Homeostasis Fluid and Electrolyte 1
Homeostasis Fluid and Electrolyte 1
Homeostasis Fluid and Electrolyte 1
2. A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His
attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing
intervention should be included in the care of plan for the client?
3. Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization.
Which client statement indicates to the nurse that Tom understands the discharge teaching
about cellular injury?
4. Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing
intervention would be appropriate when identifying nursing interventions aimed at promoting
and preventing contractures? Select all that apply.
5. A 36-year-old male client is about to be discharged from the the hospital after 5 days due
to surgery. Which intervention should be included in the home health care nurse’s
instructions about measures to prevent constipation?
A. Discouraging the client from eating large amounts of roughage-containing foods in the diet.
B. Encouraging the client to use laxatives routinely to ensure adequate bowel elimination.
C. Instructing the client to establish a bowel evacuation schedule that changes every day.
D. Instructing the client to fill a 2-L bottle with water every night and drink it the next day.
6. Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was
hospitalized and was treated for a couple of weeks. When planning care for a client with
cellular injury, the nurse should consider which scientific rationale?
7. A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to
burn trauma. Which nursing intervention should be included for reducing pain due to cellular
injury?
8. Lisa, a client with altered urinary function, is under the care of nurse Tine. Which
intervention is appropriate to include when developing a plan of care for Lisa who is
experiencing urinary dribbling?
9. Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and
has shortness of breath and asthma. Which goal is the most important for the client?
10. Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting.
Which nursing intervention is the most important to include in the plan of care?
A. Stress-reduction techniques
B. Home environment evaluation
C. Skin-care measures
D. Participation in activities of daily living
11. Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her
OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate
when addressing the client’s need to maintain skin integrity?
12. Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical
assessment. Nurse Timothy observed a reddened area over her left hip. Which should the
nurse do first?
13. Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints
of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the
nurse do?
14. Nurse Marthia is teaching her students about bacterial control. Which intervention is the
most important factor in preventing the spread of microorganism?
15. A patient with tented skin turgor, dry mucous membranes, and decreased urinary
output is under nurse Mark’s care. Which nursing intervention should be included the care
plan of Mark for his patient?
16. Khaleesi is admitted in the hospital due to having lower than normal potassium level in
her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization.
Which foods should the nurse instruct the client to increase?
18. Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed
with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of
water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of
urine during the shift. How many milliliters should the nurse document as the client’s intake.
A. 2,230
B. 2,740
C. 2,470
D. 2,320
19. Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data
does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal
spasm after the blood-pressure cuff is inflated?
20. Lab tests revealed that patient Z’s [Na+] is 170 mEq/L. Which clinical manifestation would
nurse Natty expect to assess?
21. Mang Teban has a history of chronic obstructive pulmonary disease and has the following
arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of
carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client’s blood gas values
through improved ventilation and oxygen therapy, which is the client’s primary stimulus for
breathing?
A. High PCO2
B. Low PO2
C. Normal pH
D. Normal bicarbonate (HCO3)
22. A client with very dry mouth, skin and mucous membranes is diagnosed of
having dehydration. Which intervention should the nurse perform when caring for a client
diagnosed with fluid volume deficit?
23. Which client situation requires the nurse to discuss the importance of avoiding foods high
in potassium?
25. Which electrolyte would the nurse identify as the major electrolyte responsible for
determining the concentration of the extracellular fluid?
A. Potassium
B. Phosphate
C. Chloride
D. Sodium
26. Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate?
A. Potassium supplements
B. Kayexalate
C. Calcium gluconate
D. Sodium tablets
27. Which clinical manifestation would lead the nurse to suspect that a client is experiencing
hypermagnesemia?
A. Sodium level
B. Magnesium level
C. Potassium level
D. Calcium level
29. Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure
of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a
bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse
implement?
30. A client is diagnosed with metabolic acidosis, which would the nurse expect the health
care provider to order?
A. Potassium
B. Sodium bicarbonate
C. Serum sodium level
D. Bronchodilator
Here are the answers for this exam. Gauge your performance by counter checking your answers
to those below. If you have any disputes or clarifications, please direct them to the comments
section.
Assessing dietary intake provides a foundation for the client’s usual practices and may help
determine if the client is prone to constipation or diarrhea. Limited physical activity may
contribute to constipation due to decreased peristalsis. Turning, coughing and deep breathing
help promote gas exchange. Fluid intake should be increased to aid bowel elimination.
For patient with hyperthermia, reducing the room temperature may help decrease the body
temperature. Tepid baths, cool compresses, and cooling blanket may also be necessary.
Antipyretics, and not antiemetics, are indicated to reduce fever. Oral or rectal temperature
measurements are generally accepted and are more accurate than axillary measurements.
Fluids should be encouraged, not restricted to compensate for insensible losses.
3. Answer: C. “If I have redness, drainage, or fever, I should call my healthcare provider.”
Knowledge that redness, drainage, or fever — signs of infection associated with cellular injury —
require reporting indicates that the client has understood the nurse’s discharge teaching.
Follow-up checkups should be encouraged with an emphasis of antibiotic compliance even if the
client feels better. There are usually activity limitations after cellular injury.
4. Answer: B, D, E
Correct body alignment, preventing footdrop, and range-of-motion exercises will help prevent
contractures. Clustering activities will help promote adequate rest. Monitoring intake and
output and weighing the client will help maintain fluid and electrolyte balance.
5. Answer: D. Instructing the client to fill a 2-L bottle with water every night and drink it the
next day.
Adequate fluids and fiber in the diet are key to preventing constipation. Having the client fill a 2-
L bottle with water every night and drink it the next day is one method for ensuring the client
receives at least 2,000 ml of water daily. The client also should be instructed to drink any other
fluids throughout the day. High fiber or roughage foods are encouraged. Laxatives should not be
used routinely for bowel elimination. They should be used only as a last resort, because clients
may become dependent on them. A regular bowel evacuation schedule should be established.
Infection impairs wound healing. Adequate blood supply is essential for healing. If inadequate,
healing is slowed. Nutritional needs, including protein and caloric needs, increase for all clients
undergoing cellular repair because adequate protein and caloric intake is essential to optimal
cellular repair. Elderly clients may have decreased blood flow to the skin, organ atrophy and
diminished function, and altered immunity. These conditions slow cellular repair and increase
the risk of infection.
Anti-inflammatory agents help reduce edema and relieve pressure on nerve endings,
subsequently reducing pain. Elevating the injured area increases venous return to the heart.
Maintaining clean, dry skin aids in preventing skin breakdown. Cool packs, not warm packs,
should be used initially to cause vasoconstriction and reduce edema.
Kegel exercises, which help strengthen the muscles in the perineal area, are used to maintain
urinary continence. To perform these exercises, the client tightens pelvic floor muscles for 4
seconds 10 times at least 20 times each day, stopping and starting the urinary flow. Inserting an
indwelling Foley catheter increases the risk for infection and should be avoided. The nurse
should encourage the client to develop a toileting schedule based on normal urinary habits.
However, suggesting bathroom use every 8 hours may be too long an interval to wait. Pads or
diapers should be used only as a resort.
After discharge, the client is responsible for his own care and health maintenance management.
Discharge includes assessing the home environment for determining the client’s ability to
maintain his health at home.
Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from
interfering with adequate blood supply to the tissues, helping to maintain skin integrity. Using a
foot board is appropriate for maintaining normal body function position. Monitoring intake and
output aids in assessing and maintaining bladder function.. Coughing and deep breathing help
promote gas exchange.
12. Answer: D. Turn the client to the right side for 2 hours
Turning the client to the right side relieves the pressure and promotes adequate blood supply to
the left hip. A reddened area is never massaged, because this may increase the damage to the
already reddened, damaged area. The health care provider does not need to be notified
immediately. However, the health care provider should be informed of this finding the next time
he is on the unit. Arranging for a pressure-relieving device is appropriate, but this is done after
the client has been turned.
13. Answer: D. Attempting to rule out complications before administering pain medication
When intervening with a client complaining of pain, the nurse must always determine if the pain
is expected pain or a complication that requires immediate nursing intervention. This must be
done before administering the medication. Guided imagery should be used along with, not
instead of, administration of pain medication. The nurse should medicate the client and not
discourage medication.
Handwashing remains the most effective procedure for controlling microorganisms and the
incidence of nosocomial infections. Aseptic technique is essential with invasive procedures,
including indwelling catheters. Masks, gowns, and gloves are necessary only when the likelihood
of exposure to blood or body fluids is high. Spills of blood from clients with acquired
immunodeficiency syndrome should be cleaned with sodium hydrochloride.
The client’s assessment findings would lead the nurse to suspect that the client is dehydrated.
Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client with
problems associated with impaired gas exchange or ineffective airway clearance. Monitoring
albumin and protein levels is appropriate for clients experiencing inadequate nutrition.
Clustering activities helps with energy conservation and promotes rest.
The client with hypokalemia needs to increase the intake of foods high in potassium. Orange
juice and bananas are high in potassium, along with raisins, apricots, avocados, beans, and
potatoes. Whole grains and nuts would be encouraged for the client with hypomagnesemia;
milk products and green, leafy vegetables are good sources of calcium for the client with
hypocalcemia. Pork products and canned vegetables are high in sodium and are encouraged for
the client with hyponatremia.
The client who is hyperventilating and subsequently develops respiratory alkalosis is losing too
much carbon dioxide. Measures that result in the retention of carbon dioxide are needed.
Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory alkalosis.
Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis.
Administering sodium bicarbonate is appropriate for treating metabolic acidosis, and
administering sodium chloride is appropriate for metabolic alkalosis.
The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of beef
broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the shift.
In a client with hypocalcemia, a positive Trousseau’s sign refers to carpopedal spasm that
develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about
20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood
supply to the ulnar nerve is obstructed. Chvostek’s sign refers to twitching of the facial nerve
when tapping below the earlobe. Paresthesia refers to the numbness or tingling. Tetany is a
clinical manifestation of hypocalcemia denoted by tingling in the tips of the fingers around the
mouth, and muscle spasms in the extremities and face.
Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. Typically, the
client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous membranes,
lethargy, and restlessness. Muscle weakness and paresthesia are associated with hypokalemia;
fruity breath and Kussmaul’s respirations are associated with diabetic ketoacidosis. Muscle
twitching and tetany may be seen with hypercalcemia or hyperphosphatemia.
A chronically elevated PCO2 level (above 50 mmHg) is associated with inadequate response of
the respiratory center to plasma carbon dioxide. The major stimulus to breathing then becomes
hypoxia (low PO2). High PCO2 and normal pH and HCO3 levels would not be the primary stimuli
for breathing in this client.
For the client with fluid volume deficit, assessing the client’s urine output (using a urometer if
necessary) is essential to ensure an output of at least 30 ml/hour. The client should be weighed
daily, not weekly, and at same time each day, usually in the morning. Monitoring ABGs is not
necessary for this client. Rather, serum electrolyte levels would most likely be evaluated. The
client also would have an I.V. rate at least 75 ml/hour, if not higher, to correct the fluid volume
deficit.
Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in
potassium. Clients receiving diuretics, with ileostomies, or with metabolic acidosis may be
hypokalemic and should be encouraged to eat foods high in potassium.
Sodium is the electrolyte whose level is the primary determinant of the extracellular
fluid concentration. Sodium a cation (e.g., positively charged ion), is the major electrolyte
in extracellular fluid. Chloride, an anion (e.g., negatively charged ion), is also present in
extracellular fluid, but to a lesser extent. Potassium (a cation) and phosphate (an anion) are the
major electrolytes in the intracellular fluid.
The client’s potassium level is elevated; therefore, Kayexalate would be ordered to help reduce
the potassium level. Kayexalate is a cation-exchange resin, which can be given orally, by
nasogastric tube, or by retention enema. Potassium is drawn from the bowel and excreted
through the feces. Because the client’s potassium level is already elevated, potassium
supplements would not be given. Neither calcium gluconate nor sodium tablets would address
the client’s elevated potassium level.
Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may
exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and
acute rhabdomyolysis are indicative of hypophosphatemia. Soft-tissue calcification and
hyperreflexia are indicative of hyperphosphatemia. Increased respiratory rate and depth are
associated with metabolic acidosis.
Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When the
client is also taking digoxin, the subsequent hypokalemia may potentiate the action of digoxin,
placing the client at risk for digoxin toxicity. Diuretic therapy may lead to the loss of
other electrolytes such as sodium, but the loss of potassium in association with digoxin therapy
is most important. Hypocalcemia is usually associated with inadequate vitamin D intake or
synthesis, renal failure, or use of drugs, such as aminoglycosides and corticosteroids.
Hypomagnesemia generally is associated with poor nutrition, alcoholism, and excessive GI or
renal losses, not diuretic therapy.
The ABG results indicate respiratory acidosis requiring improved ventilation and increased
oxygen to the lungs. Coughing and deep breathing can accomplish this. The nurse would
administer high oxygen levels because the client does not have chronic obstructive pulmonary
disease. Breathing into a paper bag is appropriate for a client hyperventilating and experiencing
respiratory alkalosis. Some action is necessary, because the ABG results are not within normal
limits.
Metabolic acidosis results from excessive absorption or retention of acid or excessive excretion
of bicarbonate. A base is needed. Sodium bicarbonate is a base and is used to treat documented
metabolic acidosis. Potassium, serum sodium determinations, and a bronchodilator would be
inappropriate orders for this client.