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Fluid and Electrolyte Balance: Multiple Choice Questions and Answers, Exams of Nursing

A series of multiple choice questions and answers related to fluid and electrolyte balance, covering topics such as hypovolemia, hypernatremia, hypocalcemia, and blood transfusions. It provides a valuable resource for students and professionals seeking to test their knowledge and understanding of these essential concepts in healthcare.

Typology: Exams

2023/2024

Uploaded on 10/30/2024

laura-alsleben
laura-alsleben 🇺🇸

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Fluid and Electrolyte (15 Questions on Test)
Fluid Imbalance
1. A nurse is performing an assessment on a client who has hypovolemia due to vomiting
and diarrhea. The nurse should expect which of the following findings? (Select all that
apply)
a. Hyperthermia
b. Bradycardia
c. Orthostatic hypotension
d. Tachycardia (Distended neck veins)
e. Decreased skin turgor
2. The nurse is reviewing the data on the client who has hypovolemia. The nurse should
identify which of the following findings is a manifestation of hypovolemia? (Select all
that apply)
a. Increased Hct
b. Increased blood pressure
c. Decreased urine output
d. Urine specific gravity
e. Increased sodium level
3. A nurse is teaching a class about fluid imbalances. Sort the following manifestations into
either hypovolemia or hypervolemia.
a. Breath sounds with crackles
b. Weight gain
c. Decreased urine specific gravity
d. Flat neck vein
e. Sunken eyeballs
4. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should
identify that which of the following clients is at risk for hypovolemia?
a. A client who has nasogastric suctioning
b. A client who has chronic constipation
c. A client who has syndrome of inappropriate antidiuretic hormone
d. A client who took a toxic dose of sodium bicarbonate antacids
5. A nurse is planning care for a client who has hypernatremia. Which of the following
actions should the nurse anticipate including in the plan of care?
a. Implement a fluid restriction
b. Infuse hypotonic IV fluids
c. Increase sodium intake
d. Administer sodium polystyrene sulfonate (Kayexalate)
6. A charge nurse is leading a staff education session about caring for a client who has
hypocalcemia. Which of the following statements by a staff nurse indicates the need for
further teaching?
a. "I should monitor for hand spasms during blood pressure cuff inflation."
b. "Clients who have a vitamin D deficiency are at risk for hypocalcemia."
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Fluid and Electrolyte (15 Questions on Test)

Fluid Imbalance

  1. A nurse is performing an assessment on a client who has hypovolemia due to vomiting and diarrhea. The nurse should expect which of the following findings? (Select all that apply) a. Hyperthermia b. Bradycardia c. Orthostatic hypotension d. Tachycardia (Distended neck veins) e. Decreased skin turgor
  2. The nurse is reviewing the data on the client who has hypovolemia. The nurse should identify which of the following findings is a manifestation of hypovolemia? (Select all that apply) a. Increased Hct b. Increased blood pressure c. Decreased urine output d. Urine specific gravity e. Increased sodium level
  3. A nurse is teaching a class about fluid imbalances. Sort the following manifestations into either hypovolemia or hypervolemia. a. Breath sounds with crackles b. Weight gain c. Decreased urine specific gravity d. Flat neck vein e. Sunken eyeballs
  4. A nurse on a medical-surgical unit is caring for a group of clients. The nurse should identify that which of the following clients is at risk for hypovolemia? a. A client who has nasogastric suctioning b. A client who has chronic constipation c. A client who has syndrome of inappropriate antidiuretic hormone d. A client who took a toxic dose of sodium bicarbonate antacids
  5. A nurse is planning care for a client who has hypernatremia. Which of the following actions should the nurse anticipate including in the plan of care? a. Implement a fluid restriction b. Infuse hypotonic IV fluids c. Increase sodium intake d. Administer sodium polystyrene sulfonate (Kayexalate)
  6. A charge nurse is leading a staff education session about caring for a client who has hypocalcemia. Which of the following statements by a staff nurse indicates the need for further teaching? a. "I should monitor for hand spasms during blood pressure cuff inflation." b. "Clients who have a vitamin D deficiency are at risk for hypocalcemia."

c. "Clients who have hypocalcemia are at risk for pathologic fractures." d. "I should implement seizure precautions for a client who has hypocalcemia."

  1. A nurse on a medical-surgical unit is caring for a group of clients. For which of the following clients should the nurse expect a prescription for fluid restriction? a. A client who has a new diagnosis of adrenal insufficiency b. A client who has heart failure c. A client who is receiving treatment for diabetic ketoacidosis d. A client who has abdominal ascites
  2. The nurse is caring for a client who has a positive Chvostek’s sign. The nurse should identify that this finding is a manifestation of which of the following electrolyte imbalances? (Select all that apply) a. Hypocalcemia b. Hypomagnesemia c. Hypernatremia d. Hypernatremia e. Hyperkalemia
  3. A nurse is reviewing the electronic medical record (EMR) of a client who has an electrolyte imbalance. Match the electrolyte imbalance to the associated risk factor. A. Hypernatremia (Na+) 1. Diabetes insipidus B. Hyponatremia (Na+) 2. Hypoparathyroidism C. Hypocalcemia (Ca++) 3. Hyperparathyroidism D. Hypercalcemia (Ca+ +) 4. Excessive water intake 10.The nurse is reviewing the medical record of the client. The nurse should identify which of the following findings is a risk factor for the development of hypocalcemia? (Select all that apply) a. Bariatric surgery b. Diarrhea c. Thyroid cancer d. Diabetes mellitus e. Hyperlipidemia 11.A nurse is teaching a class about electrolyte imbalances. Match the electrolyte imbalance to the clinical manifestation. A. Hypocalcemia 1. Dry swollen tongue B. Hypomagnesemi a 2. Hypertension C. Hypernatremia 3. Tingling around

c. Evaluation d. Implementation 18.A nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients? (Select all that apply.) a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid d. Eating watermelon daily e. Eating cucumbers with each meal 19.A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene? a. The nurse selects 0.45% sodium chloride to use to prime the tubing b. The nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion c. The nurse uses tubing with a filter for the blood transfusion d. The nurse discards the tubing after the first unit of blood is completed 20.A nurse is collecting data on a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications? a. Phlebitis b. Extravasation c. Air embolism d. Circulatory overload 21.A nurse is assisting in the care of a client who has heart failure and a prescription to receive a unit of packed red blood cells. The nurse should plan for the blood to infuse over which of the following lengths of time? a. 1 hr b. 2 hr c. 4 hr d. 6 hr

Fluid & Electrolyte Answer Key

  1. B, C, E
  2. A, C, E
  3. Hyper-A, B, C, ; Hypo-D, E
  4. A
  5. B
  6. C
  7. B
  8. A, B
  9. A-1, B-4, C-2, D- 10.A, B, C 11.A-3, B-2, C-1, D- 12.175 mL/hr 13.A 14.C 15.A 16.B 17.C 18.A, B, C 19.A 20.D 21.C

c. Having the client use a straw d. Encouraging the client to lie down and rest after meals

  1. A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client’s meal tray? a. Cooked barley b. Pureed broccoli c. Vanilla custard d. Lentil soup Glucose Regulation
  2. A nurse is reviewing the electronic medical record (EMR) of a client who has a blood glucose of 260 mg/dL and no documented history of diabetes mellites. Which of the following types of medications can cause hyperglycemia as an adverse effect? (Select all that apply) a. Diuretics b. Corticosteroids c. Oral anticoagulants d. Opioid analgesics e. Antipsychotics
  3. A nurse is teaching a client how to check blood glucose levels. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip? a. Smear the blood onto the strip b. Squeeze the blood onto the strip c. Touch the puncture to stimulate bleeding d. Hold the test strip nest to the blood on the fingertip
  4. A nurse attempting to collect a capillary blood specimen via finger stick for blood glucose monitoring is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take first? a. Puncture another finger to obtain a capillary specimen b. Test the urine with a urine reagent strip c. Wrap the hand in a warm, most cloth d. Perform a venipuncture to obtain a venous sample
  5. A nurse is teaching self-monitoring of blood glucose to a client who has diabetes mellitus. Which of the following instructions should the nurse include? (Select all that apply) a. Perform blood glucose monitoring once daily at bedtime b. Wipe the hand with an alcohol swab c. Hold the hand in a dependent position prior to the puncture d. Place the puncturing device perpendicular to the site

e. Prick the outer edge of the fingertip for the blood sample

  1. When preparing to demonstrate glucose testing to Mrs. Lewis, which of the following supplies should the nurse have available? (Select all that apply) a. Sterile gloves b. Antiseptic cleaner c. Reagent strips d. Reusable lancet e. Cotton balls
  2. Which of the following statements by Mrs. Lewis indicates an understanding of the blood glucose testing process? a. “I will check my blood sugar as soon as I finish my breakfast in the mornings” b. “I will wash my hands with soap and water before checking my blood sugar” c. “I will plan to monitor my blood sugar weekly” d. “I will use the tip of my finger when testing my blood sugar”
  3. The nurse is evaluating their discussion regarding nonnutritive sweetener. The nurse identifies the client understands the teaching when they select which of the following choices of sweeteners to use? a. Sucrose b. Aspartame c. Mannitol d. Xylitol e. Sucralose
  4. The nurse is reinforcing dietary teaching with the client. Which of the following information should the nurse include? a. Carbohydrates counting is vital to the meal planning approach b. Use hydrogenated oils for cooking c. Choose whole grains for choices of fiber d. Never estimate portion sizes, always have an exact measuring tool
  5. The nurse is reviewing the teaching session with the client. Which of the following client statements indicates understanding? a. “I will avoid having snacks” b. “I can’t eat anything containing sugar” c. “I will eat a variety of different foods to get my daily carbohydrates” d. “I will not eat more than 2,800mg of sodium a day” 10.A nurse is assessing a client who has hypoglycemia. Which of the following findings should the nurse expect? a. Fruity breath odor b. Diaphoresis c. Ketones in urine d. Polyuria

Elimination, Sleep, & Rest (7 Questions on Test)

Urine Elimination

  1. A nurse is teaching a client who has recurrent UTI’s. Which of the following instructions should the nurse include? (Select all that apply) a. Urinate after sexual intercourse b. Drink at least 1L a fluid each day c. Clean peritoneum from the front to back d. Wear nylon undergarments e. Avoid bubble baths
  2. a nurse is teaching a newly licensed nurse about urine specimen collection. Match the following tests to the procedure. A. Random urinalysis 1. Collect urine for a 24-hour period B. Clean-catch midstream for culture and sensitivity (C&S) 2. Obtain a non-sterile urine specimen C. Timed urine specimen 3. Obtain A sterile urine specimen from an indwelling urinary catheter D. Catheter urine specimen for C&S 4. Clean the urethral meatus prior to obtaining the urine specimen
  3. This is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take? (Select all that apply) a. Empty the client’s urinary drainage bag when it is 3/4 full b. Keep the urinary drainage bag below the level of the client's bladder c. Assess the clients need for the indwelling urinary catheter daily d. Rest the urinary collection bag on the floor when the client is sitting in the chair e. Maintain a closed system of the client’s urinary catheter
  4. A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply) a. Maintain adequate fluid intake b. Empty the bladder completely with each void c. Avoid bladder irritants (alcohol and caffeine) d. Preform pelvic muscle exercises (Kegel) 3 to 4 times each day
  5. A nurse is preparing to initiate a bladder retaining program for a client who has urge incontinence. Which of the following actions should the nurse take? (Select all that apply) a. Restrict the client’s intake of fluid during the daytime b. Have the client record urination times

c. Gradually increase the time of the client’s urination intervals d. Remind the client to hold urine until the next scheduled urination time e. Restrict the client's coffee intake to 2 servings each day Bowel Elimination

  1. A nurse is assessing a client who has had diarrhea for three days. Which of the following findings should the nurse expect? (Select all that apply) a. Bradycardia b. Hypertension c. Elevated temperature d. Peripheral edema e. Poor skin turgor
  2. A nurses teaching a client who has diarrhea. Which of the following instructions should the nurse include? (Select all that apply) a. Eat raw fruit with the skin b. Eat yogurt when diarrhea has stopped c. Increase fluid intake d. Drink hot fluids e. Avoid caffeinated beverages
  3. A nurse is teaching a client about performing a fecal occult blood test at home. Which of the following information should the nurse include? a. Do not eat red meat within one day of the test b. One stool specimen is sufficient for the test c. A red color change indicates a positive test d. Ensure the specimen does not include urine
  4. A nurse is preparing to administer a cleansing enema to a client. Place the steps the nurse should plan to take in the correct order. a. Slowly insert the rectal tube into the client's rectum b. Warm the enema solution c. Ask the client to retain the solution d. Lubricate the end of the rectal tube e. Hang that animal container 30 to 45 centimeters (12 to 18 inches) above the client's anus 10.A nurse is administering A cleansing enema to a client who reports abdominal cramping. What action should the nurse take? a. Slow the flow of the solution by lowering the container b. If the client is experiencing severe abdominal cramping, stop the enema, assess the client's vital signs, and notify the provider c. Both answers are correct Sleep & Rest

Urine Answer Key

  1. A, C, E
  2. A-2, B-4, C-1, D-
  3. B, C, E
  4. All are correct
  5. B, C, D Bowel Answer Key
  6. B, C, E
  7. B, C, E
  8. D
  9. B, D, A, E, C
  10. C Sleep & Rest Answer Key
  11. REM-A, D, E ; NREM-B, C
  12. All are correct
  13. A, B, D

4. A, B, C

5. B

Maternal Child (10 Questions on Test)

Identify options for family planning

  1. A nurse is performing a health assessment for a client who has been unable to conceive for 16 months. The nurse should recognize that which of the following are findings the nurse should report to the provider? (Select all that apply) a. Age greater than 30 b. Abnormal uterine contours c. History of STI's d. Tobacco use e. Nutritional deficiencies
  2. A nurse is preparing to discuss assistive management options with a couple who has infertility. Match the assistive management procedure to information that the nurse should discuss. A. In vitro fertilization embryo transfer (IVF- ET) 22.Procedure used to place prepared sperm in the uterus at the time of ovulation B. Intrauterine insemination 23.A couple completes a process of IVF with the embryo placed in another person who will carry the pregnancy. This is a contract agreement with the carrier having no genetic investment with the embryo. C. Donor oocyte 24.Donated eggs are collected by a donor by an IVF procedure. The eggs are inseminated. The embryos are placed in the recipients uterus. Prior to implantation the recipient undergoes hormonal

e. One-hour glucose tolerance

  1. A nurse is teaching a client who is at six weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include? (Select all that apply) a. Breast tenderness b. Urinary frequency c. Epistaxis d. Dysuria e. Epigastric pain 10.A nurse is teaching a group of clients who are pregnant about measures to relieve backache during pregnancy. What measures should the nurse include? (All of these are correct) a. Instruct the client to rock her pelvic or tilt exercise stretches to the muscles of the lower back to help relieve pain b. The use of proper body mechanics prevents back injury due to the incorrect use of muscles when lifting c. Using good posture and body mechanics 11.A nurse is caring for a client who is pregnant and reviewing manifestations of complications the client should promptly report to the provider. Which of the following complications should the nurse include? a. Vaginal bleeding b. Swelling of the ankles c. Heartburn after eating d. Lightheadedness when lying on back 12.A nurse in a prenatal clinic is caring for 4 clients. Which of the following clients’ weight gain should the nurse report to the provider? a. 1.8kg (4lb) weight gain and is in the 1st^ trimester b. 3.6kg (8lb) weight gain and is in the 1st^ trimester c. 6.8kg (15lb) weight gain and is in the 2nd^ trimester d. 11.3kg (25lb) weight gain and is in the 3rd^ trimester 13.A nurse is discussing with a client who is 6 weeks gestation food sources high is dietary content for folate and iron. Sort the below food source to the appropriate nutrient. a. Beef liver b. Leafy vegetables c. Orange juice d. Poultry

14. A nurse in a clinic is teaching a client of childbearing age about recommended folic acid

supplements. Which of the following defects can occur in the fetus or neonate as a result of folic

acid deficiency?

a. Iron deficiency anemia

b. Poor bone formation

c. Abnormal fetal growth

d. Natural tube defects

15. A nurse in a prenatal clinic is providing education to a client who is 8 weeks of gestation. The client

states I don't like milk. Which of the following foods should the nurse recommend as a good source

of calcium?

a. Dark green leafy vegetables

b. Deep red and orange vegetables

c. White breads and rice

d. Meat, poultry, and fish

Evidence-based practice for maternal / child assessments and care

16. A nurse is reviewing findings of a client’s biophysical profile (BPP). The nurse should expect which of

the following variables to be included in this test? (Select all that apply)

a. Fetal weight

b. Fetal breathing movement

c. Fetal tone

d. Fetal position

e. Amniotic fluid

17.A nurse is caring for a client who is pregnant and undergoing a nonstress test. The client asks why

the nurse is using an acoustic vibration device. Which of the following responses should the nurse

make?

a. It is used to stimulate uterine contractions

b. It will decrease the incidence of uterine contractions

c. It lulls the fetus to sleep

d. It awakens a sleeping fetus

18. A nurse is caring for a client who is pregnant and is to undergo a contraction stress test (CST). Which

of the following findings are indications for this procedure? (Select all that apply)

a. Decreased fetal movement

b. Intrauterine growth restriction (IUGR)

c. Postmaturity

d. Placenta previa

e. Amniotic fluid emboli

a. Betamethasone

b. Indomethacin

c. Nifedipine

d. Methylergonovine

25. A nurse is providing care for a client who has a marginal abruptio placentae. Which of the following

findings are risk factors for developing the condition? (Select all that apply)

a. Fetal position

b. Blunt abdominal trauma

c. Cocaine use

d. Maternal age

e. Cigarette smoking

26. A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following

techniques should the nurse use to identify the fetal lie?

a. Apply palms of both hands to sides of uterus

b. Palpate the fundus of the uterus

c. Grasp lower uterine segment between thumb and finger

d. Stand facing client’s feet with fingertips outlining cephalic prominence

27. A nurse is reviewing the electronic monitor tracing of a client who is in active labor. A fetus receives

more oxygen when which of the following appears on the tracing?

a. Peak of the uterine contraction

b. Moderate variability

c. FHR acceleration

d. Relaxation between uterine contractions

28. A nurse is caring for a client who is in active labor. The cervix is dilated to 5 cm, and the membranes

are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to

125/min with occasional increases up to 150 to 155/min that last for 25 seconds and have moderate

variability. There is no slowing of the FHR from the baseline. This client is exhibiting manifestations

of which of the following? (Select all that apply)

a. Moderate variability

b. FHR accelerations

c. FHR decelerations

d. Normal baseline FRH

e. Fetal tachycardia

29. A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal

monitor. Which of the following is the first action the nurse should take?

a. Assist the client into the left-lateral position

b. Apply a fetal scalp electrode

c. Insert an IV catheter

d. Perform a vaginal exam

30. A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the

following statements should the nurse include? (Select all that apply)

a. It is considered a noninvasive procedure

b. It can detect abnormal fetal heart rate tones early

c. It can determine that amount of amniotic fluid you have

d. It allows for accurate readings with maternal movement

e. It can measure uterine contraction intensity

31. A nurse is planning care for a newly admitted client who reports “I am in labor, and I have been

having vaginal bleeding for 2 weeks”. Which of the following should the nurse include in the plan of

care?

a. Inspect the introitus for a prolapsed cord

b. Perform a test to identify the ferning pattern

c. Monitor station of the presenting part

d. Defer vaginal examinations

32. A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void

every 2 hours. Which of the following statements should the nurse make?

a. A full bladder increases the risk for fetal trauma

b. A full bladder increases the risk for bladder infections

c. A distended bladder will be traumatized by frequent pelvic exams

d. A distended bladder reduces pelvis space needed for birth

33. A nurse is caring for a client and partner during the second stage of labor. The client’s partner asks

the nurse to explain how to know when crowning occurs. Which of the following responses should

the nurse make?

a. The placenta will protrude from the vagina

b. Your partner will report a decrease in the intensity of contractions

c. The vaginal area will bulge as the baby’s head appears

d. Your partner will report less rectal pressure

34. A nurse is caring for a client in the third stage of labor. Which of the following findings indicate

placental separation? (Select all that apply)

a. Lengthening of the umbilical cord

b. Swift gush of clear amniotic fluid

c. Softening of the lower uterine segment

d. Appearance of dark blood from the vagina