Quiz 1 fluids

Scenario: A 68-year-old client is admitted to the San Pablo City ICU from a nursing home with a diagnosis of urosepsis. His vital signs are BP 84/50 mmHg, HR 130 bpm, RR 28/min, and Temp 38.9°C. He is lethargic, has dry mucous membranes, and his central venous pressure (CVP) reading is 1 mmHg.

Based on these findings, what is the nurse's priority intervention?

• Administering a prescribed IV vasopressor to increase blood pressure.

• Administering a rapid IV bolus of 0.9% Sodium Chloride.

• Obtaining a urine culture and sensitivity.

• Placing the client on a cooling blanket to reduce fever.

A 75-year-old client with a history of a previous stroke is admitted with confusion and lethargy. The lab results reveal a serum sodium level of 118 mEq/L. The client is placed on seizure precautions.

Which physician's order should the nurse question?

• Infuse 3% Sodium Chloride at 30 mL/hr via an infusion pump.

• Seizure precautions and bed rest.

• Furosemide (Lasix) 40 mg IV once.

• Neurological checks every hour.

Scenario: A 72-year-old client with a history of heart failure is admitted to the ICU. His potassium level is 2.5 mEq/L. The monitor shows frequent premature ventricular contractions (PVCs). The physician orders 40 mEq of Potassium Chloride in 100 mL of normal saline to be infused over 1 hour.

What is the nurse's priority action?

• Start the infusion as ordered to correct the potassium level quickly.

• Administer the infusion through a peripheral IV line in the hand.

• Contact the physician to question the rate of the infusion.

• Place the client on a 12-lead ECG monitor.

Scenario: A client who underwent a total thyroidectomy 24 hours ago becomes irritable and complains of tingling in her fingers and around her mouth. The nurse attempts to take her blood pressure and observes a carpopedal spasm.

Question: The nurse correctly interprets this sign (Trousseau's sign) as an indication of which electrolyte imbalance?

• Hypokalemia

• Hypocalcemia

• Hyponatremia

• Hypomagnesemia

Scenario: An 18-year-old client is brought to the ICU with diabetic ketoacidosis (DKA). Her breathing is deep and rapid. Her initial arterial blood gas (ABG) results are: pH 7.20, PaCO₂ 28 mm Hg, and HCO₃⁻ 12 mEq/L.

How should the nurse interpret this ABG result?

• Uncompensated Respiratory Acidosis

• Partially Compensated Metabolic Acidosis

• Fully Compensated Metabolic Acidosis

• Uncompensated Metabolic Alkalosis

A 55-year-old client is admitted with end-stage liver disease and severe ascites. His weight has increased by 3 kg in two days, and he has 3+ pitting edema in his lower extremities. His serum albumin level is 1.8 g/dL.

The nurse understands that the fluid accumulation is primarily due to which physiological mechanism?

• Increased hydrostatic pressure and decreased oncotic pressure

• Decreased hydrostatic pressure and increased oncotic pressure.

• Increased fluid intake and decreased urine output.

• Failure of the sodium-potassium pump.

Scenario: An 80-year-old client receiving enteral tube feedings is lethargic and has dry, sticky mucous membranes. The lab results show a serum sodium level of 158 mEq/L.

What is the nurse's priority intervention?

• Administer a PRN dose of an antiemetic.

• Hold the next scheduled tube feeding.

• Administer free water flushes via the feeding tube as prescribed.

• Re-orient the client to person, place, and time.

Scenario: A client with chronic kidney disease has a potassium level of 6.8 mEq/L. The cardiac monitor shows tall, peaked T waves and a widened QRS complex.

Which prescribed intervention should the nurse administer first?

• Sodium polystyrene sulfonate (Kayexalate)

• A 500 mL bolus of 0.9% Sodium Chloride

• Furosemide (Lasix) 40 mg IV

• Intravenous regular insulin and dextrose

Scenario: A 45-year-old client is admitted with a gastrointestinal bleed. He is hypotensive and tachycardic. The physician orders a unit of packed red blood cells (PRBCs) to be transfused.

Which IV fluid should the nurse use to prime the tubing and administer with the PRBCs?

• 0.45% Sodium Chloride

• 0.9% Sodium Chloride

• Lactated Ringer's Solution

• Dextrose 5% in Water (D5W)

Scenario: A client with severe heart failure receiving high doses of furosemide (Lasix) has a potassium level of 3.0 mEq/L. The cardiac monitor shows a flattened T wave and the presence of a U wave.

Which nursing diagnosis is the priority for this client?

• Risk for Fluid Volume Deficit related to diuretic therapy.

• Decreased Cardiac Output related to cardiac dysrhythmias.

• Activity Intolerance related to muscle weakness.

• Altered Nutrition: Less than Body Requirements.