ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 41 : Fluid, Electrolyte, and Acid?Base Balance Questions
Question 1 of 5
A nurse has begun administering an intravenous antibiotic via the patient's peripheral venous access. Immediately, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings?
Correct Answer: D
Rationale: Edema and coolness indicate infiltration, requiring catheter removal. Repositioning (
A) or raising the pole (
B) worsens infiltration. Applying pressure (
C) is inappropriate. Pulling and reinserting (
D) risks further tissue damage.
Question 2 of 5
When caring for a patient receiving hemodialysis through an arteriovenous fistula, which action is essential for the nurse to take?
Correct Answer: C
Rationale:
To protect the fistula, BP and venipuncture should be performed on the opposite extremity. IM injections (
A) are not contraindicated. Radial pulse assessment (
B) is safe. Using the fistula for IV medications (
D) is prohibited.
Question 3 of 5
A nurse is administering a blood transfusion for a patient following surgery. During the transfusion, the patient displays signs of dyspnea, dry cough, and pulmonary edema. What would be the nurse's priority actions related to these symptoms?
Correct Answer: A
Rationale: Symptoms indicate circulatory overload. Slowing or stopping the infusion, monitoring vital signs, notifying the provider, and positioning the patient upright with feet dependent are appropriate. Options B, C, and D address allergic, febrile, or bacterial reactions, respectively.
Question 4 of 5
A nurse is performing physical assessments for patients with fluid imbalance. Which findings indicate a fluid volume excess? Select all that apply.
Correct Answer: C,D,E
Rationale: Moist crackles, tachycardia, and distended neck veins indicate fluid volume excess. Pinched expression (
A) and sluggish turgor (F) suggest fluid deficit. Deep, rapid respirations (
B) may indicate acidosis or alkalosis, not necessarily fluid excess.
Question 5 of 5
A nurse is caring for a patient experiencing a fluid volume deficit. What should be included in the recorded intake and output for the patient? Select all that apply.
Correct Answer: A,B,D,E
Rationale: Urine, vomitus, carbonated beverages, and the liquid portion of chicken noodle soup are included in intake and output. Formed stool (
C) and wound irrigant (F) are not typically measured unless liquid.