Fluid, Electrolyte, and Acid-Base Balance

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. "Increase fluids if your mouth feels dry. b. "More fluids are needed if you feel thirsty." c. "Drink more fluids in the late evening hours." d. "If you feel lethargic or confused, you need more to drink."

A. "Increase fluids if your mouth feels dry. An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur.

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a. Assign the patient to a room near the nurse's station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place an order for a low-salt diet.

A. Assign the patient to a room near the nurse's station. The patient should be placed near the nurse's station if confused in order for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. This patient needs sodium replacement, not restriction.

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

A. Infuse 5% dextrose in water at 125 mL/hr.; Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

A. Lung sounds Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess.

A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

A. Metabolic acidosis The pH and HCO3 indicate that the patient has a metabolic acidosis. The ABGs are inconsistent with the other responses.

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

A. Monitor ionized calcium level. This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased.

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the magnesium level on the patient's chart. d. Teach the patient about the risk of magnesium-cont

A. Notify the patient's health care provider. The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia.

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every evening

A. Oral digoxin (Lanoxin) 0.25 mg daily Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias.

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing

A. Presence of the Chvostek's sign The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy.

The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order will the nurse perform the steps, starting with the first one? 1. Remove the sleeve of the gown from the arm without the IV. 2. Remove the sleeve of the gown from the arm with the IV. 3. Remove the IV solution container from its stand. 4. Pass the IV bag and tubing through the sleeve. a. 1, 2, 3, 4 b. 2, 3, 4, 1 c. 3, 4, 1, 2 d. 4, 1, 2, 3

ANS: A Change regular gowns by following these steps for maximum speed and arm mobility: (1) To remove a gown, remove the sleeve of the gown from the arm without the IV line, maintaining the patient's privacy. (2) Remove the sleeve of the gown from the arm with the IV line. (3) Remove the IV solution container from its stand and pass it and the tubing through the sleeve. (If this involves removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental infusion of a large volume of solution or medication.)

The nurse administers an intravenous (IV) hypertonic solution to a patient expects the fluid shift to occur in what direction? a. From intracellular to extracellular b. From extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitial

ANS: A Hypertonic solutions will move fluid from the intracellular to the extracellular (intravascular). A hypertonic solution has a concentration greater than normal body fluids, so water will shift out of cells because of the osmotic pull of the extra particles. Movement of water from the extracellular (intravascular) into cells (intracellular) occurs when hypotonic fluids are administered. Distribution of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic and osmotic pressures.

The nurse is laboratory blood results will expect to observe which cation in the most abundance? a. Sodium b. Chloride c. Potassium d. Magnesium

ANS: A Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation. Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium is found predominantly inside cells and in bone.

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2° F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60

ANS: A The infant should be seen first. An infant's proportion of total body water (70% to 80% total body weight) is greater than that of children or adults. Infants and young children have greater water needs and immature kidneys. They are at greater risk for extracellular volume deficit and hypernatremia because body water loss is proportionately greater per kilogram of weight. A teenager with excessive edema from a sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older adult with a blood pressure of 112/60.

6. A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? a. Renal b. Endocrine c. Respiratory d. Gastrointestinal

ANS: A The kidneys (renal) are responsible for respiratory acidosis compensation. A problem with the respiratory system causes respiratory acidosis, so another organ system (renal) needs to compensate. Problems with the gastrointestinal and endocrine systems can cause acid-base imbalances, but these systems cannot compensate for an existing imbalance.

The nurse is teaching about the process of passively moving water from an area of lower particle concentration to an area of higher particle concentration. Which process is the nurse describing? a. Osmosis b. Filtration c. Diffusion d. Active transport

ANS: A The process of moving water from an area of low particle concentration to an area of higher particle concentration is known as osmosis. Filtration is mediated by fluid pressure from an area of higher pressure to an area of lower pressure. Diffusion is passive movement of electrolytes or other particles down the concentration gradient (from areas of higher concentration to areas of lower concentration). Active transport requires energy in the form of adenosine triphosphate (ATP) to move electrolytes across cell membranes against the concentration gradient (from areas of lower concentration to areas of higher concentration).

In which patient will the nurse expect to see a positive Chvostek's sign? a. A 7-year-old child admitted for severe burns b. A 24-year-old adult admitted for chronic alcohol abuse c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism d. A 75-year-old patient admitted for a broken hip related to osteoporosis

ANS: B A positive Chvostek's sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis (which also can be affected by alcohol consumption). Burn patients frequently experience extracellular fluid volume deficit. Hyperparathyroidism causes hypercalcemia. Immobility is associated with hypercalcemia.

The nurse receives the patient's most recent blood work results. Which laboratory value is of greatest concern? a. Sodium of 145 mEq/L b. Calcium of 15.5 mg/dL c. Potassium of 3.5 mEq/L d. Chloride of 100 mEq/L

ANS: B Normal calcium range is 9 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145 mEq/L, potassium 3.5 to 5.0 mEq/L, and chloride 98 to 106 mEq/L.

The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. An increase b. A decrease c. Equal to calcium d. No change in phosphate

ANS: B Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is elevated, the other decreases, except in some patients with end-stage renal disease.

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis? a. pH 7.60, PaCO2 40 mm Hg, HCO3 - 30 mEq/L b. pH 7.53, PaCO2 30 mm Hg, HCO3 - 24 mEq/L c. pH 7.35, PaCO2 35 mm Hg, HCO3 - 26 mEq/L d. pH 7.25, PaCO2 48 mm Hg, HCO3 - 23 mEq/L

ANS: B Respiratory alkalosis should show an alkalotic pH and decreased CO2 (respiratory) values, with a normal HCO3 - . In this case, pH 7.53 is alkaline (normal = 7.35 to 7.45), PaCO2 is 30 (normal 35 to 45 mm Hg), and HCO3 - is 24 (normal = 22 to 26 mEq/L). A result of pH 7.60, PaCO2 40 mm Hg, HCO3 - 30 mEq/L is metabolic alkalosis. pH 7.35, PaCO2 35 mm Hg, HCO3 - 26 mEq/L is within normal limits. pH 7.25, PaCO2 48 mm Hg, HCO3 - 23 mEq/L is respiratory acidosis.

In reviewing the results of the client's blood work, the nurse recognizes that the unexpected value that should be reported to the health care provider is: A) Calcium 3.9 mEq/L B) Sodium 140 mEq/L C) Potassium 3.5 mEq/L D) Magnesium 2.1 mEq/L

Answer: A Rationale: A calcium level of 3.9 mEq/L should be reported to the health care provider. A normal calcium level is 4.5 to 5.5 mEq/L. A sodium level of 140 mEq/L is within the normal range of 135 to 145 mEq/L. A potassium level of 3.5 mEq/L is within the normal range of 3.5 to 5.0 mEq/L.

When a client's serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system? A) Neurological B) Gastrointestinal C) Pulmonary D) Hepatic

Answer: A Rationale: Because sodium is necessary for nerve impulse transmission, the priority nursing assessment with hyponatremia is the neurological system.

A client is prescribed 0.9% sodium chloride (normal saline), which is an isotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: A) Expand the volume of fluid in the vascular system B) Pull fluid from the cells C) Keep protein levels normal D) Move fluid into the cells

Answer: A Rationale: Isotonic solutions such as normal saline, 0.9% sodium chloride, expand the body's fluid volume without causing a fluid shift from one compartment to another.

A client is currently taking Lasix and digoxin. As a result of the medication regimen, the nurse is alert to the presence of: A) Cardiac dysrhythmias B) Severe diarrhea C) Hyperactive reflexes D) Peripheral cyanosis

Answer: A Rationale: Lasix is a non-potassium-sparing diuretic. Without a potassium supplement, the client may become hypokalemic. Hypokalemia increases the risk for digoxin toxicity. Both hypokalemia and digoxin toxicity can cause cardiac dysrhythmias. Clients with hypokalemia from diuretic use may experience intestinal distention and decreased bowel sounds. Severe diarrhea may be a cause of hypokalemia, not a result of hypokalemia. Clients with hyperactive reflexes may have hypocalcemia. Lasix and digoxin do not predispose a client to hypocalcemia. Peripheral cyanosis is not a potential problem related to the client's medication regimen.

A homeless client is brought into the emergency department with indications of extremely poor nutrition. Arterial blood gas levels are assessed, and the nurse anticipates that this client will demonstrate which of the following results? A) pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L B) pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L C) pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L D) pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L

Answer: A Rationale: Metabolic acidosis may be found in cases of starvation. The client's pH is below the normal of 7.35 (at 7.3), the PaCO2 is in the normal range of 35 to 45 mm Hg (at 38 mm Hg), and the HCO3 is below the normal of 22 mEq/L (at 19 mEq/L). These findings demonstrate metabolic acidosis. Values of pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L are consistent with respiratory alkalosis, compensated, which would not be typical of malnutrition. Values of pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L are consistent with metabolic alkalosis, compensated, which would not be an expected finding with extremely poor nutrition.

Which of the following foods will have the greatest impact on the water balance of the person consuming it? A) A pickle B) A banana C) A milkshake D) A spinach salad

Answer: A Rationale: Sodium ions are the major contributors to maintaining water balance through their effect on serum osmolality, nerve impulse transmission, regulation of acid-base balance, and participation in cellular chemical reactions. Pickles are a high-sodium food. The remaining options are good sources of potassium, calcium, and magnesium.

A client experiences a loss of intracellular fluid. The nurse anticipates that the intravenous (IV) therapy that will be used to replace this type of loss is: A) 0.45% normal saline (NS) B) 10% dextrose C) 5% dextrose in lactated Ringers D) Dextrose 5% in NS

Answer: A Rationale: The client will need a hypotonic solution, such as 0.45% NS. A hypotonic solution has an osmolality that is less than body fluids, so the cells will draw the fluid in, which is the desired effect when the client has experienced a loss of intracellular fluid. Dextrose 5% in NS, 10% dextrose, and 5% dextrose in lactated Ringers are all hypertonic solutions that will draw fluid into the vascular space by osmosis. The client needs a hypotonic solution to rehydrate the cells.

A client who takes furosemide presents at the emergency department with weakness and fatigue and complains of nausea and vomiting for 3 days. Upon assessment, the nurse finds that the client has decreased bowel sounds and ECG abnormalities including a flattened T wave and flattened ST segment. The nurse knows that these are signs of: A) Hypokalemia B) Hyperkalemia C) Hyponatremia D) Hypocalcemia

Answer: A Rationale: The described symptoms and ECG abnormalities are consistent with hypokalemia, which can result from the use of potassium-wasting diuretics like furosemide.

The nurse is caring for a 73-year-old female client who is 3 days postoperative for a bowel obstruction. The nurse knows that the stress response of surgery causes fluid-balance changes in the second to fifth postoperative day, when aldosterone, glucocorticoids, and antidiuretic hormone (ADH) are increasingly secreted, causing sodium and chloride retention and potassium excretion. Because of this, it is important for the nurse to closely monitor: A) Urine output B) Intake of sodium C) Activity l

Answer: A Rationale: The nurse should closely monitor urine output because of the fluid-balance changes that occur after surgery. Increased secretion of ADH and other hormones can affect urine output.

A client with partial-thickness burns over 40% of the body is likely to lose body fluid via: A) Water vapor that is lost through the skin that is burned B) Plasma and interstitial fluids that are lost as burn exudate C) Blood leakage via damaged capillaries in the dermis D) Respiratory acidosis resulting from altered respiratory function E) Plasma that leaves the intravascular space and becomes trapped in blisters F) Sodium and water shift out of the vessels because of increased permeability

Answer: A, B, C, E, F Rationale: Clients with significant burns can lose fluids through various mechanisms, including water vapor loss through burned skin, loss of plasma and interstitial fluids as burn exudate, blood leakage from damaged capillaries, plasma trapped in blisters, and sodium and water shift due to increased permeability.

A client is prescribed 3% sodium chloride, which is a hypertonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: A) Expand the volume of fluid in the vascular system B) Pull fluid from the cells C) Keep protein levels normal D) Move fluid into the cells

Answer: B Rationale: A hypertonic solution (a solution of higher osmotic pressure), such as 3% sodium chloride, pulls fluid from cells, causing them to shrink.

Which of the following clinical assessment findings is most likely seen in a client experiencing hyperkalemia as a result of adrenal insufficiency? A) Dry, sticky tongue B) Increased anxiety C) Nausea and vomiting D) Decreased bowel sounds

Answer: B Rationale: Hyperkalemia can lead to anxiety, dysrhythmias, and other symptoms.

For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms? A) Weak, thready pulse B) Hypertension C) Dry mucous membranes D) Flushed skin

Answer: B Rationale: Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess.

A client complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the following actions should the nurse take immediately? A) Check the vital signs. B) Stop the blood transfusion. C) Slow down the rate of blood flow. D) Notify the health care provider and blood bank personnel.

Answer: B Rationale: If a blood reaction is suspected, the nurse stops the blood transfusion immediately. The nurse should take the client's vital signs, but the initial action should be to stop the blood transfusion. Once the transfusion is stopped, the nurse could notify the health care provider and blood bank personnel.

Which of the following clients is at greatest risk for insensible water loss? A) A 37-year-old with a superficial burn to the left hand B) A 15-year-old experiencing an asthmatic attack C) A 50-year-old with type 2 diabetes D) A 73-year-old with a history of pneumonia

Answer: B Rationale: Insensible water loss is continuous and occurs through the skin and lungs. A person does not perceive the loss, but it can significantly increase with fever or burns. This insensible water loss increases in response to changes in respiratory rate and depth. In addition, devices for administering oxygen increase insensible water loss from the lungs. The teenager experiencing the asthmatic attack is at greatest risk because of the increased respiratory involvement and possible fever. Type 2 diabetes does not necessarily increase insensible water loss, and the remaining clients may have a small risk.

A client has intravenous therapy for the administration of antibiotics and is stating that the IV site hurts and is swollen. Which of the following information assessed on the client indicates the presence of phlebitis, as opposed to infiltration? A) Intensity of the pain B) Warmth of integument surrounding the IV site C) Amount of subcutaneous edema D) Skin discoloration of a bruised nature

Answer: B Rationale: Signs of phlebitis may include increased temperature over the vein, erythema, pain, and edema. With phlebitis, the area is warm to the touch; with infiltration, the area is cool to the touch. The intensity of pain is not a differentiating factor between phlebitis and infiltration. Pain may occur with both. The amount of subcutaneous edema is not a differentiating factor between phlebitis and infiltration. Edema may occur with both. Skin discoloration of a bruised nature is not the best way to differentiate phlebitis from infiltration. With phlebitis, the area is typically reddened. With infiltration, the area is typically pale.

A mother brings her 2-year-old daughter to the clinic with a 2-day history of a fever of unknown origin. The mother explains to the nurse that the air conditioning in her apartment is not working, and it has been very hot; her daughter has been vomiting for 2 days and has had a fever, and the child is lethargic. The child's rectal temperature is 101.1 F. The nurse knows the child is probably dehydrated and should do which of the following first? A) Give the child some juice to drink. B) Prepare

Answer: B Rationale: The child with suspected dehydration should have IV fluid replacement as the first priority, followed by any necessary treatment for fever or other symptoms.

An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment, the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse determines that the child is suffering from: A) Metabolic acidosis B) Respiratory acidosis C) Respiratory alkalosis D) Metabolic alkalosis

Answer: B Rationale: These assessment findings (i.e., warm and flushed skin, lethargy, and medical diagnosis of pneumonia) are indicative of respiratory acidosis. Lethargy and flushed skin may be seen with metabolic acidosis, but this child has a respiratory problem with difficulty breathing, which is consistent with respiratory acidosis.

The health care provider orders 1000 mL of D5LR with 20 mEq KCl to run for 8 hours. Using an infusion set with a drop factor of 15 gtt/mL, the nurse calculates the flow rate to be: A) 12 gtt/min B) 22 gtt/min C) 32 gtt/min D) 42 gtt/min

Answer: C Rationale: (1000 mL / 8 hr) x (15 gtt/mL / 60 min) = 125 gtt/hr = 32 gtt/min

A client is admitted to the hospital with a diagnosis of adrenal insufficiency. In preparing to complete the admission history, the nurse anticipates that the client will have experienced: A) Decreased muscle tone B) Hypertension C) Diarrhea D) Fever

Answer: C Rationale: A cause of hyponatremia is adrenal insufficiency. The client with hyponatremia may experience diarrhea, abdominal cramping, and nausea and vomiting. Decreased muscle tone is a symptom of hypokalemia. A client with adrenal insufficiency is not likely to experience hypertension. Resultant hyponatremia with adrenal insufficiency may be exhibited as postural hypotension. Fever is a symptom of hypernatremia, not hyponatremia. Hypernatremia is not caused by adrenal insufficiency.

Blood replacement or transfusion is the IV administration of whole blood or a component such as plasma, packed red blood cells (RBCs), or platelets. The minimum gauge IV cannula necessary for administering a blood transfusion is: A) 24 gauge B) 22 gauge C) 20 gauge D) 18 gauge

Answer: C Rationale: A minimum of a 20-gauge IV cannula is recommended for administering a blood transfusion, although an 18-gauge cannula is considered ideal.

Which of the following foods will have the greatest impact on the blood-clotting mechanism of the person consuming it? A) A pickle B) A banana C) A milkshake D) A spinach salad

Answer: C Rationale: Calcium is necessary for blood clotting, and milk is a high-calcium food, making it the best choice among the options.

A magnesium level of 2.1 mEq/L is within the normal range of 1.5 to 2.5 mEq/L. The nurse anticipates that the client with a fluid volume excess will manifest a(n): A) Increased urine specific gravity B) Decreased body weight C) Increased blood pressure D) Decreased pulse strength

Answer: C Rationale: Hypertension is manifested with fluid volume excess. The urine specific gravity would be decreased with fluid volume excess. The nurse would anticipate an increased urine specific gravity with fluid volume deficit, as well as an increase in body weight and an increase in pulse strength.

Which of the following clinical assessment findings is most likely seen in a client experiencing partial-thickness burns over 35% of the body as a result of hyponatremia? A) Dry, sticky tongue B) Increased anxiety C) Nausea and vomiting D) Decreased bowel sounds

Answer: C Rationale: Hyponatremia can result in nausea and vomiting, among other symptoms.

Of all the following clients, the individual who is most at risk for a fluid volume deficit is: A) A 6-month-old learning to drink from a cup B) A 12-year-old who is moderately active in 80 F weather C) A 42-year-old with severe diarrhea D) A 90-year-old with frequent headaches

Answer: C Rationale: The client at greatest risk for a fluid volume deficit is the client who has severe diarrhea. Any condition that results in the loss of gastrointestinal (GI) fluids predisposes the client to dehydration and a variety of electrolyte disturbances. The very young are at risk for a fluid volume deficit because their body water loss is proportionately greater per kilogram of weight. A 12-year-old who is moderately active in warm weather will lose body water through sweating. The very old are at increased risk for fluid volume deficit as they have a decreased thirst sensation and a decreased number of filtering nephrons.

Which of the following clients is most at risk for fluid volume deficit? A) 25-year-old male near-drowning victim B) 56-year-old woman with salicylate poisoning C) 45-year-old woman with second-degree burns over 20% of her body D) 13-year-old boy with an oral temperature of 103.4 F

Answer: C Rationale: The client with second-degree burns over a significant body surface area is at the highest risk for fluid volume deficit due to fluid loss from burn injuries.

The compensating mechanism that is most likely to occur in the presence of respiratory acidosis is: A) Hyperventilation to decrease the CO2 levels B) Hypoventilation to increase the CO2 levels C) Retention of HCO3 by the kidneys to increase the pH level D) Excretion of HCO3 by the kidneys to decrease the pH level

Answer: C Rationale: The compensating mechanism in the presence of respiratory acidosis is retention of bicarbonate by the kidneys to increase the pH level. Hyperventilation would be the compensating mechanism in metabolic acidosis to decrease CO2 levels. Hypoventilation would be the compensating mechanism in metabolic alkalosis to increase CO2 levels. The compensating mechanism in the presence of metabolic alkalosis is excretion of bicarbonate to decrease the pH level.

The nurse is discontinuing a client's IV line in preparation for the client's discharge home. Upon withdrawing the cannula from the peripheral site, the nurse notes that the tip of the cannula is missing. The first thing that the nurse should do is: A) Notify the health care provider immediately B) Apply pressure to the IV site C) Apply a tourniquet high on the extremity D) Ask another nurse to double-check the cannula

Answer: C Rationale: The nurse's first action should be to apply a tourniquet high on the extremity to restrict the movement of the catheter embolus, followed by notifying the health care provider.

The nurse is assessing the client with an IV line. The nurse notes that the IV insertion site is red, edematous, and painful. The nurse's first action should be to: A) Immediately discontinue the IV line and remove the cannula B) Put cool compresses on the IV site to decrease the edema C) Notify the health care provider of the situation D) Put warm compresses on the IV site to decrease the pain

Answer: C Rationale: The nurse's first action should be to notify the health care provider to determine the appropriate course of action for the client with an inflamed IV site.

A client has severe anemia and will be receiving blood transfusions. The nurse prepares and begins the infusion. Ten minutes after the infusion has begun, the client develops tachycardia, chills, and low back pain. After stopping the transfusion, the nurse should: A) Administer an antipyretic B) Begin an infusion of epinephrine C) Run normal saline through the blood tubing D) Obtain and send a urine specimen to the laboratory

Answer: D Rationale: After stopping the blood transfusion, the nurse should obtain and send a urine specimen to the laboratory to determine the presence of hemoglobin as a result of red blood cell (RBC) hemolysis. In an acute hemolytic reaction, management of the reaction does not include the administration of an antipyretic. The nurse should be prepared to administer emergency drugs, such as diuretics, per the health care provider's order. The nurse should not turn off the blood and simply turn on the normal saline that is connected to the Y-tubing set. This would cause blood remaining in the Y-tubing to infuse into the client. Even a small amount of mismatched blood can cause a major reaction. The nurse should run normal saline directly into the IV line (not through the blood tubing).

When an excess of body fluid exists in the intravascular compartment, all of the following signs can be expected except: A) Rales B) A bounding pulse C) Engorged peripheral veins D) An elevated hematocrit level

Answer: D Rationale: An elevated hematocrit level would be expected with a deficit of body fluid in the intravascular compartment. When an excess of body fluid exists in the intravascular compartment, a decreased hematocrit would be expected. Crackles (in lungs) are consistent findings with fluid volume excess. An assessment finding associated with fluid volume excess is a bounding pulse. Engorged peripheral veins may be seen with fluid volume excess.

A client with transient atrial fibrillation has been taking 83 mg of aspirin daily for the past 3 years. When preparing the client for discharge from the hospital, the nurse discontinues his IV line. In order to prevent a hematoma, the nurse needs to hold pressure on the IV site for: A) 1 to 2 minutes B) 2 to 3 minutes C) 3 to 5 minutes D) 5 to 10 minutes

Answer: D Rationale: Due to the client's daily aspirin use, which can affect clotting, the nurse should hold pressure on the IV site for 5 to 10 minutes to prevent a hematoma.

The client has been experiencing right flank and lower back pain. Which of the following laboratory values would be most desirable for the nurse to obtain based on the client's assessment? A) Serum potassium B) Serum sodium C) Serum magnesium D) Serum calcium

Answer: D Rationale: Flank pain and lower back pain may be indicative of kidney stones from excess calcium. The laboratory value for the nurse to obtain would be a serum calcium level.

Which of the following clinical assessment findings is most likely seen in a client experiencing hypokalemia as a result of the misuse of potassium-wasting diuretics? A) Dry, sticky tongue B) Increased anxiety C) Nausea and vomiting D) Decreased bowel sounds

Answer: D Rationale: Hypokalemia can cause decreased bowel sounds, along with other symptoms such as weakness, nausea, and vomiting.

A client is prescribed 0.45% sodium chloride, which is a hypotonic solution. The nurse recognizes the primary goal of such intravenous therapy is to: A) Expand the volume of fluid in the vascular system B) Pull fluid from the cells C) Keep protein levels normal D) Move fluid into the cells

Answer: D Rationale: Hypotonic solutions (a solution of lower osmotic pressure), such as 0.45% sodium chloride, move fluid into the cells, causing them to enlarge.

The nurse recognizes which of the following clients is at the greatest risk for dehydration? A) A 35-year-old client diagnosed with Crohn's disease B) A 15-year-old client who is following a low-carbohydrate diet C) A 2-year-old client diagnosed with an allergy to milk proteins D) A 79-year-old client who has been diagnosed with advanced Alzheimer's disease

Answer: D Rationale: Infants, clients with neurological or psychological problems, and some older adults who are unable to perceive or respond to the thirst mechanism are at risk for dehydration.

An IV solution of 125 mL is to be infused over a 1-hour period. A microdrip infusion set will be used. The nurse calculates the infusion rate as: a) 32 gtt/min b) 60 gtt/min c) 125 gtt/min d) 250 gtt/min

Answer: c Rationale: (60 gtt/mL * 60 min) x 125 mL = 125 gtt/min)

For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and symptoms consistent with: a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis

Answer: d Rationale: A salicylate overdose may cause respiratory alkalosis because of hyperventilation. Aspirin overdose is not associated with metabolic acidosis, metabolic alkalosis, or respiratory acidosis.

The single best indicator of fluid status is the nurse's assessment of the client's: a) Skin turgor b) Intake and output c) Serum electrolyte levels d) Daily weight

Answer: d Rationale: Daily weights are the single most important indicator of fluid status. Skin turgor is a measure of hydration, as are intake and output. Serum electrolyte levels help monitor fluid status; however, daily weights are the single best indicator of a client's fluid status.

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

B

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.

B. Check the patient's blood pressure. Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Presence of edema d. Hourly urine output

B. Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds.

An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation? a. Pallor b. Edema c. Confusion d. Restlessness

B. Edema; The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels.

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suction. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow,

B. Give the patient the PRN IV morphine sulfate 4 mg. The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain.

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.

B. Infuse the KCl at a rate of 10 mEq/hour. IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias.

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast

B. Milk carton Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets.

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

B. Serum calcium is 18 mg/dL. The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias.

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

B. The patellar and triceps reflexes are absent. The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels.

The nurse is caring for a patient who has a central venous access device (CVAD). Which action by the nurse is appropriate? a. Avoid using friction when cleaning around the CVAD insertion site. b. Use the push-pause method to flush the CVAD after giving medications. c. Obtain an order from the health care provider to change CVAD dressing. d. Position the patient's face toward the CVAD during injection cap changes.

B. Use the push-pause method to flush the CVAD after giving medications. The push-pause enhances the removal of debris from the CVAD lumen and decreases the risk for clotting.

During the admission process, the nurse obtains information about a patient through the physical assessment and diagnostic testing. Based on the data shown in the accompanying figure, which nursing diagnosis is appropriate? a. Deficient fluid volume b. Impaired gas exchange c. Risk for injury: Seizures d. Risk for impaired skin integrity

C

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided imagery.

C. Administer the prescribed normal saline bolus and insulin. The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis.

The long-term care nurse is evaluating the effectiveness of protein supplements for an older resident who has a low serum total protein level. Which assessment finding indicates that the patient's condition has improved? a. Hematocrit 28% b. Absence of skin tenting c. Decreased peripheral edema d. Blood pressure 110/72 mm Hg

C. Decreased peripheral edema Edema is caused by low oncotic pressure in individuals with low serum protein levels. The decrease in edema indicates an improvement in the patient's protein status.

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1° F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Gradually decreasing level of consciousness (LOC) d. Weight gain of 2 pounds (1 kg) above the admission weight

C. Gradually decreasing level of consciousness (LOC) The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions.

A patient who has a small cell carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding? a. Reported weight gain b. Serum hematocrit of 42% c. Serum sodium level of 120 mg/dL d. Total urinary output of 280 mL during past 8 hours

C. Hyponatremia is the most important finding to report. SIADH causes water retention and a decrease in serum sodium level. Hyponatremia can cause confusion and other central nervous system effects. A critically low value likely needs to be treated. At least 30 mL/hr of urine output indicates adequate kidney function. The hematocrit level is normal. Weight gain is expected with SIADH because of water retention.

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

C. Mental status Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures.

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

C. Na+ 154 mEq/L (154 mmol/L) The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal.

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

C. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes. The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for life-threatening complications.

A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate? a. "There is a decreased risk for infection when 25% dextrose is infused through a central line." b. "The prescribed infusion can be given much more rapidly when the patient has a central line." c. "The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line."

C. The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line." The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give the prescribed PRN morphine sulfate IV.

C. The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax.

A patient who was involved in a motor vehicle crash has had a tracheostomy placed to allow for continued mechanical ventilation. How should the nurse interpret the following arterial blood gas results: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

D

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseau's and Chvostek's signs. d. Encourage fluid intake up to 4000 mL every day.

D. Encourage fluid intake up to 4000 mL every day. To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift.

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/minute. b. There is sediment and blood in the patient's urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields.

D. There are crackles audible throughout both lung fields. Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions.

Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective? a. "I will try to drink at least 8 glasses of water every day." b. "I will use a salt substitute to decrease my sodium intake." c. "I will increase my intake of potassium-containing foods." d. "I will drink apple juice instead of orange juice for breakfast."

D. "I will drink apple juice instead of orange juice for breakfast." Because spironolactone is a potassium-sparing diuretic, patients should be taught to choose low-potassium foods (e.g., apple juice) rather than foods that have higher levels of potassium (e.g., citrus fruits). Because the patient is using spironolactone as a diuretic, the nurse would not encourage the patient to increase fluid intake. Teach patients to avoid salt substitutes, which are high in potassium.

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel.

D. Ask the health care provider to order a basic metabolic panel. Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are associated with hyperkalemia.

Which of the following foods will have the greatest impact on the neurochemical activity of the person consuming it? A) A pickle B) A banana C) A milkshake D) A spinach salad

Answer: D Rationale: Magnesium is essential for neurochemical activity, and spinach is a high-magnesium food, making it the most suitable choice.

The nurse recognizes that the client, based on the imbalance that is present, will require fluid replacement with isotonic solution. One of the isotonic solutions that may be ordered by the health care provider is: A) 0.45% saline B) Lactated Ringers C) 5% dextrose in normal saline D) 5% dextrose in lactated Ringers

Answer: B Rationale: Lactated Ringers is an isotonic solution. 0.45% saline is a hypotonic solution. 5% dextrose in normal saline and 5% dextrose in lactated Ringers are both hypertonic solutions.

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives

A. Daily alcohol intake Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level.

A 66-year-old female client is admitted to the hospital with diabetic ketoacidosis. The client has a running IV line through which she receives her medications and fluid maintenance. Which of the following would not be counted in the daily intake and output (I&O)? A) IV fluids B) Cream of mushroom soup C) Gelatin D) Mashed potatoes

Answer: D Rationale: Mashed potatoes do not contain enough liquid to be counted in the fluid intake of the client, while IV fluids, soup, and gelatin should be included in the daily fluid intake.

The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse? a. Blood pressure is 90/40 mm Hg. b. Urine output is 30 mL over the last hour. c. Oral fluid intake is 100 mL for the last 8 hours. d. There is prolonged skin tenting over the sternum.

A. The blood pressure indicates that the patient may be developing hypovolemic shock as a result of intravascular fluid loss due to the burn injury. This finding will require immediate intervention to prevent the complications associated with systemic hypoperfusion. The poor oral intake, decreased urine output, and skin tenting all indicate the need for increasing the patient's fluid intake but not as urgently as the hypotension

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

A. The patient is experiencing laryngeal stridor. Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level.

A patient is experiencing dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular

ANS: A Intracellular (inside the cells) fluid accounts for approximately two thirds of total body water. Extracellular (outside the cells) is approximately one third of the total body water. Intravascular fluid (liquid portion of the blood) and transcellular fluid are two major divisions of the extracellular compartment.

Which of the following clinical assessment findings is most likely seen in a client experiencing hypernatremia as a result of diabetes insipidus? A) Dry, sticky tongue B) Increased anxiety C) Nausea and vomiting D) Decreased bowel sounds

Answer: A Rationale: Hypernatremia can lead to dry and sticky tongue and mucous membranes, which are characteristic symptoms.

A 2-year-old child has ingested a quantity of a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

ANS: B Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.

A nurse is caring for a patient whose electrocardiogram (ECG) presents with changes characteristic of hypokalemia. Which assessment finding will the nurse expect? a. Dry mucous membranes b. Abdominal distention c. Distended neck veins d. Flushed skin

ANS: B Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration and hypernatremia.

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis

ANS: B The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much acid is in the body like kidney failure.

The nurse observes edema in a patient who is experiencing venous congestion as a result of right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration

ANS: C Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic pressures involve the concentrations of solutes and can contribute to edema in other situations, such as inflammation or malnutrition. Concentration pressure is not a nursing term.

A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse perform the steps starting with the first one? 1. Clean site. 2. Select vein. 3. Apply tourniquet. 4. Release tourniquet. 5. Reapply tourniquet. 6. Advance and secure. 7. Insert vascular access device. a. 1, 3, 2, 7, 5, 4, 6 b. 1, 3, 2, 5, 7, 6, 4 c. 3, 2, 1, 5, 7, 6, 4 d. 3, 2, 4, 1, 5, 7, 6

ANS: D The steps for inserting an intravenous catheter are as follows: Apply tourniquet, select vein, release tourniquet, clean site, reapply tourniquet, insert vascular access device, and advance and secure.

Which of the following foods will have the greatest impact on the heart's conductivity of the person consuming it? A) A pickle B) A banana C) A milkshake D) A spinach salad

Answer: B Rationale: Potassium is the major electrolyte and principal cation in the intracellular compartment. It regulates many metabolic activities and is necessary for glycogen deposits in the liver and skeletal muscle, transmission and conduction of nerve impulses, normal cardiac conduction, and skeletal and smooth muscle contraction. Bananas are a high-potassium food. The remaining options are good sources of sodium, calcium, and magnesium.

Arterial blood gas levels are obtained for the client. If the client's results are pH 7.48, CO2 42 mm Hg, and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances? A) Metabolic acidosis B) Respiratory acidosis C) Respiratory alkalosis D) Metabolic alkalosis

Answer: D Rationale: The client's pH is elevated at 7.48 (normal 7.35 to 7.45), the CO2 is normal at 42 mm Hg (normal 35 to 45 mm Hg), and the bicarbonate is elevated at 32 mEq/L (normal 22 to 26 mEq/L). The client is experiencing metabolic alkalosis. In metabolic acidosis, the client's pH would be below 7.35, and the bicarbonate would be below 22 mEq/L. In respiratory acidosis, the client's pH would be below 7.35, and the CO2 would be elevated above 45 mm Hg. In respiratory alkalosis, the client's pH would be above 7.45, and the CO2 would be below 35 mm Hg.

The nurse will be starting a new intravenous infusion and needs to select the site for the insertion. In selection of a site, the nurse should: A) Start with the most proximal site B) Look for hard, cordlike veins C) Use the dominant arm D) Avoid sites on the extremity away from a dialysis graft

Answer: D Rationale: The nurse should avoid veins in an extremity with compromised circulation, such as a dialysis graft. The nurse should use the most distal site in the nondominant arm, if possible, and should avoid hardened cordlike veins.