Ch. 40 Fluid, Electrolyte, and Acid-Base
Balance NCLEX Questions.
1. A nurse is caring for an older patient with type II diabetes who is living in a long-term care facility. The
nurse determines that the patient's fluid intake and output is approximately 1200 mL daily. What
patient teaching would the nurse provide for this patient? Select all that apply.
a."Try to drink at least six to eight glasses of water each day."
b."Try to limit your fluid intake to one quart of water daily."
c."Limit sugar, salt, and alcohol in your diet."
d."Report side effects of medications you are taking, especially diarrhea."
e."Temporarily increase foods containing caffeine for their diuretic effect."
f."Weigh yourself daily and report any changes in your weight." - correct answer a, c, d, f.
Generally, fluid intake and output averages 2,600 mL per day. This patient is experiencing dehydration
and should be encouraged to drink more water, maintain normal body weight, avoid consuming excess
amounts of products high in salt, sugar, and caffeine, limit alcohol intake, and monitor side effects of
medications, especially diarrhea and water loss from diuretics.
2. A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess.
Upon examination of the patient's legs, the nurse documents: "Pitting edema; 6 mm pit; pit remains
several seconds after pressing with obvious skin swelling." What grade of edema has this nurse
documented?
a.1+ pitting edema
b.2+ pitting edema
c.3+ pitting edema
d.4+ pitting edema - correct answer c. 3+ pitting edema is represented by a deep pit (6 mm) that
remains seconds after pressing with skin swelling obvious by general inspection. 1+ is a slight
indentation (2 mm) with normal contours associated with interstitial fluid volume 30% above normal. 2+
is a 4-mm pit that lasts longer than 1+ with fairly normal contour. +4 is a deep pit (8 mm) that remains
for a prolonged time after pressing with frank swelling.
3. A nurse is preparing an IV solution for a patient who has hypernatremia. Which solutions are the best
choices for this condition? Select all that apply.
