exercise and a hyperinflated chest noted on the chest x-ray