CHECK FOR UNDERSTANDING (60 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be
given to correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in
you answer/ratio is not allowed. You are given 60 minutes for this activity:

Multiple Choice

1. When a burn damages cells, you would expect the cells to release the major electrolyte:

A. potassium.
B. chloride.
C. calcium.
D. sodium.

Answer: A
Rationale: Potassium is one of the major electrolytes inside the cell that leaks out into extracellular fluid
after a major trauma, such as a burn. This puts the patient at risk for hyperkalemia.

2. Diuretics affect the kidneys by altering the reabsorption and excretion of:
A. water only.
B. electrolytes only.
C. water and electrolytes.
D. other drugs.

Answer: C
Rationale: Diuretics generally affect how much water and sodium the body excretes. At the same time,
other electrolytes such as potassium can also be excreted in urine.

3. The main extracellular cation is:

A. calcium.
B. potassium.
C. bicarbonate.
D. sodium.

Answer: D
Rationale: Sodium is the main extracellular cation. In addition to other functions, it helps regulate fluid
balance in the body.

4. Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is

appropriate for maintaining normal bowel function?
A. Assessing dietary intake
B. Decreasing fluid intake
C. Providing limited physical activity
D. Turning, coughing, and deep breathing
Answer: A
Rationale: Assessing dietary intake provides a foundation for the client’s usual practices and may help
determine if the client is prone to constipation or diarrhea. Limited physical activity may contribute to
constipation due to decreased peristalsis. Turning. coughing and deep breathing help promote gas
exchange. Fluid intake should be increased to aid bowel elimination.

5. A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending
nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention
should be included in the care of plan for the client?
A. Room temperature reduction
B. Fluid restriction of 2,000 ml/day
C. Axillary temperature measurements every 4 hours
D. Antiemetic agent administration

Answer: A
Rationale: For a patient with hyperthermia. reducing the room temperature may help decrease body
temperature. Tepid baths. cool compresses. and a cooling blanket may also be necessary. Antipyretics.
and not antiemetics. are indicated to reduce fever. Oral or rectal temperature measurements are
generally accepted and are more accurate than axillary measurements. Fluids should be encouraged.
not restricted to compensate for insensible losses.

6. A 36-year-old male client is about to be discharged from the hospital after 5 days due to surgery.
Which intervention should be included in the home health care nurse’s instructions about measures
to prevent constipation?
A. Discouraging the client from eating large amounts of roughage-containing foods in the diet.
B. Encouraging the client to use laxatives routinely to ensure adequate bowel elimination.
C. Instructing the client to establish a bowel evacuation schedule that changes every day.
D. Instructing the client to fill a 2-L bottle with water every night and drink it the next day.

Answer: D
Rationale: Adequate fluids and fiber in the diet are key to preventing constipation. Having the client fill a
2-L bottle with water every night and drink it the next day is one method for ensuring the client receives
at least 2.000 ml of water daily. The client also should be instructed to drink any other fluids throughout
the day. High fiber or roughage foods are encouraged. Laxatives should not be used routinely for bowel
elimination. They should be used only as a last resort. because clients may become dependent on them.
A regular bowel evacuation schedule should be established.

7. Mrs. Dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN
requested her to have a complete bed rest. Which nursing intervention is appropriate when
addressing the client’s need to maintain skin integrity?
A. Monitoring intake and output accurately
B. Instructing the client to cough and deep-breathe every 2 hours
C. Keeping the linens dry and wrinkle free
D. Using a foot board to maintain correct anatomic position
Answer: C
Rationale: Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from
interfering with adequate blood supply to the tissues. helping to maintain skin integrity. Using a foot
board is appropriate for maintaining normal body function position. Monitoring intake and output aids
in assessing and maintaining bladder function.. Coughing and deep breathing help promote gas
exchange.

8. A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under
nurse Mark’s care. Which nursing intervention should be included the care plan of Mark for his
patient?
A. Administering I.V. and oral fluids
B. Clustering necessary activities throughout the day
C. Assessing color, odor, and amount of sputum
D. Monitoring serum albumin and total protein levels

Answer: A
Rationale: The client’s assessment findings would lead the nurse to suspect that the client is
dehydrated. Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client
with problems associated with impaired gas exchange or ineffective airway clearance. Monitoring
albumin and protein levels is appropriate for clients experiencing inadequate nutrition. Clustering
activities helps with energy conservation and promotes rest.

9. A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration.
Which intervention should the nurse perform when caring for a client diagnosed with fluid volume
deficit?
A. Assessing urinary intake and output
B. Obtaining the client’s weight weekly at different times of the day
C. Monitoring arterial blood gas (ABG) results
D. Maintaining I.V. therapy at the keep-vein-open rate

Answer: A
Rationale: For the client with fluid volume deficit. assessing the client’s urine output (using a urometer if
necessary) is essential to ensure an output of at least 30 ml/hour. The client should be weighed daily.
not weekly. and at same time each day. usually in the morning. Monitoring ABGs is not necessary for
this client. Rather. serum electrolyte levels would most likely be evaluated. The client also would have
an I.V. rate at least 75 ml/hour. if not higher. to correct the fluid volume deficit.

10. Which electrolyte would the nurse identify as the major electrolyte responsible for determining
the concentration of the extracellular fluid?
A. Potassium
B. Phosphate
C. Chloride
D. Sodium
Answer: D
Rationale: Sodium is the electrolyte whose level is the primary determinant of the extracellular fluid
concentration. Sodium a cation (e.g.. positively charged ion). is the major electrolyte in extracellular
fluid. Chloride. an anion (e.g.. negatively charged ion). is also present in extracellular fluid. but to a lesser
extent. Potassium (a cation) and phosphate (an anion) are the major electrolytes in the intracellular
fluid.