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
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 2 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 3 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 4 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.
Question 5 of 5
A nurse is caring for an older adult with a fluid volume deficit related to decreased thirst sensation. For which signs and symptoms of this health problem will the nurse assess?
Correct Answer: D
Rationale: Weight loss is a key indicator of fluid volume deficit due to fluid loss. Edema (
A), crackles (
B), and neck vein distention (
C) indicate fluid volume excess.