Online Practice Test 52 - Last

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 52 > NCLEX® Review Date/Time Submitted: August 2, 2012 at 6:34 AM (UTC/GMT)

Summary of Results 70% Correct of 10 Scored items: 7 Correct:  70% 3 Incorrect:  30% More information about scoring

1.		Which individual would least likely suffer from a disturbance in fluid volume, electrolyte, or acid-base balance? Your Answer: Clients who are confused Correct Answer: An elderly client suffering from a type I decubitus
		Objective: Identify factors affecting normal body fluid, electrolyte, and acid-base balance. Rationale: The proportion of body water decreases with aging. Tissue trauma, such as burns, causes fluids and electrolytes to be lost from the damaged cells, and the breakdown in the continuity of the tissue. In Type I Decubitus, the skin remains intact, and any shifting of fluids is due to the inflammatory process and internally maintained within the body. Vomiting and diarrhea can cause significant fluid loses. Age, sex, and body fat affect total body water. Infants have the delete spaces highest proportion of water; it accounts for 70-80% of their body weight. Decreased blood flow to the kidneys as caused by impaired cardiac function stimulates the renin-angiotensin-aldosterone system, causing sodium and water retention. Clients who are confused or unable to communicate are at risk for inadequate fluid intake. Age does not play a significant factor here. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		An elderly patient was hydrated with lactated Ringer's solution in the emergency room for the last hour. During the most recent evaluation of the patient by the nurse, a finding of a rapid bounding pulse and shortness of breath were noted. Reporting this episode to the physician, the nurse suspects that the patient now shows signs of: Your Answer: Hypervolemia, and needs the fluids adjusted
		Objective: Evaluate the effect of nursing and collaborative interventions on the client's fluid, electrolyte, or acid-base balance. Rationale: Isotonic solutions has the same osmolality as body fluids. Isotonic solutions, such as Normal Saline and Ringer's Lactate, initially remain in the vascular compartment, expanding vascular volume. Isotonic imbalances occur when water and electrolytes are lost or gained in equal proportions, and serum osmolality remains constant. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		A client taking lasix (furosemide) for congestive heart failure is seeing the physician for a potassium value of 3.0. An order for oral potassium taken daily is written and discussed with the client. In addition, potassium-rich foods should be eaten. The nurse educator meets with this client and has the client identify all of the following foods as potassium-rich except:  Your Answer: White bread
		Objective: Teach clients measures to maintain fluid and electrolyte balance. Rationale: White bread is known to help meet fiber needs for the body. Potassium is found in many fruits, vegetables, meat, and fish. Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		Edema that forms in clients with kidney disease is due to: Your Answer: Decreased capillary hydrostatic pressures pushing fluid into the interstitial tissues Correct Answer: Reduced plasma oncotic pressure, so that fluid is not drawn into the capillaries from interstitial tissues
		Objective: Discuss the risk factors for and the causes and effects of fluid, electrolyte, and acid-base imbalances. Rationale: The edema is due to low levels of plasma proteins that exist with this disease, altering the oncotic pressure that helps regulate fluid movement in the vascular space moving into interstitial area. Increased capillary hydrostatic pressure is the cause. Capillaries have increased permeability when edema formation is possible. Obstructed lymph flow impairs the movement of fluid from interstitial tissues back into the vascular compartment, resulting in edema. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		A client suffering from a narcotic overdose is seen in the Emergency Department. The client is confused, with warm, flushed skin, headache, and weakness. Vital signs of noted are T 102.6, HR 128, R 24, and BP 130/86. A blood gas analysis sample was drawn on room air, and the results are as follows: pH 7.33, PaCO2 53, PaO2 72, HCO3 24. This client is at risk for:  Your Answer: Respiratory acidosis
		Objective: Identify examples of nursing diagnoses, outcomes, and interventions for clients with altered fluid, electrolyte, or acid-base balance. Rationale: Narcotic overdose causes more carbonic acid levels to rise because of hypoventilation and carbon dioxode retention. Nursing Process: Assessment and Evaluation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		Measurements related to fluid balance of clients that a nurse can initiate without a physician's order include:  Your Answer: Daily weights, vital signs, and fluid intake and output
		Objective: Teach clients measures to maintain fluid and electrolyte balance. Rationale: Daily weights, checking vital signs, and monitoring fluid I&O all fall within the realm of nursing interventions. The remaining interventions either have the nurse perform a task requiring an MD order, such as giving diuretics or placing a Foley catheter, or have an action unrelated to this problem, such as the calorie count. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		The nurse has been invited to discuss "the importance of promoting a good fluid and electrolyte balance in children" for a group of parents at the local school parents club meeting. Of the following actions, which is not representative of this topic? Your Answer: Encouraging excessive amounts of foods or fluids high in salt or caffeine
		Objective: Teach clients measures to maintain fluid and electrolyte balance. Rationale: Salt causes the body to retain fluids due to an increase in the concentration of sodium and the release of ADH. Caffeine acts as a diuretic in individuals and may lead to loss of excess fluids in the body. The remaining identified measures are all appropriate. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		The nurse is admitting a new client, 80 years old, with congestive heart failure into your home health agency. The following assessment findings have been determined after meeting the client: overweight but no gain since the client left the hospital two days ago; VS: T 99.0, HR 100, R 22, BP 130/86. Foods eaten include canned soup at each meal, ham, and cheese. When completing the care plan for this client, the nurse should include which of the following nursing diagnosis: Your Answer: Risk for Fluid Volume Imbalance
		Objective: Identify examples of nursing diagnoses, outcomes, and interventions for clients with altered fluid, electrolyte, or acid-base balance. Rationale: Sodium is found in high quantities in the foods noted that the client has consumed. When sodium levels increase in the body, water is retained, adding to the volume of fluid in circulation, making it harder for the body to move fluids through the circulation. Therefore, the excess fluid may in time impair gas exchange if levels eventually act on the lungs; fluid volume is increasing, not decreasing, in this situation, and this problem has no involvement with platelets. Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		The results of an arterial blood gas are as follows: pH: 7.5, PaCO2: 50, PaO2: 88, HCO3: 28; Base excess: +5. Evaluate the acid-base imbalance. __________ Your Answer: Metabolic Alkalosis Correct Answer: Metabolic alkalosis with a respiratory compensation.
		Objective: Collect assessment data related to the client’s fluid, electrolyte, and acid-base balances. Rationale: Arterial blood gases are performed to evaluate the client’s acid-base balance and oxygenation. pH is the measure of relative acidity or alkalinity. PaCO2: is the partial pressure of carbon dioxide in arterial plasma. PaO2 is the pressure exerted by oxygen dissolved in the plasma, HCO3: is the measure of the metabolic component of acid-base balance. Base excess is a calculated value of bicarbonate levels. Nursing Process: Assessment and Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		Following surgery, the client requires a blood transfusion. The main reason the nurse wants to complete the unit transfusion within a four-hour period that blood: Your Answer: Hanging for a longer four hours creates an increased risk of sepsis
		Objective: Implement measures to correct imbalances of fluids and electrolytes or acids and bases such as enteral or parenteral replacements and blood transfusions. Rationale: Hanging for a longer four hours creates an increased risk of sepsis, which is why the nurse wants to complete the unit transfusion in less than four hours. The remaining items are not likely to happen. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and process of elimination.