Chapter 39: Fluid, Electrolytes, and Acid-Base Balance Yoost & Crawford: Fundamentals of Nursing: Active Learning For Collaborative Practice, 2nd Edition

Chapter 39: Fluid, Electrolytes, and Acid-Base Balance
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative

Practice, 2nd Edition
MULTIPLE CHOICE
1. The nurse will be caring for a patient who is severely malnourished. Laboratory test results show
that the patient’s albumin level is critically low. What assessment finding will the nurse expect to
note when assessing the patient?
a. The patient has generalized 3+ pitting
edema.
b. The patient is confused and disoriented.
c. The patient’s urine is dark and very
concentrated.
d. The patient lung sounds are very
diminished.
ANS: A
The patient’s low albumin level will lead to generalized pitting edema because there isn’t enough
protein in the blood to keep water within the bloodstream. Lack of oncotic pressure from low
serum albumin leads to edema. The other findings are not related to malnutrition.
DIF: Understanding OBJ: 39.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Fluid and Electrolyte Balance
2. The nurse is reviewing the patient’s laboratory results. Which result must be communicated to
the physician immediately?
a. Serum chloride level 85 mEq/L
b. Serum sodium level 134 mEq/L
c. Serum potassium level 6.8 mEq/L
d. Serum magnesium level 2.3 mEq/L
ANS: C
Normal serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 6.8 mEq/L is
very high and puts the patient at risk for cardiac arrhythmias. The potassium level should be
reported to the physician immediately. The chlorine and sodium levels are slightly low and the
magnesium level is slightly elevated.
DIF: Understanding OBJ: 39.2 TOP: Implementation

3. The nurse is caring for a patient who is at risk for fluid overload due to a history of congestive
heart failure. Which intervention will the nurse teach the patient to perform at home to monitor
fluid balance?
a. “Check to make sure that your urine is a
bright yellow color.”
b. “Weigh yourself every morning before
breakfast.”
c. “Count your heart rate every evening
before you go to bed.”
d. “Drink plain water rather than soda,
coffee, or fruit juice.”
ANS: B
Checking the weight every morning before breakfast is a sensitive indicator of the patient’s fluid
volume status. Weight gain of 2 kg in 3 days generally indicates fluid retention and should be
reported to the physician.
DIF: Understanding OBJ: 39.6 TOP: Teaching/Learning

MSC: NCLEX Client Needs Category: Health Promotion and Maintenance
NOT: Concepts: Patient Education
4. The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis.
Which assessment finding indicates an attempt made by the patient’s body to correct the pH?
a. The patient’s respirations are very deep
and rapid.
b. The patient’s urine is dark and
concentrated.
c. The patient’s skin is pale, cool, and
diaphoretic.
d. The patient is sleepy and difficult to
arouse.
ANS: A
The patient with diabetic ketoacidosis is in a state of metabolic acidosis. The body will attempt
to compensate for the acidosis by blowing off extra amounts of carbon dioxide through deep,
rapid respirations. Since carbon dioxide is converted to carbonic acid, removal of carbon dioxide
will help shift the body’s pH to a less acidotic state.
DIF: Applying OBJ: 39.3 TOP: Assessment

MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Acid-Base Balance
5. The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart
failure. The nurse will watch for which electrolyte imbalance that may occur due to this therapy?
a. Hypocalcemia
b. Hypernatremia
c. Hypokalemia
d. Hyperphosphatemia
ANS: C
Furosemide is a loop diuretic that causes loss of potassium through the urine. Patients taking this
medication are at risk for hypokalemia, so the nurse should check the patient’s electrolyte values
closely, particularly the serum potassium level.

MSC: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral
Therapies NOT: Concepts: Fluid and Electrolyte Balance
6. The nurse is caring for a patient who was brought to the ED after overdosing on narcotic pain
medication. The patient was found unresponsive with no respirations. Arterial blood gases were
drawn shortly after the patient’s arrival to the hospital. Which results will the nurse expect to
see?
a. pH 7.56, PaCO2 32 mm Hg, HCO3 32
mEq/L, PaO2 90 mm Hg
b. pH 7.35, PaCO2 45 mm Hg, HCO3 26
c. pH 7.45, PaCO2 38 mm Hg, HCO3 28
d. pH 7.27, PaCO2 58 mm Hg, HCO3 24
ANS: D
The patient who overdosed on narcotic pain medication will be in respiratory acidosis due to
respiratory suppression. Low pH of 7.27 and elevated PaCO2 are consistent with respiratory
acidosis as insufficient carbon dioxide is removed from the blood. The low 60 mm Hg PaO2 is
due to insufficient oxygen intake.

7. The nurse is caring for a patient who is admitted to the hospital with dehydration and
gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out
of bed. The nurse knows which condition to be the most likely cause of the patient’s collapse?
a. Orthostatic hypotension
b. Circulatory overload
c. Hemolytic reaction
d. Catheter embolism
ANS: A
The patient with dehydration is at risk for orthostatic hypotension or falling of the blood pressure
when the patient rises to a standing position. When the blood pressure falls sufficiently, fainting
may occur. The patient should be assisted to rise slowly from a supine to a sitting position first
before slowly getting to his feet. Circulatory overload, hemolytic anemia, and catheter embolism
are unlikely to be causative factors.

8. The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 32
mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse expect to see in the
patient’s chart as the underlying cause of these results?
a. Gastroenteritis with severe nausea,
vomiting, and diarrhea
b. Widespread tissue ischemia caused by
cardiogenic shock
c. Respiratory failure caused by pneumonia
with pleural effusions
d. Hyperventilation after a panic attack
ANS: A
Gastroenteritis with nausea, vomiting, and diarrhea will lead to a metabolic alkalosis resulting
from loss of electrolytes and acids through emesis and loose stools. Metabolic alkalosis features
the elevated pH of 7.56, elevated HCO3 42 mEq/L, and normal PaCO2 of 32 mm Hg. Widespread
tissue ischemia would lead to metabolic acidosis with low pH resulting from release of lactic
acid from the tissues. Respiratory failure leads to a respiratory acidosis with a low pH and
elevated PaCO2 level. Hyperventilation leads to respiratory alkalosis with an elevated pH and
elevated HCO3 level.

9. The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has
consumed 250 mL with each of the three meals and had another 150 mL with medication
administration. The patient has received 150 mL of IV fluids during the day. How many mL of
fluid may the patient still consume to stay within the prescribed fluid restriction?
a. 100 mL
b. 150 mL
c. 250 mL
d. 300 mL
ANS: B
The patient has had an oral fluid intake of 900 mL and an IV fluid intake of 150 mL, giving a
total of 1050 mL. This leaves 150 mL that the patient may consume for the rest of the evening to
stay within the prescribed fluid restriction.

10. The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes
the diagnosis hypervolemia in the patient’s care plan. Which goal statement has the highest
priority for the patient and nurse?
a. The patient’s lung sounds will remain
clear.
b. The patient will have urine output of at
least 30 mL/hr.
c. The patient will verbalize understanding
of fluid restrictions.
d. The patient’s pitting pedal edema will
resolve within 72 hours.
ANS: A
Oxygenation is the highest priority for the patient with congestive heart failure and
hypervolemia. Keeping the patient’s lungs clear is the most important goal for the nurse to
consider when caring for this patient.
DIF: Applying OBJ: 39.5 TOP: Planning

MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
11. The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion
(SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which
IV fluid will the nurse expect to administer to this patient to correct the patient’s fluid
imbalance?
a. 0.33% normal saline
b. 0.45% normal saline
c. 0.9% normal saline
d. 3% normal saline
ANS: D
A hypertonic 3% saline solution will be used to correct the patient’s hyponatremia and fluid
overload that have developed due to SIADH. A 0.9% normal saline solution can be used once the
serum sodium level has been raised nearer to normal range. A 0.45% or 0.33% normal saline
solution is hypotonic and will only worsen the patient’s fluid overload and hyponatremia.
DIF: Applying OBJ: 39.6 TOP: Implementation

12. The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus
doses of furosemide (Lasix) to correct fluid volume overload. No continuous IV fluids are
ordered. Which type of IV will the nurse insert to administer the patient’s medication?
a. Peripherally inserted central catheter
b. Midline inside-the-needle catheter
c. Central venous catheter
d. Over-the-needle catheter
ANS: D
Intermittent doses of IV diuretics are best administered via an over-the-needle angiocatheter that
is connected to a saline lock. The other IV catheter options are used when the patient requires a
vesicant drug that could cause significant damage to tissues or when the patient requires weeks
of IV therapy.

13. The nurse is caring for a patient who has a central venous catheter (CVC). Which nursing
intervention is the most important for the nurse to include in the patient’s plan of care?
a. Carefully document all assessments of the
catheter site.
b. Use strict sterile procedure when
performing dressing changes.
c. Label each new dressing with the date,
time, and nurse’s initials.
d. Ensure that the CVC is discontinued as
soon as possible.
ANS: B
Strict sterile procedure is mandatory when changing CVC dressings because of the high risk of
septicemia and/or sepsis. The other actions are appropriate, but not of the highest priority.

NOT: Concepts: Infection
14. The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful
and puffy. What is the nurse’s best action?
a. Discontinue the IV and start another line
in the other arm.
b. Aspirate to check for blood return and
flush the IV with sterile saline.
c. Clean the IV site with chlorhexidine and
apply a new sterile dressing.
d. Change the IV tubing and administer
prescribed pain medication.
ANS: A
An IV site that is puffy and painful should be discontinued promptly because the fluid has
infiltrated outside the vein and is causing localized irritation. The IV should be restarted in the
other arm if possible. The other actions are inappropriate.

15. The nurse is caring for a patient who is to receive dopamine (Intropin) through the IV line.
Which intervention has the highest priority when administering this medication?
a. Check for IV blood return prior to
administration.
b. Use a new IV tubing set each time the
medication is administered.
c. Document the date, time, and nurse’s
initials after each dose is administered.
d. Use sterile gloves when drawing up and
administering the medication.
ANS: A
Dopamine is a vesicant and can cause significant irritation to blood vessels and tissues when
administered via IV. For this reason, the nurse must ensure that the IV catheter is located
correctly in the vein by checking for a blood return prior to administration.

Therapies NOT: Concepts: Caregiving
16. The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The
patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will
the nurse perform before obtaining the packed red blood cells from the blood bank?
a. Identify the blood group, type, and
expiration date with another nurse.
b. Assess the patency of the current IV site
for the administration of the packed
RBCs.
c. Program the IV infusion pump so that the
transfusion will complete within 4 hours.
d. Obtain a new microdrip tubing and
extension tubing from the clean utility
room.
ANS: B
Before obtaining the blood from the blood bank, the nurse ensures the patient’s IV is patent.
Research confirms blood can be safely infused in as small as a 24 gauge IV. Then the nurse
obtains the blood and double checks the blood group, type, expiration date, and patient ID with a
second nurse. Next the nurse sets up the IV and IV pump. Blood is not run through a microdrip
tubing set.

17. The nurse is caring for a patient who is receiving a blood transfusion. Fifteen minutes into the
transfusion, the patient’s blood pressure decreases significantly, and the patient complains of a
severe headache. What is the priority action of the nurse?
a. Check the patient’s temperature and
administer acetaminophen (Tylenol) if
higher than 101 °F.
b. Recheck the patient’s blood pressure in 15
minutes after administering pain
medication.
c. Stop the blood transfusion and administer
0.9% normal saline through new IV
tubing.
d. Double-check that the transfusion blood
type is an exact match to the patient.
ANS: C
A significant drop in blood pressure and a severe headache are signs that the patient may be
experiencing a transfusion reaction. Also, most reactions to a transfusion occur within the first 15
minutes of initiation. Therefore the nurse should remain with the patient at the bedside during
this time to observe for signs of a reaction. The transfusion should be stopped and 0.9% normal
saline should be administered through new IV tubing to prevent infusion of additional blood
through the tubing used for the transfusion. The physician should be notified immediately to
evaluate the patient. Ensuring that the transfusion blood type is an exact match to the patient is
done before the transfusion is begun.

18. The nurse is caring for a patient who is very dehydrated. Which goal best indicates that
dehydration has been corrected and that the patient’s fluid balance has been restored?
a. The patient had 1300 mL of light yellow
urine in the last 24 hours.
b. The patient’s lung sounds are clear
bilaterally.
c. The patient has no jugular venous
distention.
d. The patient verbalizes need for adequate
daily fluid intake.
ANS: A
The goal that best indicates that the patient’s dehydration has been corrected is output of 1300
mL of clear yellow urine in the last 24 hours. Dark concentrated urine is a symptom of
dehydration. Jugular venous distention and presence of crackles in the lungs are both indicative
of fluid volume overload.

19. The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L.
Which is the most important intervention for the nurse to perform?
a. Perform regular neurologic checks and
institute seizure precautions.
b. Encourage the patient to eat foods that are
high in sodium.
c. Administer hypotonic IV solutions as
ordered by the physician.
d. Assess for signs and symptoms of digoxin
(Lanoxin) toxicity.
ANS: A
A serum sodium level of 124 mEq/L is dangerously low and may cause neurologic problems
including seizures, confusion, and weakness. Regular neurologic checks should be performed
and the patient should be placed on seizure precautions until the sodium level is corrected.
Encouraging the patient to eat high-sodium foods is fine, but it is not as important as the patient’s
safety. A hypotonic saline solution will further lower the patient’s sodium level. Digoxin toxicity
is seen with hypokalemia rather than hyponatremia.

20. The nurse is caring for a patient who has a history of congestive heart failure and takes once-
daily furosemide (Lasix) to prevent fluid overload and pulmonary edema. The patient admits to
stopping the medication due to nocturia. What is the nurse’s best response?
a. “You should ask your doctor to decrease
the dose.”
b. “Take the diuretic early in the morning
before breakfast.”
c. “Eat foods high in potassium and limit
your salt intake.”
d. “Restrict your fluid intake after dinner and
in the evening.”
ANS: B
The patient should be instructed to take the diuretic early in the morning so that the effects will
wear off before the patient goes to bed at night. Decreasing the dose could lead to fluid overload
and pulmonary edema.
DIF: Applying OBJ: 39.6 TOP: Teaching/Learning

Therapies NOT: Concepts: Patient Education
21. The nurse is caring for a patient with renal failure who has a serum potassium level of 7.1 mEq/L
and serum magnesium level of 3.5 mEq/L. The nurse prepares to administer 10 units of insulin
and an ampule of 50% dextrose to the patient. The patient asks why he will be receiving insulin
when he is not diabetic. What is the nurse’s best answer?
a. “The doctor has prescribed these
medications for you to help heal your
kidneys.”
b. “These medications will lower your
potassium level and prevent an irregular
heart rate.”
c. “These medications will prevent you from
having a seizure from too little
magnesium.”
d. “These medications will increase your
urine output until your kidneys recover.”
ANS: B
Serum potassium levels above 7.0 mEq/L can lead to dangerous cardiac arrhythmias, so the
potassium level must be lowered promptly. Administration of IV insulin with 50% dextrose will
push potassium into the cells to avoid hyperkalemia symptoms.
DIF: Understanding OBJ: 39.6 TOP: Teaching/Learning

22. The nurse is caring for a patient with a history of hyperparathyroidism who presents with a
serum calcium level of 14.5 mg/dL. What is the highest priority Nursing diagnosis for this
patient?
a. Risk for injury related to weakened bones
that may easily fracture
b. Lack of knowledge related to need for
supplemental calcium in diet
c. Risk for constipation caused by decreased
gastrointestinal motility
d. Activity intolerance related to muscle
cramping and spasms
ANS: A
Chronic hypercalcemia can lead to weakened bones as strengthening calcium is removed over
time. Pathologic fractures can easily result, so risk for injury is a high priority Nursing diagnosis
for this patient. The other Nursing diagnoses apply but are less important than the safety of the
patient.
DIF: Applying OBJ: 39.4 TOP: Diagnosis

23. The nurse is caring for a patient who has a serum magnesium level of 0.8 mEqL. Which is the
highest priority goal to include in the patient’s plan of care?
a. The patient will maintain urine output of
at least 30 mL/hr.
b. The patient will verbalize the importance
of sufficient dietary intake of magnesium.
c. The patient’s oral mucous membranes will
remain free of ulceration and pain.
d. The patient will remain alert and oriented
×3 with no confusion or seizure activity.
ANS: D
A patient with low serum magnesium is at risk for neurologic symptoms including confusion,
disorientation, and seizures. The highest priority goal for this patient is to avoid neurologic
problems that could lead to injury. The other goals are applicable to the patient with low
magnesium but are less important.
DIF: Applying OBJ: 39.5 TOP: Planning

24. The nurse is caring for a hospitalized patient with hyperparathyroid disease and a serum calcium
level of 14.2 mg/dL. What is the priority intervention of the nurse?
a. Instruct the patient to always call for
assistance before getting out of bed.
b. Assist the patient to change into dry
clothing after episodes of diaphoresis.
c. Teach stress-relieving techniques,
including progressive muscle relaxation.
d. Notify the provider if urine output is less
than 30 mL/hr.
ANS: A
The patient with hypercalcemia should always call for assistance before getting out of bed
because of the risk of falling due to muscle weakness, soft bones, and lethargy. Diaphoresis and
decreased urine output are not common symptoms of hypercalcemia. Teaching stress-relieving
techniques is not a priority.

MULTIPLE RESPONSE
1. The nurse is caring for a patient who has B-positive blood. The patient is severely anemic and
requires a blood transfusion. The nurse knows which types of blood can the patient receive?
(Select all that apply.)
a. AB positive
b. AB negative
c. B negative
d. B positive
e. O positive
f. O negative
ANS: C, D, E, F
If a person produces the B antigen, the blood type is classified as B. Type O blood is classified as
universal donors because their blood cells contain no antigens. Rh positive (Rh+) blood which
means the person has the Rh factor on the surface of the red blood cells. Those who do not have
the Rh factor are considered Rh negative (Rh−). A person who is B positive can receive B or O
blood, and it can be positive or negative Rh factor.

Therapies NOT: Concepts: Perfusion

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Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative

DIF: Understanding OBJ: 39.3 TOP: Assessment

DIF: Understanding OBJ: 39.2 TOP: Implementation

DIF: Understanding OBJ: 39.6 TOP: Teaching/Learning

DIF: Applying OBJ: 39.3 TOP: Assessment

DIF: Understanding OBJ: 39.2 TOP: Assessment

DIF: Applying OBJ: 39.2 TOP: Assessment

DIF: Understanding OBJ: 39.2 TOP: Assessment

DIF: Applying OBJ: 39.2 TOP: Assessment

DIF: Applying OBJ: 39.2 TOP: Assessment

DIF: Applying OBJ: 39.5 TOP: Planning

DIF: Applying OBJ: 39.6 TOP: Implementation

DIF: Understanding OBJ: 39.6 TOP: Implementation

DIF: Understanding OBJ: 39.6 TOP: Implementation

DIF: Understanding OBJ: 39.6 TOP: Implementation

DIF: Applying OBJ: 39.6 TOP: Implementation

DIF: Applying OBJ: 39.6 TOP: Implementation

DIF: Applying OBJ: 39.6 TOP: Implementation

DIF: Applying OBJ: 39.5 TOP: Assessment

DIF: Understanding OBJ: 39.6 TOP: Implementation

DIF: Applying OBJ: 39.6 TOP: Teaching/Learning

DIF: Understanding OBJ: 39.6 TOP: Teaching/Learning

DIF: Applying OBJ: 39.4 TOP: Diagnosis

DIF: Applying OBJ: 39.5 TOP: Planning

DIF: Applying OBJ: 39.6 TOP: Implementation

DIF: Understanding OBJ: 39.1 TOP: Implementation

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