Chapter 38. Fluids, Electrolytes, & Acid–Base Balance

Chapter 38. Fluids, Electrolytes, & Acid–Base Balance

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

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?

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?

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?

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?

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