Mikee J.

Delos Santos
BSN III-2

1. You are caring for a patient taking the diuretic furosemide. Yesterday, the
patient’s weight was 62 kg. After the dose of furosemide yesterday, the
patient’s urine output was 2,500 ml. What do you expect the patient’s
weight to be today?
Answer: 59.5 kg

2. In prioritizing patient care, you recognize that the pt most at risk for FVD is
a) A 30 year old man with a fractured tibia
b) An 82 year old woman with a fractured hip
c) A 62 year old man with a heart attack
d) A 35 year old woman who just delivered a baby

Answer: An 82 year old woman with a fractured hip

Rationale: Although all of these clients might experience fluid volume deficit, the
most at risk are clients at the extreme of age, either young or old; in this
case the 82-year-old client.

Ms. Hicks

3. 39 year old female

 history of vomiting & diarrhea from the flu
 rapid pulse orthostatic hypotension
 urine output of 20 mL/hr
 skin turgor poor with tenting
 increased respiratory rate

 Which type of dehydration do you suspect that this Ms. Hicks has? Explain
your answer.
Answer: Isotonic dehydration, in this form of dehydration, water and
sodium are lost from the extracellular fluid in equivalent amounts and
there is no osmotic movement of water from the inside of cells to the
Mikee J. Delos Santos
BSN III-2
outside. Isotonic dehydration is often caused by diarrhea, vomiting or
inadequate intake of fluid.

4. In evaluating the client’s laboratory values, would you expect the following
values to be normal, elevated, or decreased?
 Urine specific gravity- elevated
 Urine volume- decreased
 Serum sodium- elevated
 Serum hct & hgb- elevated
 BUN- normal
 Serum osmolality- elevated

5. When assessing a patient with FVD, the nurse would expect to find:
 Increased pulse rate and BP
 Dyspnea and respiratory crackles
 Headache and muscle cramps
 Orthostatic hypotension and flat

Answer: Orthostatic hypotension and flat

Rationale:
In fluid volume deficit, there is less volume in the vascular system, which
decreases venous return and cardiac output, leading to manifestations of
dizziness, orthostatic hypotension, and flat neck veins. The heart rate increases
and the blood pressure falls. Dyspnea and crackles usually are associated with
excess fluid volume. Headache and muscle cramps are often due to electrolyte
imbalance, not fluid loss

 What compensatory mechanism responsible for the client’s rapid pulse?

Answer: The brain signals the heart to beat faster by sending messages
to your heart's electrical system, which controls the timing of your
heartbeat. When your cardiac output is low, your adrenal glands also
release more norepinephrine (adrenaline), which travels in the
bloodstream and stimulates your heart to beat faster.
Mikee J. Delos Santos
BSN III-2

 What immediate interventions are necessary to correct this client’s fluid

volume imbalance?
Answer:
 Provide extra fluid with meals, including juice, soup, ice cream
and sherbet, gelatin, water on trays.
 Serve beverages at activities.
 All staff should encourage at least 60 ml of fluid of the resident's
choice upon entering each resident's room.
 Encourage the resident to consume at least 180 ml with
medications.
 Give or provide electrolytes, particularly sodium, help the body
maintain normal fluid levels in the fluid compartments because
the amount of fluid a compartment contains depends on the
amount (concentration) of electrolytes in it.

6. Admitted with hypovolemia. Which IV solution would the nurse anticipate

administering?
 Ringer’s solution
 10% dextrose in water
 3% sodium chloride
 0.24% sodium chloride

Answer: Ringer’s solution

Rationale: Ringer's solution is an isotonic, balanced electrolyte solution that can

expand plasma volume and help restore electrolyte balance.

 What would be most important to monitor to determine the client’s

response to corrective interventions?
Anwer: Urinary output

 What assessment data would indicate that the client is having a negative
response to fluid resuscitation?
Mikee J. Delos Santos
BSN III-2
Answer: When volume loss occurs, the body reacts by triggering a wide
range of physiologic regulatory responses to maintain perfusion in the
vascular beds of the most important organs, namely the heart, brain, and
kidneys. Decreases in circulating blood volume lead to a drop in arterial
blood pressure, and diminished venous return reduces preload, stroke
volume, and, therefore, cardiac output.

Mrs. Hsu

7. Admitted to the hospital with a decreased serum osmolality and a serum

sodium of 126 mEq/L. You recognize that dehydration or over hydration
may accompany hypotonic conditions. A priority assessment for this client
with FVE is:
 Mental status
 Weight
 Postural vital signs
 Urine output

Answer: weight

Rationale: Mental status is rarely affected in a fluid excess without a change in

osmolality. Postural vital signs are most important in clients with fluid volume
deficit. Urine output may be increased or decreased, depending on the cause of
the fluid excess. Weight is an important indicator of fluid balance.

8. In further assessing the client, what assessment data would indicate that
the client has fluid volume excess?
A. Distended hand & neck veins
B. Decreased urine output
C. Decreased capillary refill
D. Increased rate and depth of respirations
Mikee J. Delos Santos
BSN III-2
9. Which of the following assessments would indicate that Mrs. Jones has
fluid volume excess?
 Increased, bounding pulse
 JVD
 Diminished peripheral pulses
 Presence of crackles
 Thirst
 Elevated blood pressure
 Orthostatic hypotension
 Skin pale & cool to touch

10.After determining the client is not dehydrated, which of the following

interventions would be appropriate to correct this hypotonic
overhydration?
A. Administration of 0.9% NS
B. Restriction of free water
C. Administration of antihypertensives
D. Restriction of potassium

11.A patient is exhibiting sudden onset of crackles in the lungs, moist

respirations, & rapid respiratory rate. Which intervention should be
performed first?
 Weigh the patient
 Assess capillary refill
 Measure edema
 Reduce IV rate

Answer: Reduce IV rate

Rationale: Weighing the client and measuring edema are important interventions
in clients with fluid vol- ume excess. However, the priority intervention is to
reduce the cause of the excess, in this case, the IV fluid. Capillary refill is an
important assessment but is not specific for assessing fluid balance.
Mikee J. Delos Santos
BSN III-2

12.What would you assess for evidence of a worsening hypotonic condition?

A. Mental status
B. Urine output
C. Skin changes
D. Bowel sounds

Answer: Skin changes

13. The assessment of a patient with hypokalemia should focus on

 BP
 Edema
 Chvostek’s sign
 Heart rhythm

Answer: Heart rhythm

Rationale: The major risk associated with a low po- tassium level is cardiac
dysrhythmia. Chvostek's sign is associated with hypocalcemia. Although blood
pres- sure may be affected by cardiac dysrhythmia, it is not specific to potassium
balance. Edema is associated with fluid balance.

14.Laboratory results for a patient show a potassium level of 2.2 mEq/L. Which
of the following nursing actions is highest priority for this patient?
A. Keep the patient on bedrest
B. Initiate cardiac monitoring
C. Start oxygen at 2L/min
D. Initiate seizure precautions

Answer: B. Initiate cardiac monitoring

Rationale: Hypokalemia affects nerve impulse transmission, including the

transmission of cardiac impulses. The client may develop ECG changes and atrial
or ventricular dysrhythmias. Although hypokalemia can lead to muscle weakness
Mikee J. Delos Santos
BSN III-2
and activity intolerance, bed rest generally is unnecessary. Starting oxygen would
be appropriate only if the client is in respiratory distress. The client is more likely
to experience cardiac arrest, not seizures; in any case, the priority is cardiac
monitoring. The client is not hypoxic, so oxygen is not needed.

15. You are caring for a patient with hyperkalemia. You prepare for
administration of which medication?
 Kayexalate
 K-Lor
 Kaopectate
 Keflex

Answer: Kayexalate

Rationale: Kayexalate is indicated for the removal of excess potassium. K-Lor is a

potassium supplement in- dicated for clients with hypokalemia. Kaopectate is an
antidiarrheal medicine, and Keflex is an antibiotic.

Mr. Williams

16.Adm for palpitations

K+ 5.4 mEq/L
Takes Spironolactone 50 mg daily for HTN
Missed 1 month follow-up appointment

 Which foods in his diet contribute to his hyperkalemia?

Mikee J. Delos Santos
BSN III-2

17.What would be a relevant nursing diagnosis for this client based on the
client’s assessed data?
Answer: Hyperkalemia related to electrolyte imbalance or Hyperkalemia
related to fluid volume imbalance

18.C/O abdominal cramping and several very loose diarrhea stools since
yesterday. What is the etiology of the client’s symptoms?
Answer: Food poisoning

19.Physician orders Kayexalate retention enema to be given stat. Should you

clarify the physician’s orders before administering the enema?
Answer: No, because it is indicated for the removal of excess potassium.

20.Will the physician continue the order for Spironolactone? Explain.

Answer: No, spironolactone is a potassium sparing diuretics.

 What would be some teaching and learning priorities for d/c?

Answer:
 Advise the patient to avoid eating potassium rich foods such as
potatoes, banana amd oranges.
 Advise to have a low-fat diet for his diarrhea.

21.A patient presents with a serum sodium level of 115 mEq/L. A priority
nursing intervention is:
 Seizure precautions
 Vital signs every two hours
 Frequent mouth care
 Cardiac rhythm monitoring

Answer: Seizure precautions

Mikee J. Delos Santos
BSN III-2
Rationale: Clients with hyponatremia are at high risk for seizures. Vital sign
assessment is important, but client safety takes priority. Frequent oral care would
be important in a client with hypernatremia or fluid volume deficit. Cardiac
monitoring is important in hyperkalemia or hypokalemia.

22.The nurse caring for a client with hypernatremia includes which of the
following in the plan of care? (Select all that apply)
 Conduct frequent neurologic checks
 Restrict fluids to 1500 ml per day
 Orient to time, place, & person frequently
 Maintain intravenous access
 Limit length of visits

Answer: Conduct frequent neurologic checks

Orient to time, place, and person frequently.
Maintain intravenous access.
Rationale: Frequent neurological checks are necessary as hypernatremia draws
water out of brain cells, causing them to shrink. As the brain shrinks, tension is
placed on cerebral vessels, which may cause them to tear and bleed.
Hypernatremia affects mental status and brain function (including orientation to
time, place, and person), as can rapid correction of hypernatremia. Fluid
replacement is the primary treatment for hypernatremia. Maintaining
intravenous access is necessary for administration of fluids and possible
emergency medications. There is no reason to limit visit length.

23.A patient receiving D5W at 100 mL/hr is most at risk for developing 
 Hypernatremia
 Hyponatremia
 FVE
 FVD

Answer: Hyponatremia
Mikee J. Delos Santos
BSN III-2
Rationale: D5W is a hypotonic intravenous (IV) solu- tion. While administration of
large volumes of any IV solution may result in fluid volume excess, a hypo- tonic
IV solution also places the client specifically at risk for hyponatremia. Fluid volume
deficit is not a risk of IV fluid administration.

Mrs. Hudson

77-year-old female
Found confused, unable to get up to the bathroom
Weak, anxious, confused to time & place
P 110; B 108/58
Skin dry
Urine Specific gravity 1.028
Deep tendon reflexes slightly reduced
24.Would the client’s serum sodium be elevated, decreased, or normal?
Answer: Decreased

25.What would be your priority assessment plan?

Answer: Assess vital signs and mental status

26.What treatment would you expect this client to receive at this time?
Answer: Oral potassium supplement

27.What would be a teaching plan for this client?

Answer:
 No K+ supplement if taking K+ sparing diuretic
 Do not chew enteric-coated tablets
 Take with meals
 Do not use salt substitutes

28.The most important assessment in a patient with hypercalcemia is

 Heart rhythm
Mikee J. Delos Santos
BSN III-2
 Urine output
 Trousseau’s sign
 Weight

29.The nurse evaluates teaching about calcium supplement therapy as

effective when the patient states that she will take her calcium tablets
 All at one time in the morning
 With meals
 As needed for tremulousness
 With a full glass of water
Answer: Calcium should be taken with full glass of water.
Rationale: Calcium should be taken with a full glass of water to allow maximum
absorption. It is more effectively absorbed when it is taken on an empty stomach
and the prescribed doses are spaced throughout the day. Taking calcium is not an
immediate fix for problems; it is a long-term replacement therapy. Calcium
supplements should actually be taken 1-1.5 hours after meals and at bedtime.

30.A patient who is known to be an alcoholic presents with confusion,

hallucinations, and positive Chvostek’s sign. Which medication should the
nurse anticipate administering?
 Magnesium sulfate
 Calcium chloride
 Insulin and glucose
 Sodium bicarbonate
Answer: Magnesium sulfate
Rationale: A positive Chvostek's sign indicates increased neuromuscular
excitability, commonly associated with both hypomagnesemia and hypocalcemia,
often seen in people who abuse alcohol and who are nutritionally depleted.
Additional manifestations of hypomagnesemia include confusion, hallucinations,
and possible psychoses. Administration of magnesium sulfate helps restore
magnesium balance and neuromuscular function. The symptoms presented are
Mikee J. Delos Santos
BSN III-2
not those of potassium depletion, the need for glucose and insulin, or sodium
depletion.

31.A patient is experiencing nausea with severe vomiting. The nurse realizes
that this patient is at risk for which of the following?
1. Interstitial fluid volume overload
2. Intracellular fluid volume deficit
3. Extracellular fluid volume deficit
4. Interstitial fluid volume deficit

Answer: Extracellular fluid volume deficit

Rationale: Extracellular fluid is found outside the cells in areas such as the
gastrointestinal secretions. Prolonged vomiting can cause a reduction of this fluid
volume.

32.A male patient’s hematocrit is 56%

Serum sodium 150 mEq/L and
Potassium of 5.8 mEq/L
Which of the following would be indicated for this patient?
1. Prepare to administer a hypertonic IV soultion
2. Prepare to administer a hypotonic IV solution
3. Prepare to administer an isotonic IV solution
4. Implement a fluid and sodium restriction for the patient

Answer: Prepare to administer a hypotonic intraveous solution

Rationale: This patient is dehydrated, as evidenced by the elevated hemoglobin
and serum sodium and potassium levels. The nurse would prepare to administer
a hypotonic solution, which has a lower osmolality to hydrate the patient.

33.The nurse is caring for a patient and has just received the laboratory data
report. Which of the following results would cause the most concern to the
nurse?
1. Na+: 115 mEq/L
Mikee J. Delos Santos
BSN III-2
2. K+: 4.0 mEq/L
3. Ca+: 9mg/dL
4. Mg+: 2.0mg/dL

Answer: Na+: 115 mEq/L

Rationale: Normal values for sodium are 135-145 milliequivalents/liter (mEq/L),
so this level is very low

34.The nurse is caring for a patient with severe vomiting and diarrhea
Nasogastric tube to low wall suction.
The nurse realizes that this patient is at risk for which of the following
electrolyte imbalances?
1. Hypokalemia
2. Hypercalcemia
3. Hypermagnesemia
4. Hypophosphatemia
Answer: Hypokalemia
Rationale: Diarrhea can increase excretion of potassium to 200 mEq/day.
Vomiting and/or nasogastric suction can increase loss through GI fluids removed.

35.A patient is admitted to the hospital with a fluid volume excess. Which of
the following will the nurse most likely assess for this patient?
1. Dependent edema
2. Blood pressure: 92/55 mm Hg
3. Respiratory rate 14 breaths/minute and unlabored
4. Heart rate 86 beats per minute without ectopy

Answer: Dependent edema

Rationale: With fluid volume excess, the patient would likely show dependent
edema, an increased blood pressure, decreased urine output, shortness of breath,
and adventitious sounds. An example of this condition would be a patient with
CHF.
Mikee J. Delos Santos
BSN III-2
36.The nurse is caring for a patient in renal failure with a serum potassium
level of 7.1mEq/L. Which of the following should the nurse do first to assist
this patient?
1. Assess level of consciousness.
2. Measure urine output hourly.
3. Have arterial blood gases drawn.
4. Obtain an electrocardiogram.
Answer: Obtain an electrocardiogram
Rationale: Obtaining an ECG is a priority because serum potassium levels greater
than 6.0 mEq/L can be life-threatening due to the decreased ability of the heart to
repolarize, as evidenced by the tented T wave, loss of the P wave, and a wide,
bizarre QRS with a depressed ST segment.

37.The nurse is providing discharge instructions to a patient with hypokalemia.

Which of the following should the nurse include in these instructions?
1. Take oral Kaexylate as prescribed.
2. Limit the intake of spinach and carrots.
3. Eat a balanced diet, including tomato juice and potatoes.
4. Expect muscle cramps and weakness for at least six weeks.

Answer: Eat a balanced diet, including tomato juice and potatoes.

Rationale: Discharge teaching of patient/family in regard to hypokalemia
includes properly taking potassium supplements such as K-Dur. In addition,
increasing potassium rich foods in the diet and recognizing/reporting increased
muscle weakness are critical teaching points.