Chapter 9: Acid-Base Balance, NCLEX Fluids and Electrolytes Chapter 9, fundamentals Chapter 42: Fluid, Electrolyte, and Acid-Base Balance, Fluid & Electrolytes

The nurse is providing care for a patient admitted to the unit with respiratory failure and respiratory acidosis. Which data from the nursing history is the probable cause for the patient's current diagnoses? 1) Aspiration pneumonia 2) A recent trip to South America 3) Recent recovery from a cold virus 4) Use of ibuprofen for the control of pain

1) Aspiration pneumonia Aspiration of a foreign body and acute pneumonia would put the patient at risk for respiratory acidosis.

The nurse is analyzing the patient's arterial blood gas report, which reveals a pH of 7.15. The patient has just suffered a cardiac arrest. Which consequences of this pH value does the nurse consider for this patient? 1) Decreased cardiac output 2) Decreased potassium levels 3) Increased magnesium levels 4) Decreased free calcium in the ECF

1) Decreased cardiac output The nurse knows that severe acidosis depresses myocardial contractility, which leads to decreased cardiac output.

The nurse is reviewing the health-care provider orders for a patient who is diagnosed with respiratory alkalosis. Which prescription is appropriate for this patient's care needs? 1) Draw arterial blood gas analysis. 2) Administer oxygen via face mask. 3) Restrict fluids to two liters per day. 4) Infuse one ampule of sodium bicarbonate.

1) Draw arterial blood gas analysis.

The nurse is providing care to a patient who has been vomiting for several days. The nurse knows that the patient is at risk for metabolic alkalosis because gastric secretions have which characteristic? 1) Gastric secretions are acidic. 2) Gastric secretions are alkaline. 3) Gastric secretions have a foul smell. 4) Gastric secretions are green in color.

1) Gastric secretions are acidic.

The nurse is planning care for an older adult patient with respiratory acidosis. Which intervention should the nurse include in this patient's plan of care? 1) Maintain adequate hydration. 2) Reduce environmental stimuli. 3) Administer intravenous sodium bicarbonate. 4) Administer prescribed intravenous fluids carefully.

1) Maintain adequate hydration. In respiratory acidosis, there are a drop in the blood pH, reduced level of oxygen, and retaining of carbon dioxide. The body needs to be well-hydrated so that pulmonary secretions can be removed to improve oxygenation.

The nurse is providing care for an adult patient who is admitted to the emergency department (ED) after passing out. The patient has been fasting and currently has ketones in the urine. Which acid-based imbalance should the nurse monitor the patient for based on the current data? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis

1) Metabolic acidosis The patient who is fasting is at risk for metabolic acidosis. The body recognized fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acid.

Which is the priority nursing action when providing care to a patient who is admitted with metabolic alkalosis? 1) Monitoring oxygen saturation 2) Setting goals for the plan of care 3) Administering prescribed medications 4) Teaching the family about risk factors

1) Monitoring oxygen saturation The priority for this patient is monitoring oxygen saturation. The depressed respiratory drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired oxygenation of the tissues.

A patient with metabolic acidosis has been admitted to the unit from the emergency department (ED). The patient is experiencing confusion and weakness. Which independent nursing intervention is the priority? 1) Protecting the patient from injury 2) Placing the patient in a high-Fowler's position 3) Administering sodium bicarbonate to the patient 4) Providing the patient with appropriate skin care

1) Protecting the patient from injury The patient with metabolic acidosis may have symptoms of drowsiness, lethargy, confusion, and weakness. A priority of care would be preventing injury.

A patient recently diagnosed with diabetes mellitus (DM) is hospitalized in diabetic ketoacidosis (DKA) after a religious fast. The patient tells the nurse, "I have fasted during this season every year since I became an adult. I am not going to stop now." The nurse is not knowledgeable about this particular religion. Which nursing actions would be appropriate? Select all that apply. 1) Request a consult from a diabetes educator. 2) Assess the meaning and context of fasting for this religion. 3) Tell the patient that things are different now because of the new diagnosis. 4) Ask family members of the same religion to discuss fasting with the patient. 5) Encourage the patient to seek medical care if signs of ketoacidosis occur in the future.

1) Request a consult from a diabetes educator. 2) Assess the meaning and context of fasting for this religion. 5) Encourage the patient to seek medical care if signs of ketoacidosis occur in the future.

Which nursing actions are appropriate when conducting an Allen test? Select all that apply. 1) Rest the patient's arm on the mattress. 2) Support the patient's wrist with a rolled towel. 3) Tell the patient to relax the hand and then clench a fist. 4) Ensure that a second nurse is available to assist with the procedure. 5) Press the patient's radial and ulnar arteries using the index and middle fingers.

1) Rest the patient's arm on the mattress. 2) Support the patient's wrist with a rolled towel. 5) Press the patient's radial and ulnar arteries using the index and middle fingers.

51. Nurse reviews client's serum phosphorus level and notes that level is 2.0 mg/dL. Nurse understands that which condition causes this serum phosphorus level?

1. Alcoholism Normal 2.7 to 4.5 Hypohosphatemia Causative factors relate to decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism.

49. Nurse is instructing a client on how to decrease the intake of potassium in the diet. The nurse tells the client that which food contains the least amount of potassium?

1. Lettuce Lettuce contains less than 100 mg of potassium. (potatoes, apricots, and avocados are potassium-containing food and s/be avoided by client on a potassium-restricted diet.)

48. Nurse is caring for a client w/hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which medication w/the nurse prepare to administer as prescribed to the client?

3. Calcitonin (Miacalcin) Normal - 8.6 to 10.0 mg/dL This patient is hypercalcemic; Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

38. Nurse is reading physician's progress notes in client's record and sees that physician has documented "insensible fluid loss of approximately 800mL daily." Nurse understands that this type of fluid loss can occur through:

1. The skin Sensible losses are those that the person is aware of, such as those that occur through wound drainage, GI tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

Magnesium Mg+

1.3-2.1 mEq/L

The nurse is providing care to a patient who is admitted to the hospital with sudden, severe abdominal pain. Which arterial blood gas supports the patient's current diagnosis of respiratory alkalosis? 1) pH is 7.35 and PaO2 is 88. 2) pH is 7.30 and HCO3 is 30. 3) pH is 7.47 and PaCO2 is 25. 4) pH is 7.33 and PaCO2 is 36.

3) pH is 7.47 and PaCO2 is 25.

Sodium Na+

136-145 mEq/L

Which patient statement indicates the need for additional education regarding the use of sodium bicarbonate to treat acidosis? 1) "I need to purchase antacids without salt." 2) "I should use the antacid for at least 2 months." 3) "I should contact the doctor if I have any gastric discomfort with chest pain." 4) "I should call the doctor if I get short of breath or start to sweat with this medication."

2) "I should use the antacid for at least 2 months." Bicarbonate antacid should not be used for longer than two weeks. This statement indicates the need for additional teaching.

The nurse completes discharge teaching for a patient with an anxiety disorder. Which patient statement indicates correct understanding of information related to respiratory alkalosis? 1) "I will eat more bananas at breakfast." 2) "I will see my counselor on a regular basis." 3) "I will not take antacids when I have heartburn." 4) "I will breathe faster when I am feeling anxious."

2) "I will see my counselor on a regular basis."

Which risk factors exhibited by the patient presenting in the emergency department (ED) would place the patient at risk for metabolic acidosis? Select all that apply. 1) Pneumonia 2) Abdominal fistulas 3) Acute renal failure 4) Hypovolemic shock 5) Chronic obstructive pulmonary disease

2) Abdominal fistulas 3) Acute renal failure 4) Hypovolemic shock

The nurse is providing care to a patient who is intubated and receiving mechanical ventilation after a motor vehicle crash. The patient is fighting the ventilator and attempting to remove the endotracheal tube. Which nursing action decreases the patient's risk for developing respiratory alkalosis? 1) Apply wrist restraints. 2) Administer a prescribed sedative. 3) Teach the patient to take slow, deep breaths. 4) Discuss removing the endotracheal tube with the health-care provider.

2) Administer a prescribed sedative.

The nurse is caring for the patient experiencing hypovolemic shock and metabolic acidosis. Which nursing actions are appropriate for this patient? Select all that apply. 1) Limit the intake of fluids. 2) Administer sodium bicarbonate. 3) Monitor ECG for conduction problems. 4) Keep the bed in the locked and low position. 5) Monitor weight on admission and discharge.

2) Administer sodium bicarbonate. 3) Monitor ECG for conduction problems. 4) Keep the bed in the locked and low position. (The patient recovering from hypovolemic shock is at risk for injury, so the bed should be kept in the locked and low position.)

The nurse is providing care to a patient who is admitted with manifestations of metabolic alkalosis. Which diagnostic test findings support the admitting diagnosis? Select all that apply. 1) Serum glucose level 142 mg/dL 2) Blood pH 7.47 and bicarbonate 34 mEq/L 3) Intravenous pyelogram shows kidney stones 4) Bilateral lower lobe infiltrates noted on chest x-ray 5) Electrocardiogram changes consistent with hypokalemia

2) Blood pH 7.47 and bicarbonate 34 mEq/L (In metabolic alkalosis, the blood pH will be greater than 7.45 and the bicarbonate level greater than 28 mEq/L.) 5) Electrocardiogram changes consistent with hypokalemia

The results of a patient's arterial blood gas sample indicate an oxygen level of 72 mmHg. Which should the nurse closely assess when providing care to this patient? 1) Perfusion 2) Cognition 3) Communication 4) Fluid and electrolytes

2) Cognition An oxygen level of less than 75 mmHg can be due to hypoventilation. This drop in oxygen will change the patient's level of responsiveness

47. Nurse is instructing a client on how to decrease intake of calcium in diet. Nurse tells the client that which food item contains the least amount of calcium?

2. Butter Butter comes from milk fat and does not contain significant amounts of calcium. (Milk, spinach, and collard greens are calcium-containing foods and s/be avoided by client on a calcium-restricted diet.

44. Nurse is caring for client w/diagnosisof hyperparathyroidism. Lab studies are performed, and serum calcium level is 12.0 mg/dL. On basis of this lab value, nurse takes which action?

2. Informs RN of lab value. The normal serum calcium level ranges from 8.6 to 10.0 mg/dL. The client is experiencing hypercalcemia, and the nurse w/inform the RN of the lab value.

52. A nurse is instructing a client regarding how to decrease the intake of phosphorus in the diet. The nurse tells the client that which food item contains the least amount of phosphorus?

2. Oranges Foods high in phosphorus include fish, pork, beef, chicken, organ meats, nuts, whole-grain breads, and cereals.

45. Nurse reviews client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands that which condition w/cause this serum calcium level?

2. Prolonged bedrest The normal serum calcium level is 8.6 to 10.0 mg/dL. A client w/a serum calcium level of 8.0 mgdL is experiencing hypocalcemia. Long term effect of prolonged bedrest is hypocalcemia. (The excessive ingestion of vit. D, renal disease, and hyperparathyroidism are causative factors assoc. w/hypercalcemia.

53. Nurse is told in report that client has a positive Chvostek's sign. What data would the nurse expect to note during the data collection?

2. Tetany 3. Diarrhea 4. Possible seizure activity 6. A positive Trousseau's sign

40. A nurse is reviewing health records of assigned clients. Nurse plans care knowing that which client is at risk for fluid volume deficit?

2. The client with a colostomy. Causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fisulas, ileostomy, and colostomy.

36. Nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. Nurse understands that potassium value at this level w/be noted w/which condition?

2. Traumatic burn A serum potassium level that exceeds 5.1 mEq/L is inidcative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in early stages of massive cell destruction (trauma, burns, sepsis, metabolic or respiratory acidosis), are at risk for hyperkalemia. (The client w/Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.)

The nurse is reviewing new orders provided by the health-care provider for a critical care patient with metabolic acidosis. Which prescription should the nurse question? 1) Draw serum potassium levels every two hours. 2) Draw arterial blood gas samples every two hours. 3) Administer one ampule of sodium bicarbonate now. 4) Begin intravenous infusion of 0.9% normal saline.

3) Administer one ampule of sodium bicarbonate now. Administering bicarbonate to correct acidosis increases the risk for hypernatremia, hyperosmolality, and fluid volume excess. This is the order that the nurse should question before providing.

Which chronic lung condition noted in the patient's health history supports the current diagnosis of respiratory acidosis? 1) Aspiration 2) Pneumonia 3) Cystic fibrosis 4) Hyperthyroidism

3) Cystic fibrosis

Which clinical manifestation supports the nurse's plan of care focusing on chronic respiratory acidosis? 1) Irritability 2) Blurred vision 3) Daytime sleepiness 4) Warm, flushed skin

3) Daytime sleepiness

The nurse is caring for a comatose patient with respiratory acidosis. For which intervention will the nurse need to collaborate when caring for this patient? 1) Monitoring vital signs 2) Measuring intake and output 3) Determining recent eating behaviors 4) Identifying current oxygen saturation level

3) Determining recent eating behaviors For patients in severe distress, family members may need to be consulted for critical information such as recent eating habits and history of vomiting.

The nurse is reviewing the latest arterial blood gas results for a patient with metabolic alkalosis. Which result indicates that the metabolic alkalosis is compensated? 1) pH 7.32 2) HCO3 8 mEq/L 3) PaCO2 48 mmHg 4) PaCO2 18 mmHg

3) PaCO2 48 mmHg To compensate for this imbalance, the rate and depth of respirations decrease, leading to retention of carbon dioxide. The PaCO2 will be elevated

The nurse is providing care to patient with the following laboratory values: pH - 7.31; PaCO2 - 48 mmHg; and a normal HCO3. Which condition should the nurse plan care for based on the current data? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis

3) Respiratory acidosis If the pH is decreased and the PaCO2 is increased with a normal HCO3, it is uncompensated respiratory acidosis

The nurse is providing care to a patient who is admitted after a morphine overdose. Which acid-base imbalance should the nurse plan this patient's care to reflect? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis

3) Respiratory acidosis Morphine is a narcotic and generally acts to decrease or suppress respirations; therefore, this patient is probably hypoventilating. The expected acid-base imbalance would be respiratory acidosis.

Potassium K+

3.5-5.0 mEq/L

Which diagnostic test should the nurse anticipate when providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) to monitor acid-base balance? 1) Pulse oximetry 2) Bronchoscopy 3) Sputum studies 4) Arterial blood gases

4) Arterial blood gases Arterial blood gas analysis is done to assess alterations in acid-base balance caused by respiratory disorders, metabolic disorders, or both.

The patient is receiving sodium bicarbonate intravenously (IV) for correction of acidosis secondary to diabetic coma. The nurse assesses the patient to be lethargic, confused, and breathing rapidly. Which is the nurse's priority response to the current situation? 1) Stop the infusion and notify the provider because the patient is in alkalosis. 2) Increase the rate of the infusion and continue to assess the patient for symptoms of acidosis. 3) Decrease the rate of the infusion and continue to assess the patient for symptoms of alkalosis. 4) Continue the infusion, because the patient is still in acidosis, and notify the provider.

4) Continue the infusion, because the patient is still in acidosis, and notify the provider. The client continues to exhibit signs of acidosis; symptoms of acidosis include lethargy, confusion, CNS depression leading to coma, and a deep, rapid respiration rate that indicates an attempt by the lungs to rid the body of excess acid, and the provider should be notified.

The nurse is caring for a patient admitted with renal failure and metabolic acidosis. Which clinical manifestation would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective? 1) Tachypnea 2) Palpitations 3) Increased deep tendon reflexes 4) Decreased depth of respirations

4) Decreased depth of respirations The patient with metabolic acidosis will have an increased respiratory rate and depth. Signs that care has been effective would include a decrease in the rate and depth of respirations.

A patient is admitted to the emergency department for the treatment of a drug overdose causing acute respiratory acidosis. Which substance noted on the toxicology report is the most likely cause for the current diagnosis? 1) PCP 2) Cocaine 3) Marijuana 4) Oxycodone

4) Oxycodone

The client is admitted to the emergency department (ED) with symptoms of a panic attack. Based on this data, the nurse plans care for which health problem? 1) Emesis 2) Memory loss 3) Hypoventilation 4) Respiratory alkalosis

4) Respiratory alkalosis

34. Nurse caring for client w/cirrhosis. Nurse notes client is dyspneic and crackles heard on auscultation of lungs; fluid volume excess suspected. What additional signs w/nurse expect to note in this client if fluid volume excess is present?

4. An increase in blood pressure. Findings assoc. w/fluid volume excess include: Dyspnea Crackles tachypnea tachycardia elevated blood pressure bounding pulse elevated central venous pressure weight gain edema neck and hand vein distention altered level of consciousness/confusion decreased hematocit level

46. A nurse is caring for a client w/a suspected diagnosis of hypercalcemia. Which of the following signs w/be an indication of this diagnosis?

4. Generalized muscle weakness.

41. Nurse is caring for client who has been taking diuretics on a long-term basis. A fluid volume deficit is suspected. Which finding would be noted in client w/this condition?

4. Increased specific gravity of the urine. Finding in a client w/a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. (Gurgling respirations, increased BP, decreased hematocrit level are seen in fluid volume excess)

50. Nurse is caring for client w/renal failure. Lab results reveal a magnesium level of 3.6 mg/dL. Which of the following signs w/the nurse expect to note in the client based on this magnesium level?

4. Loss of deep tendon reflexes Normal 1.6 to 2.6 This patient is experiencing hypermagnesemia.

37.Nurse reviews a client's electrolyte results and notes that potassium level is 5.4 mEq/L. Which of following w/nurse note on cardiac monitor as a result of this lab value?

4. Narrow, peaked T waves. A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave, a prolonged PR interval; a widened QRS complex; narrow, peaked T-waves; and a depressed ST segment.

43. Nurse is caring for a client w/leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. What additional signs w/the nurse expect to note in this client if hyponatremia is present?

4. Postural blood pressure changes. Postural blood pressure changes occur in the client w/hyponatremia. (Dry mucous membranes and intense thirst are seen in clients w/hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client w/hyponatremia, a rapid thready pulse is noted.) S/s of hyponatremia: Rapid, thready pulse Postural blood pressure changes Weakness Abdominal cramping Poor skin turgor Muscle twitching and seizures Apprehension

35. Nurse is reviewing health records of assigned clients. Nurse plans care knowing that which client is at risk for potassium deficit?

4. The client receiving nasogastric suction Potassium-rich GI fluids are lost through GI suction, which places client at risk for hypokalemia. (The client w/renal disease, Addison's disease and metabolic acidosis is at risk for hyperkalemia)

42. Nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. Nurse understands that this sodium level w/be noted in a client wi/which condition?

4. The client w/the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can result secondary to SIADH. (The client w/an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.)

39. Nurse reviewing health records of assigned clients. Nurse plans care knowing that which client is at lowest risk for development of third-spacing?

4. The client with diabetes mellitus. Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless, because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

Calcium Ca+

9.0-10.5 mg/dL

Chloride Cl-

98-106 mEq/L

21.The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? a. 0.45% sodium chloride (1/2 NS) b. 0.9% sodium chloride (NS) c. Lactated Ringer's (LR) d. Dextrose 5% in Lactated Ringer's (D5LR)

ANS: A 0.45% sodium chloride is a hypotonic solution. NS and LR are isotonic. D5LR is hypertonic.

17.A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? a. Recording intake and output b. Regulating intravenous flow rate c. Starting peripheral intravenous therapy d. Changing a peripheral intravenous dressing

ANS: A A nursing assistive personnel (NAP) can record intake and output. An RN cannot delegate regulating flow rate, starting an IV, or changing an IV dressing to an NAP.

10.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.)

4.The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? 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.

27.The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? a. Intake 255; output 375 b. Intake 285; output 375 c. Intake 505; output 125 d. Intake 535; output 125

ANS: A Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since ice chips are half of the amount), and 75 mL of chicken broth; 150 + 30 + 75 = 255. Output = 125 mL of urine (void) and 250 mL of vomitus; 125 + 250 = 375.

1.A patient has 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.

6.The nurse is reviewing laboratory results. Which cation will the nurse observe is the mostabundant in the blood? 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.

9.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.

16.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

18.The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis? a. pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L b. pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L c. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L d. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L

ANS: A The laboratory values that reflect metabolic acidosis are pH 7.3, PaCO2 36 mm Hg, HCO3- 19 mEq/L. A laboratory finding of pH 7.5, PaCO2 35 mm Hg, HCO3- 35 mEq/L is metabolic alkalosis. pH 7.32, PaCO2 47 mm Hg, HCO3- 23 mEq/L is respiratory acidosis. pH 7.35, PaCO2 40 mm Hg, HCO3- 25 mEq/L values are within normal range.

34.The nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient with D5W hanging with the blood b. A patient with type A blood receiving type O blood c. A patient with intravenous potassium chloride that is diluted d. A patient with a right mastectomy and an intravenous site in the left arm

ANS: A The nurse will see the patient with D5W and blood to prevent a medication error. When preparing to administer blood, prime the tubing with 0.9% sodium chloride (normal saline) to prevent hemolysis or breakdown of RBCs. All the rest are normal. A patient with type A blood can receive type O. Type O is considered the universal donor. A patient with a mastectomy should have the IV in the other arm. Potassium chloride should be diluted, and it is never given IV push.

2.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).

38.A nurse is assessing a patient who is receiving a blood transfusion and finds that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The nurse auscultates crackles in both lung bases and sees jugular vein distention. On which transfusion complication will the nurse focus interventions? a. Fluid volume overload b. Hemolytic reaction c. Anaphylactic shock d. Septicemia

ANS: A The signs and symptoms are concurrent with fluid volume overload. Anaphylactic shock would have presented with urticaria, dyspnea, and hypotension. Septicemia would include a fever. A hemolytic reaction would consist of flank pain, chills, and fever.

31.A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output. The patient has voided 400 mL of urine. After reporting these values to the health care provider, which order does the nurse anticipate? a. Add a potassium supplement to replace loss from output. b. Decrease the rate of intravenous fluids to 100 mL/hr. c. Administer a diuretic to prevent fluid volume excess. d. Discontinue the nasogastric suctioning.

ANS: A The total fluid intake and output equals 700 mL, which meets the provider goals. Patients with nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium supplement to correct this condition. Remember to record half the volume of ice chips when calculating intake. The other measures would be unnecessary because the net fluid volume is equal.

44. Which assessments will alert the nurse that a patient's IV has infiltrated? (Select all that apply.) a. Edema of the extremity near the insertion site b. Reddish streak proximal to the insertion site c. Skin discolored or pale in appearance d. Pain and warmth at the insertion site e. Palpable venous cord f. Skin cool to the touch

ANS: A, C, F Infiltration results in skin that is edematous near the IV insertion site. Skin is cool to the touch and may be pale or discolored. Pain, warmth, erythema, a reddish streak, and a palpable venous cord are all symptoms of phlebitis.

43. A nurse is selecting a site to insert an intravenous (IV) catheter on an adult. Which actions will the nurse take? (Select all that apply.) a. Check for contraindications to the extremity. b. Start proximally and move distally on the arm. c. Choose a vein with minimal curvature. d. Choose the patient's dominant arm. e. Select a vein that is rigid. f. Avoid areas of flexion.

ANS: A, C, F The vein should be relatively straight to avoid catheter occlusion. Contraindications to starting an IV catheter are conditions such as mastectomy, AV fistula, and central line in the extremity and should be checked before initiation of IV. Avoid areas of flexion if possible. The nurse should start distally and move proximally, choosing the nondominant arm if possible. The nurse should feel for the best location; a good vein should feel spongy, a rigid vein should be avoided because it might have had previous trauma or damage.

30.A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and programs the pump to infuse at 50 mL/hr. At what time should the infusion be completed? a. 2300 Monday b. 2345 Monday c. 0015 Tuesday d. 0045 Tuesday

ANS: B 250 mL ÷ 50 mL/hr = 5 hr 1845 + 5 hr = 2345, which would be 2345 on Monday.

35.A nurse is administering a blood transfusion. Which assessment finding will the nurse report immediately? a. Blood pressure 110/60 b. Temperature 101.3° F c. Poor skin turgor and pallor d. Heart rate of 100 beats/min

ANS: B A fever should be reported immediately and the blood transfusion stopped. All other assessment findings are expected. Blood is given to elevate blood pressure, improve pallor, and decrease tachycardia.

15.In which patient will the nurse expect to see a positive Chvostek 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 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.

7.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 8.4 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.

8.The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? a. Increased b. Decreased 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.

28.A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for extracellular fluid volume deficit? a. Moist mucous membranes b. Postural hypotension c. Supple skin turgor d. Pitting edema

ANS: B Physical examination findings of deficit include postural hypotension, tachycardia, thready pulse, dry mucous membranes, and poor skin turgor. Pitting edema indicates that the patient may be retaining excess extracellular fluid

25.A nurse is administering a diuretic to a patient and teaching the patient about foods to increase. Which food choices by the patient will best indicate successful teaching? a. Milk and cheese b. Potatoes and fresh fruit c. Canned soups and vegetables d. Whole grains and dark green leafy vegetables

ANS: B Potatoes and fruits are high in potassium. Milk and cheese are high in calcium. Canned soups and vegetables are high in sodium. Whole grains and dark green leafy vegetables are high in magnesium

13.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.

11.A 2-year-old child is brought into the emergency department after ingesting 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.

14.A nurse is caring for a patient whose 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.

12.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.

45. A nurse is discontinuing a patient's peripheral IV access. Which actions should the nurse take? (Select all that apply.) a. Wear sterile gloves and a mask. b. Stop the infusion before removing the IV catheter. c. Use scissors to remove the IV site dressing and tape. d. Apply firm pressure with sterile gauze during removal. e. Keep the catheter parallel to the skin while removing it. f. Apply pressure to the site for 2 to 3 minutes after removal.

ANS: B, E, F The nurse should stop the infusion before removing the IV catheter, so the fluid does not drip on the patient's skin; keep the catheter parallel to the skin while removing it to reduce trauma to the vein; and apply pressure to the site for 2 to 3 minutes after removal to decrease bleeding from the site. Scissors should not be used because they may accidentally cut the catheter or tubing or may injure the patient. During removal of the IV catheter, light pressure, not firm pressure, is indicated to prevent trauma. Clean gloves are used for discontinuing a peripheral IV access because gloved hands will handle the external dressing, tubing, and tape, which are not sterile.

22.The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.

ANS: C An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time every day using the same scale and the same amount of clothing. Although intake and output records are important assessment measures, some patients are not able to keep their own records themselves. Blood pressure can decrease with extracellular volume (ECV) deficit but will not necessarily increase with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical dehydration.

26.The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? a. Urine output increases to 150 mL/hr. b. Systolic and diastolic blood pressure decreases. c. Serum sodium concentration returns to normal. d. Large amounts of emesis and diarrhea decrease.

ANS: C Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large dilute urine output can cause further hypernatremia.

36.A nurse has just received a bag of packed red blood cells (RBCs) for a patient. What is the longest time the nurse can let the blood infuse? a. 30 minutes b. 2 hours c. 4 hours d. 6 hours

ANS: C Ideally a unit of whole blood or packed RBCs is transfused in 2 hours. This time can be lengthened to 4 hours if the patient is at risk for extracellular volume excess. Beyond 4 hours there is a risk for bacterial contamination of the blood.

29.A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? a. 12 drops/min b. 24 drops/min c. 125 drops/min d. 150 drops/min

ANS: C Microdrip tubing delivers 60 drops/mL. Calculation for a rate of 125 mL/hr using microdrip tubing: (125 mL/1 hr)(60 drops/1 mL)(1 hr/60 min) = 125 drop/min.

24.A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)

ANS: C Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45% sodium chloride are hypotonic. 3% sodium chloride is hypertonic.

42.While the nurse is taking a patient history, the nurse discovers the patient has a type of diabetes that results from a head injury and does not require insulin. Which dietary change should the nurse share with the patient? a. Reduce the quantity of carbohydrates ingested to lower blood sugar. b. Include a serving of dairy in each meal to elevate calcium levels. c. Drink plenty of fluids throughout the day to stay hydrated. d. Avoid food high in acid to avoid metabolic acidosis.

ANS: C The patient has diabetes insipidus, which places the patient at risk for dehydration and hypernatremia. Dehydration should be prevented by drinking plenty of fluids to replace the extra water excreted in the urine. Foods high in acid are not what causes metabolic acidosis. A reduction in carbohydrates to lower blood sugar will not help a patient with diabetes insipidus but it may help a patient with diabetes mellitus. Calcium-rich dairy products would be recommended for a hypocalcemic patient.

19.The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.

ANS: C The patient is in fluid overload. Raising the head of the bed to ease breathing is the first action. Offering calcium-rich foods is for hypocalcemia, not fluid overload. Administering a diuretic is the second action. Increasing fluids is contraindicated and would make the situation worse.

23.A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN) will the nurse add to the care plan? a. Stimulate the patient's appetite to eat. b. Deliver antibiotics to fight off infection. c. Replace fluid, electrolytes, and nutrients. d. Provide medication to raise blood pressure.

ANS: C Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace the ones the patient is not eating or losing. TPN does not stimulate the appetite. TPN does not contain blood pressure medication or antibiotics.

3.The nurse observes edema in a patient who has venous congestion from 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.

39.A nurse is preparing to start a blood transfusion. Which type of tubing will the nurse obtain? a. Two-way valves to allow the patient's blood to mix and warm the blood transfusing b. An injection port to mix additional electrolytes into the blood c. A filter to ensure that clots do not enter the patient d. An air vent to let bubbles into the blood

ANS: C When administering a transfusion you need an appropriate-size IV catheter and blood administration tubing that has a special in-line filter. The patient's blood should not be mixed with the infusion blood. Air bubbles should not be allowed to enter the blood. The only substance compatible with blood is normal saline; no additives should be mixed with the infusing blood.

20.A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse is most appropriate? a. "Are you following any weight loss program?" b. "How many calories a day do you consume?" c. "Do you have dry mouth or feel thirsty?" d. "How many times a day do you urinate?"

ANS: D A rapid gain in weight usually indicates extracellular volume (ECV) excess if the person began with normal ECV. Asking the patient about urination habits will help determine whether the body is trying to excrete the excess fluid or if renal dysfunction is contributing to ECV excess. This is too rapid a weight gain to be dietary; it is fluid retention. Asking about following a weight loss program will not help determine the cause of the problem. Caloric intake does not account for rapid weight changes. Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.

33.A nurse is assisting the health care provider in inserting a central line. Which action indicates the nurse is following the recommended bundle protocol to reduce central line-associated bloodstream infections (CLABSI)? a. Preps skin with povidone-iodine solution. b. Suggests the femoral vein for insertion site. c. Applies double gloving without hand hygiene. d. Uses chlorhexidine skin antisepsis prior to insertion.

ANS: D A recommended bundle at insertion of a central line is hand hygiene prior to catheter insertion; use of maximum sterile barrier precautions upon insertion; chlorhexidine skin antisepsis prior to insertion and during dressing changes; avoidance of the femoral vein for central venous access for adults; and daily evaluation of line necessity, with prompt removal of non-essential lines. Povidone-iodine is not recommended.

40.The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac

ANS: D Cardiac is the priority. Hyperkalemia places the patient at risk for potentially serious dysrhythmias and cardiac arrest. Potassium balance is necessary for cardiac function. Respiratory is the priority with hypokalemia. Monitoring of gastrointestinal and neurological systems would be indicated for other electrolyte imbalances.

32.A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Record a phlebitis grade of 4. b. Assign an infiltration grade. c. Apply moist compress. d. Discontinue the IV.

ANS: D The IV site has phlebitis. The nurse should discontinue the IV. The phlebitis score is 3. The site has phlebitis, not infiltration. A moist compress may be needed after the IV is discontinued.

37.A patient has an acute intravascular hemolytic reaction to a blood transfusion. After discontinuing the blood transfusion, which is the nurse's next action? a. Discontinue the IV catheter. b. Return the blood to the blood bank. c. Run normal saline through the existing tubing. d. Start normal saline at TKO rate using new tubing.

ANS: D The nurse should first attach new tubing and begin running in normal saline at a rate to keep the vein open, in case any medications need to be delivered through an IV site. The existing tubing should not be used because that would infuse the blood in the tubing into the patient. It is necessary to preserve the IV catheter in place for IV access to treat the patient. After the patient has been assessed and stabilized, the blood can be returned to the blood bank.

5.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.

41.Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Light-headedness when standing up d. Tingling of extremities with possible tetany

ANS: D This patient has hypocalcemia because the normal calcium range is 8.4 to 10.5 mg/dL. Hypocalcemia causes muscle tetany, positive Chvostek's sign, and tingling of the extremities. Sodium and potassium values are within their normal ranges: sodium 135 to 145 mEq/L; potassium 3.5 to 5.0 mEq/L. Light-headedness when standing up is a manifestation of ECV deficit or sometimes hypokalemia. Weak quadriceps muscles are associated with potassium imbalances. Decreased deep tendon reflexes are related to hypercalcemia or hypermagnesemia.