Fluid and Electrolytes and Acid Base Practice Questions

Which intervention is most important for the nurse to teach the client who has lymphedema in her right arm from a mastectomy 1 year ago? -"Exercise your are and use it during tasks that occur at the level of your chest or higher." -"Be sure to use sunscreen or protective clothing to reduce the risk of injuring this arm." -"Reduce your salt intake to prevent excess water retention -"Do not expose the right arm to temperature extreme."

-"Exercise your are and use it during tasks that occur at the level of your chest or higher." Rationale: Want gravity to help with fluid movement

Which statement made by the 74-year old client should alert the nurse to the possibility of fluid and electrolyte imbalance? -"My skin is always so dry, especially here in the Southwest." -"I often use a glycerin suppository for constipation." -"I don't drink liquids after 5 PM so I don't have to get up at night." -"In addition to coffee, I drink at least one glass of water with each meal."

-"I don't drink liquids after 5 PM so I don't have to get up at night."

Which assessment finding obtained while taking the history of an older client should alert the nurse to the possibility of fluid or electrolyte imbalance? -"I am often cold and need to wear a sweater, even when other people are warm." -"I seem to urinate more when I drink coffee." -"In the summer, I feel thirst more often." -"My rings are tighter this month."

-"My rings are tighter this month." Rationale: Fluid retention

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 -0.45% NS -10% dextrose -5% dextrose in LRs -Dextrose 5% in 1/2 NS

-0.45% NS

The nurse is caring for a client with a nasogastric (NG) tube who has a prescription for NG tube irrigation once every 8 hours. To maintain homeostasis, which solution would the nurse use to irrigate the NG tube? -Tap water -Sterile water -0.9% sodium chloride -0.45% sodium chloride

-0.9% sodium chloride Rationale: Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and 0.45% sodium chloride are hypotonic solutions.

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? Select all that apply. -10% dextrose in water -0.45% sodium chloride -5% dextrose in 0.9% saline -5% dextrose in 0.45% saline -5% dextrose in 0.225% saline -5% dextrose in lactated Ringer's solution

-10% dextrose in water -5% dextrose in 0.9% saline -5% dextrose in 0.45% saline -5% dextrose in lactated Ringer's solution Rationale: Hypertonic fluids include 10% dextrose in water, 5% dextrose in 0.9% saline, 5% dextrose in 0.45% saline, and 5% dextrose in lactated Ringer's solution. The solutions of 0.45% sodium chloride and 5% dextrose in 0.225% saline are not hypertonic solutions.

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? -32 gtt/min -60 gtt/min -125 gtt/min -250 gtt/min

-125 gtt/min Rationale: 125mL/ 60 gtt x 60 min

The HCP orders 1000 mL of D5LR with 20 mEq KCI 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: -12 gtt/min -22 gtt/min -32 gtt/min -42 gtt/min

-32 gtt/min

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

-A 15 year old experiencing an asthmatic attack

Of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is: -A 6 month old learning to drink from a cup - A 12 year old who is moderately active in 80 degree Fahrenheit weather -A 42 year old with severe diarrhea -A 90 year old with frequent headaches

-A 42 year old with severe diarrhea

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

-A 79 year old client who has been diagnosed with advanced Alzheimer's disease

Which of the following foods will have the greatest impact on the hearts conductivity of the person consuming it? -A pickle -A banana -A milkshake - A spinach salad

-A banana

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client would the nurse monitor closely for signs of hyperkalemia? -A client with ulcerative colitis -A client with Cushing's syndrome -A client admitted 6 hours ago with a 40% burn injury -A client who has a history of long-term laxative abuse

-A client admitted 6 hours ago with a 40% burn injury Rationale: Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium caused by early massive cell destruction, such as in trauma or burns. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis (with the exception of diabetic acidosis). Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? -A client with an ileostomy -A client with heart failure -A client on long-term corticosteroid therapy -A client receiving frequent wound irrigations

-A client with an ileostomy Rationale: A fluid volume deficit occurs when the fluid intake is insufficient to meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with heart failure or on long-term corticosteroid therapy or a client receiving frequent wound irrigations is most at risk for fluid volume excess.

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

-A milkshake Rationale: High in calcium, making bones strong, blood and heart beats thus cardiac conductivity

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

-A spinach salad Rationale: high in magnesium

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? -An oral temperature of 98.8° F (37.1° C) -A urine specific gravity of 1.043 -A urine output that is pale yellow -A blood pressure of 120/80 mm Hg

-A urine specific gravity of 1.043 Rationale: The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.003 to 1.030. A temperature of 98.8° F (37.1° C) is only 0.2 of a point above the normal temperature and would not be as specific an indicator of hydration status as the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

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

-An elevated hematocrit level Rationale: Dehydrations consistent with fluid volume excess

A client with a 3-day history of nausea and vomiting and suspected gastroenteritis presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths per minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats per minute. Arterial blood gases are drawn, and the nurse reviews the results, expecting to note which finding? -A decreased pH and an increased Paco2 -An increased pH and a decreased Paco2 -A decreased pH and a decreased HCO3- -An increased pH and an increased HCO3-

-An increased pH and an increased HCO3- Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include a decrease in the respiratory rate and depth, and tachycardia. Option 1 reflects a respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects a metabolic acidotic condition.

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse would determine that the client's status is returning to normal if which is no longer exhibited? -Tetany -Tremors -Areflexia -Muscular excitability

-Areflexia Rationale: Signs and symptoms of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

A school nurse is teaching an athletic coach how to prevent dehydration in athletes during football practice. Which action by the coach during football practice would indicate that further teaching is needed? -Weighs athletes before, during, and after football practice -Asks the athletes to take a salt tablet before football practice -Schedules fluid breaks every 30 minutes throughout practice -Tells the athletes to drink 16 oz of fluid per pound lost during practice

-Asks the athletes to take a salt tablet before football practice Rationale: Salt tablets would not be taken because they can contribute to dehydration. Frequent fluid breaks need to be taken to prevent dehydration. Early detection of decreased body weight alerts the athlete to drink fluids before becoming dehydrated. To prevent dehydration, 16 oz of fluid needs to be consumed for every pound lost.

When evaluating the hydration status, the nurse observes tenting of the skin on the back of the 87-year old clients hand when testing the skin turgor. What is the nurses best actions? -Notify the physician -Examine dependent body areas -Assess turgor on the clients forehead -Document the finding as the only action.

-Assess turgor on the clients forehead

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 shouls: -Start with the most proximal site -Look for hard, cordlike veins -Use the dominant arm -Avoid sites on the extremity away from a dialysis graft

-Avoid sites on the extremity away from a dialysis graft

A client in the later stages of chronic kidney disease (CKD) has hyperkalemia. With CKD, what other factors besides tissue breakdown can cause high potassium levels? Select all that apply. -Blood transfusions -Metabolic alkalosis -Bleeding or hemorrhage -Decreased sodium excretion -Ingestion of potassium in medications -Failure to restrict dietary potassium

-Blood transfusions -Bleeding or hemorrhage -Ingestion of potassium in medications -Failure to restrict dietary potassium Rationale: With CKD, factors other than tissue breakdown that can cause hyperkalemia include blood transfusions, bleeding or hemorrhage, ingestion of potassium in medications, and failure to restrict dietary potassium. Metabolic alkalosis and decreased sodium excretion are not contributing factors.

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? Select all that apply. -Bounding pulse -Difficulty breathing -Increased urine output -Presence of dependent edema -Neck vein distention in the upright position

-Bounding pulse -Difficulty breathing -Presence of dependent edema -Neck vein distension in the upright position Rationale: Care of a client with HF and fluid overload includes monitoring for bounding pulses, difficulty breathing, neck vein distention in the upright position, and dependent edema. Increased urine output is not associated with HF and fluid overload.

Which electrolyte should the nurse closely monitor in a client who has decreased parathyroid function? -Sodium -Potassium -Calcium -Chloride

-Calcium

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: -Calcium 3.9 mEq/L -Sodium 140 mEq/L -Potassium 3.5 mEq/L -Magnesium 2.1 mEq/L

-Calcium 3.9 mEq/L

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

-Cardiac dysrhythmias

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding would the nurse expect to note? -Bradycardia -Elevated blood pressure -Changes in mental status -Bilateral crackles in the lungs

-Changes in mental status Rationale: A client with dehydration is likely to be lethargic or complain of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What would the nurse do next? -Document this assessment finding. -Call another nurse to verify this finding. -Check skin turgor over the client's sternum. -Call the primary health care provider (PHCP) to obtain a prescription for fluid replacement.

-Check skin turgor over the client's sternum. Rationale:In an older adult, skin turgor needs to be checked by pinching the skin over the sternum or even the forehead, instead of the back of the hand or forearm. As a client gets older, the skin loses elasticity and can tent over the hands and arms, even when the client is adequately hydrated. Therefore, the next nursing action would be to obtain additional assessment data.

The nurse is caring for a group of clients on the clinical nursing unit. Which client would the nurse plan to monitor for signs of fluid volume deficit? -Client in heart failure -Client in acute kidney injury -Client with an ileostomy -Client with controlled hypertension

-Client with an ileostomy Rationale: The client with an ileostomy is at risk for fluid volume deficit caused by increased gastrointestinal tract losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output such as diabetes insipidus, insufficient intravenous fluid replacement, and draining fistulas. Clients who have heart failure or kidney disease are at risk for fluid volume excess. Hypertension may be associated with fluid volume excess.

The nurse is assisting in the care of a group of clients on the nursing unit. When considering the effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third spacing of fluid? -Client with a major burn -Client with an ischemic stroke -Client with Laënnec's cirrhosis -Client with chronic kidney disease

-Client with an ischemic stroke Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third spacing.

The nurse has a prescription to hang a crystalloid intravenous solution of lactated Ringer's on a newly admitted client. The nurse notices that the client has a history of alcoholic cirrhosis. What action would the nurse take first? -Hang the solution. -Check the client's daily laboratory results. -Contact the primary health care provider (PHCP). -Ask the client whether any liver study tests have ever been done.

-Contact the primary health care provider (PHCP). Rationale: The nurse must contact the PHCP before administering the solution. Fluid and electrolyte replacement solutions such as lactated Ringer's are contraindicated for clients with kidney and liver disease or lactic acidosis.

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? -Daily weight -Urinary output -IV fluid intake -NG tube intake

-Daily weight Rationale: Daily weight is the best indicator of fluid balance. Options 2, 3, and 4 are related to intake or output but are incomplete indicators of fluid balance.

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? -Dry,sticky tongue -Increased anxiety -Nausea and vomiting -Decreased bowel sounds

-Decreased bowel sounds

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. -Dehydration -Hypertension -Physiological stress -Decreased blood volume -Decreased plasma osmolarity

-Dehydration -Physiological stress -Decreased blood volume Rationale: ADH, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality; decreased blood volume; hypotension; pain; dehydration from nausea, vomiting, or diarrhea; and stress.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/min, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, pastelike coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? -Dehydration -Hypokalemia -Fluid overload -Hypernatremia

-Dehydration Rationale: When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

The nurse who is caring for a client with severe malnutrition reviews the laboratory results and notes that the client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which electrocardiographic change would the nurse expect to observe based on the client's magnesium level? -Prominent U waves -Prolonged PR interval -Depressed ST segment -Widened QRS complexes

-Depressed ST segment Rationale:The normal serum magnesium level is 1.8-2.6 mEq/L (0.74-1.07 mmol/L). A magnesium level of 1.0 mEq/L (0.5 mmol/L) indicates hypomagnesemia. In hypomagnesemia, tall T waves and a depressed ST segment would be observed. Options 2 and 4 would be noted in a client experiencing hypermagnesemia. Prominent U waves occur with hypokalemia.

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. -Decreased muscle tone -Hypertension -Diarrhea -Fever

-Diarrhea Rationale: Adrenal insufficiency is addison's disease, add salt, add sugar, add sex. Hyponatremia (Severe diarrhea)

What is the nurses best action for the client whose serum chloride level is 101 mEq/L? -Document the finding as the only action -Assess the client's deep tendon reflexes -Urge the client to drink more water -Notify the physician

-Document the finding as the only action

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 hypernatremia? -Dry,sticky tongue -Increased anxiety -Nausea and vomiting -Decreased bowel sounds

-Dry,sticky tongue

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid which action? -Keeping the head of the bed elevated -Monitoring the flow rate of supplemental oxygen -Assisting the client to turn, cough, and breathe deeply -Encouraging the client to breathe slowly and shallowly

-Encouraging the client to breathe slowly and shallowly Rationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels caused by insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply to expand alveoli and to promote better gas exchange. The actions listed in options 1, 2, and 3 are helpful actions on the part of the nurse.

The nurse is creating a plan of care for a client with hypokalemia. Which interventions would be included in the plan of care? Select all that apply. -Ensure adequate fluid intake. -Implement safety measures to prevent falls. -Encourage low-fiber foods to prevent diarrhea. -Instruct the client about foods that contain potassium. -Encourage the client to obtain assistance to ambulate.

-Ensure adequate fluid intake. -Implement safety measures to prevent falls. -Instruct the client about foods that contain potassium. -Encourage the client to obtain assistance to ambulate. Rationale: Clients with hypokalemia will need instruction on potassium-rich foods, and all clients need to maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care would the nurse include? Select all that apply. -Ensure adequate oxygenation. -Provide assistance to prevent falls. -Monitor medication administration of diuretics. -Monitor for numbness and tingling around the mouth. -Prevent complications during potassium administration.

-Ensure adequate oxygenation. -Provide assistance to prevent falls. -Monitor medication administration of diuretics. -Prevent complications during potassium administration. Rationale: The priorities for nursing care of a client with hypokalemia are to ensure adequate oxygenation, to assure client safety in fall prevention and potassium administration, and to monitor for complications related to diuretic therapy and client response to therapy. Option 4 is related to hypocalcemia.

Why is it important to keep the sodium level of the plasma volume so much higher than the sodium level of the intracellular volume? -Intracellular sodium is toxic to living human cells -Excess sodium displaces oxygen on the hemoglobin of red blood cells -High plasma levels of sodium are needed to balance the high plasma levels of magnesium -Excitable membranes are dependent on sodium concentration differences for depolarization

-Excitable membranes are dependent on sodium concentration differences for depolarization

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

-Expand the volume of fluid in the vascular system rationale: Keeps fluid within vascular space, which expands the volume within the vascular system

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional sign would the nurse expect to note in a client with hyponatremia? -Muscle twitches -Decreased urinary output -Hyperactive bowel sounds -Increased specific gravity of the urine

-Hyperactive bowel sounds Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L (135 mmol/L). Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

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

-Hypertension

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? -Hypotension -Increased heart rate -Bounding peripheral pulses -Shortened QT interval on electrocardiography (ECG)

-Hypotension Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the ECG, the nurse would note a prolonged ST interval and a prolonged QT interval.

The client is receiving 150 mL of 5.0% saline intravenously in the next 2 hours. What response should the nurse expect as a result of this therapy? -Increased blood pressure -Increased dependent edema -Increased urine concentrations of potassium -Increased hematocrit and hemoglobin levels

-Increased blood pressure

The nurse anticipates that the client with a fluid volume excess will manifest a(n): -Increased urine specific gravity -Decreased body weight -Increased blood pressure -Decreased pulse strength

-Increased blood pressure

What effect would an infusion of 200 mL of albumin have on a healthy clients plasma osmotic and hydrostatic pressures? -Increased osmotic pressure, increased hydrostatic pressure -Increased osmotic pressure, decreased hydrostatic pressure -Decreased osmotic pressure, increased hydrostatic pressure -Decreased osmotic pressure, increased hydrostatic pressure

-Increased osmotic pressure, increased hydrostatic pressure

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns would the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply. -U waves -Absent P waves -Inverted T waves -Depressed ST segment -Widened QRS complex

-Inverted T waves -Depressed ST segment -U waves Rationale: The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially life threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in hypermagnesemia.

The nurse recognized 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 HCP is: -0.45% saline -Lactated Ringer's -5% dextrose in NS -5% dextrose in LR's

-Lactated Ringer's

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding would the nurse most likely expect to note in the client based on this magnesium level? -Tetany -Twitches -Positive Trousseau's sign -Loss of deep tendon reflexes

-Loss of deep tendon reflexes Rationale: The normal serum magnesium level is 1.8-2.6 mEq/L (0.74-1.07 mmol/L). A client with a magnesium level of 3.5 mEq/L (1.75 mmol/L) is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.

A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which priority problem? -Diarrhea -Metabolic acidosis -Metabolic alkalosis -Hyperactive bowel sounds

-Metabolic Alkalosis

ABG levels are obtained for the client. If the clients results are pH 7.48, CO2 42 mmHg, HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances? -metabolic acidosis -Respiratory acidosis -Respiratory alkalosis -Metabolic alkalosis

-Metabolic alkalosis

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? -Metabolic acidosis -Metabolic alkalosis -Respiratory acidosis -Respiratory alkalosis

-Metabolic alkalosis Rationale: Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.0 mEq/L (0.5 mmol/L). Which would be the most appropriate nursing action for this client? -Monitor the client for dysrhythmias. -Encourage increased intake of phosphate antacids. -Discontinue any magnesium-containing medications. -Encourage intake of foods such as ground beef, eggs, or chicken breast

-Monitor the client for dysrhythmias. Rationale: The normal serum magnesium level is 1.8-2.6 mEq/L (0.74-1.07 mmol/L). Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use needs to be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

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

-Move fluid into the cells

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? -Confusion -Muscle weakness -Mental status changes -Depressed deep tendon reflexes

-Muscle weakness Rationale: Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse monitors the client for which clinical manifestations associated with these ABG results? Select all that apply. -Nausea -Confusion -Bradypnea -Tachycardia -Hyperkalemia -Light-headedness

-Nausea -Confusion -Tachycardia -Light-headedness Rationale:Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, light-headedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations that are regular but abnormally slow. Hyperkalemia is associated with acidosis.

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

-Neurological

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 infusion, the nurse should: -Administer an antipyretic -Begin an infusion of epinephrine -Run normal saline through the blood tubing -Obtain and send a urine specimen to the laboratory

-Obtain and send a urine specimen to the laboratory Rationale: Hemolytic reaction, are there RBCs in the urine? There is not suppose to be RBCs

Which protein source should the nurse recommend for a client who needs to restrict dietary potassium intake? -Raw broccoli -Grilled salon -Poached eggs -Baked chicken

-Poached eggs

The nurse is monitoring a client on telemetry notes the presence of prominent U waves. The nurse assesses the client and checks the most recent electrolyte results. The nurse expects to note which electrolyte value? -Sodium 135 mEq/L (135 mmol/L) -Sodium 140 mEq/L (140 mmol/L) -Potassium 3.0 mEq/L (3.0 mmol/L) -Potassium 5.0 mEq/L (5.0 mmol/L)

-Potassium 3.0 mEq/L (3.0 mmol/L) Rationale:The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. In hypokalemia, the electrocardiographic (ECG) changes that occur include inverted T waves, ST segment depression, heart block, and prominent U waves.

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? -Magnesium level of 1.8 (0.74 mmol/L) -Sodium level of 145 mEq/L (145 mmol/L) -Potassium level of 3.0 mEq/L (3.0 mmol/L) -Phosphorus level of 3.0 mg/dL (0.97 mmol/L)

-Potassium level of 3.0 mEq/L (3.0 mmol/L) Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Some clinical manifestations of respiratory alkalosis include light-headedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, diarrhea, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what would the nurse do with the 40 mL of gastric aspirate? -Pour the aspirate into the NG tube and reinstill through a syringe with the plunger removed. -Dilute with water and inject into the NG tube by putting pressure on the plunger. -Discard properly and record as output on the client's intake and output (I&O) record. -Mix with the formula and instill through the NG tube through a syringe with the plunger removed.

-Pour the aspirate into the NG tube and reinstill through a syringe with the plunger removed. Rationale: After checking residual feeding contents, the gastric contents need to be reinstilled to maintain the client's electrolyte balance. The gastric contents would be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water and would not be discarded.

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL (2 mmol/L).Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. -Peaked T wave -Widened T wave -Prominent U wave -Prolonged QT interval -Prolonged ST segment

-Prolonged QT interval -Prolonged ST segment Rationale: A client with Crohn's disease is at risk for hypocalcemia. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. Peaked T waves occur with myocardial infarction. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? -Prolonged bed rest -Renal insufficiency -Hyperparathyroidism -Excessive ingestion of vitamin D

-Prolonged bed rest Rationale: The normal serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a serum calcium level of 6.0 mg/dL (1.66 mmol/L) is experiencing hypocalcemia. Prolonged bed rest is a cause of hypocalcemia. Although immobilization initially can cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia. End-stage renal disease, rather than renal insufficiency, is a cause of hypocalcemia. Hyperparathyroidism and excessive ingestion of vitamin D are causative factors associated with hypercalcemia.

A client is prescribed 3% NaCl, which is a hypertonic solution. The nurse recognized the primary goal of such intravenous therapy is to: -Expand the volume of fluid in the vascular system -Pull fluid from the cells -Keep protein levels normal -Move fluid into the cells

-Pull fluid from the cells

What problem is likely to occur when a client's fluid intake is so low that his or her urine output is less than 400 mL/day? -Cellular swelling and subsequent edema -Reduced excretion of body wastes, especially nitrogen -Expansion of the interstitial volume, with reduced plasma volume -Dilution of the serum sodium levels to the extent that excitable membranes can no longer depolarized

-Reduced excretion of body wastes, especially nitrogen

The nurse reviews a client's record and determines that the client is at risk for developing a potassium deficit if which situation is documented? -Sustained tissue damage -Requires nasogastric suction -Has a history of Addison's disease -Uric acid level of 9.4 mg/dL (557 mcmol/L)

-Requires nasogastric suction Rationale:The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level ranges from 2.7 to 8.5 mg/dL (160 to 501 mcmol/L).

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply. -Respirations that are shallow -Respirations that are increased in rate -Respirations that are abnormally slow -Respirations that are abnormally deep -Respirations that cease for several seconds

-Respirations that are increased in rate -Respirations that are abnormally deep Rationale: Kussmaul's respirations are abnormally deep and increased in rate. These occur as a result of the compensatory action by the lungs. In bradypnea, respirations are regular but abnormally slow. Apnea is described as respirations that cease for several seconds.

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 -metabolic acidosis -Respiratory acidosis -Respiratory alkalosis -Metabolic alkalosis

-Respiratory acidosis Rationale: Pneumonia, Difficulty Breathing, moist rales (in lungs) all respiratory issues.

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? -Respiratory acidosis from inadequate ventilation -Respiratory alkalosis from anxiety and hyperventilation -Metabolic acidosis from calcium loss due to broken bones -Metabolic alkalosis from taking analgesics containing base products

-Respiratory acidosis from inadequate ventilation Rationale: Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs will have difficulty with breathing adequately and is at risk for hypoventilation and resultant respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking analgesics containing base products.

A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: pH is 7.12, Paco2 is 90 mm Hg, and HCO3- is 22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? -Metabolic acidosis with compensation -Respiratory acidosis with compensation -Metabolic acidosis without compensation -Respiratory acidosis without compensation

-Respiratory acidosis without compensation Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate HCO3- level is 21 to 28 mEq/L (21 to 28 mmol/L). Because the bicarbonate is still within normal limits, the kidneys have not had time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore, the condition is without compensation. The remaining options are incorrect interpretations.

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

-Respiratory alkalosis

The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco2 of 30 mm Hg, and HCO3- of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? -Metabolic acidosis, compensated -Respiratory alkalosis, compensated -Metabolic alkalosis, uncompensated -Respiratory acidosis, uncompensated

-Respiratory alkalosis, compensated Rationale: The normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Paco2. In this situation, the pH is at the high end of the normal value and the Pco2 is low. In an alkalotic condition, the pH is elevated. Therefore, the values identified in the question indicate a respiratory alkalosis that is compensated by the kidneys through the renal excretion of bicarbonate. Because the pH has returned to a normal value, compensation has occurred.

A client treated for an episode of hyperthermia is being discharged to home. The nurse determines that the client needs clarification of discharge instructions if the client states a need to perform which action? -Increase fluid intake. -Resume full activity level. -Stay in a cool environment when possible. -Monitor voiding for adequacy of urine output.

-Resume full activity level. Rationale: Discharge instructions for the client hospitalized with hyperthermia include the prevention of heat-related disorders, increased fluid intake for 24 hours, self-monitoring of voiding, and the importance of staying in a cool environment and resting.

The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is -Hyperventilation to decrease the CO2 levels -Hypoventilation to increase the CO2 levels -Retention of HCO3 by the kidneys to increase the pH level -Excretion of HCO3 by the kidneys to decrease the pH level

-Retention of HCO3 by the kidneys to increase the pH level.

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? -Serum potassium -Serum Sodium -Serum Magnesium -Serum Calcium

-Serum Calcium Rationale: Renal Calculi, Kidneys located in this area

The nurse is caring for a client with a nasogastric tube. Nasogastric tube irrigations are prescribed to be performed once every shift. The client's serum electrolyte result indicates a potassium level of 4.5 mEq/L (4.5 mmol/L) and a sodium level of 132 mEq/L (132 mmol/L). Based on these laboratory findings, the nurse would select which solution to use for the nasogastric tube irrigation? -Tap water -Sterile water -Distilled water -Sodium chloride

-Sodium chloride Rationale:A potassium level of 4.5 mEq/L (4.5 mmol/L) is within normal range. A sodium level of 132 mEq/L (132 mmol/L) is low, indicating hyponatremia. In clients with hyponatremia, sodium chloride (normal saline) rather than water would be used for gastrointestinal irrigations because it is an isotonic solution.

A registered nurse (RN) has instructed an assistive personnel (AP) to administer soap suds enemas until clear to a client. The AP reports that three enemas have been administered and the client is still passing brown, liquid stool. What would the RN instruct the AP to do? -Administer a Fleet enema. -Administer an oil retention enema. -Wait 30 minutes and then administer another enema. -Stop administering the enemas until the primary health care provider (PHCP) is notified.

-Stop administering the enemas until the primary health care provider (PHCP) is notified. Rationale: Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse would call the PHCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.

A client complains of a headache, nausea, and vomiting during a blood transfusion. Which one of the following actions should the nurse take immediately? -Check the vital signs -Stop the blood transfusion -Slow down the rate of blood flow -Notify the HCP and blood bank personnel.

-Stop the blood transfusion

The nurse is reviewing laboratory results for a client with chronic kidney disease before a hemodialysis treatment. The serum electrolyte levels are sodium 142 mEq/L (142 mmol/L), chloride 103 mEq/L (103 mmol/L), potassium 5.2 mEq/L (5.2 mmol/L), and bicarbonate 23 mEq/L (23 mmol/L). What action would the nurse plan to take? -Take no action. -Order a stat hemodialysis treatment. -Recheck the labs because these values are all abnormal. -Page the primary health care provider (PHCP) with the results.

-Take no action. Rationale: No action is needed because all of the blood levels are normal for a hemodialysis client before a treatment. The normal adult ranges of serum electrolyte levels are sodium 135 to 145 mEq/L (135 to 145 mmol/L), chloride 98 to 106 mEq/L (98 to 106 mmol/L), bicarbonate (venous) 21 to 28 mEq/L (21 to 28 mmol/L), and potassium 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Although the potassium level is elevated, the normal range for potassium for a client with chronic kidney disease receiving hemodialysis is 4 to 6.5 mEq/L (4 to 6.5 mmol/L).

The nurse reviews the electrolyte results of a client with chronic kidney disease and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. -ST depression -Prominent U wave -Tall peaked T waves -Prolonged ST segment -Widened QRS complexes

-Tall peaked T waves -Widened QRS complexes

The nurse notes that a client's total serum calcium level is 6.0 mg/dL (1.5 mmol/L). Which assessment findings would be anticipated in this client? Select all that apply. -Tetany -Constipation -Renal calculi -Hypotension -Prolonged QT interval -Positive Chvostek's sign

-Tetany -Hypotension -Prolonged QT interval -Positive Chvostek's sign Rationale: The normal total serum calcium level is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L); thus, the client's results are reflective of hypocalcemia. The most common manifestations of hypocalcemia are caused by overstimulation of the nerves and muscles; therefore, tetany and the presence of Chvostek's sign would be expected. Calcium is needed by the heart for contraction. When the serum calcium level is decreased, cardiac contractility is decreased and the client will experience hypotension. A low serum calcium level could also lead to severe ventricular dysrhythmias and prolonged QT and ST intervals on the electrocardiogram.

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas (ABG) values are pH = 7.53, Pao2 = 72 mm Hg, Paco2 = 32 mm Hg, and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client would the nurse make? -The client has acidotic blood. -The client is probably overreacting. -The client is fluid volume overloaded. -The client is probably hyperventilating.

-The client is probably hyperventilating. Rationale:The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis, not acidosis, as a result of hyperventilating. Concluding that the client is overreacting is an inaccurate analysis. No conclusion can be made about a client's fluid volume status from the information provided

Which clients are most likely to be at risk for the development of third spacing? Select all that apply. -The client with cirrhosis -The client with liver failure -The client with diabetes mellitus -The client with a minor burn injury -The client with chronic kidney disease

-The client with cirrhosis -The client with liver failure -The client with chronic kidney disease Rationale: 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 for third spacing include clients with liver or kidney disease, major trauma, severe burn injuries, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

On review of the client's' medical records, the nurse determines that which client is at risk for fluid volume excess? -The client taking diuretics who has tenting of the skin -The client with an ileostomy from a recent abdominal surgery -The client who requires intermittent gastrointestinal suctioning -The client with kidney disease that developed as a complication of diabetes mellitus

-The client with kidney disease that developed as a complication of diabetes mellitus Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. The causes of fluid volume excess include decreased kidney function, heart failure, use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. Kidney disease is a complication of diabetes mellitus and as a result of the kidney disease, the elimination of fluid is affected and the client retains fluid. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for fluid volume deficit.

Why do older adults generally have less total body water than younger adults? -As functional cells die during the aging process, less water is needed. -The muscle mass of older adults is smaller than the muscle mass of younger adults. -Older adults have a smaller extracellular fluid to intracellular fluid ration than younger adults -The plasma volume of older adults is decreased to reduce the risk for excess fluid volume and heart failure

-The muscle mass of older adults is smaller than the muscle mass of younger adults.

The nurse is assessing a client with a lactose intolerance disorder for a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? -Twitching -Hypoactive bowel sounds -Negative Trousseau's sign -Hypoactive deep tendon reflexes

-Twitching Rationale: A client with lactose intolerance is at risk for developing hypocalcemia, because food products that contain calcium also contain lactose. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? -Urine pH of 6 -Urine that is pale yellow -Urine output of 40 mL/hr -Urine specific gravity of 1.032

-Urine specific gravity of 1.032 Rationale: The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status.

Which dietary supplement would the nurse suggest to the client who needs to increase his or her intake of calcium -Vitamin A -Vitamin B -Vitamin C -Vitamin D

-Vitamin D

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 -Intensity of the pain -Warmth of integument surrounding the IV site -Amount of subcutaneous edema -Skin discoloration of a bruised nature

-Warmth of integument surrounding the IV site

The client at risk for dehydration is on strick intake and output. In addition, the client has a large draining wound. What action should the nurse take regarding fluid lost through wound drainage? -No action needs to be taken because wound drainage is considered insensible loss and is of no consquence. -Estimate the amount of wound drainage by the color of the stains on the dressing. -Weigh the dressing materials before and after the dressing change. -Weigh the client before and after the dressing change.

-Weigh the dressing materials before and after the dressing change.

The nurse caring for a client with heart failure who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? -Weight loss and poor skin turgor -Lung congestion and increased heart rate -Decreased hematocrit and increased urine output -Increased respirations and increased blood pressure

-Weight loss and poor skin turgor Rationale:A fluid volume deficit occurs when the fluid intake is insufficient to meet the fluid needs of the body. Assessment findings in a client with a fluid volume deficit include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. Lung congestion, increased urinary output, and increased blood pressure are all associated with fluid volume excess.

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? -pH 7.25, Paco2 50 mm Hg -pH 7.35, Paco2 40 mm Hg -pH 7.50, Paco2 52 mm Hg -pH 7.52, Paco2 28 mm Hg

-pH 7.25, Paco2 50 mm Hg Rationale: Atelectasis is a condition characterized by the collapse of alveoli, preventing the respiratory exchange of oxygen and carbon dioxide in a part of the lungs. The normal pH is 7.35 to 7.45. The normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is decreased and the Paco2 is elevated. Option 2 identifies normal values. Option 3 identifies an alkalotic condition, and option 4 identifies respiratory alkalosis.

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 the client will demonstrate which of the following results? -pH 7.3, PaCo2 38 mmHg, HCO3 19 mEq/L -pH 7.5, PaCO2 34 mmHg, HCO3 30 mEq/L -pH 7.35, PaCO2 35 mmHg, HCO3 234 mEq/L -pH 7.52 PaCO2 48 mmHg, HCO3 28 mEq/L

-pH 7.3, PaCo2 38 mmHg, HCO3 19 mEq/L Rationale: Homeless, extremely poor nutrition, Starvation, we would expect metabolic acidosis

A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they would be performed. 1. Uncap the distal end of the tubing. 2. Close the roller clamp on the IV tubing. 3. Open the roller clamp and fill the tubing. 4. Attach the distal end of the tubing to the client. 5. Spike the IV bag and half-fill the drip chamber.

2, 5, 3, 1, 4 Rationale:The nurse would close the roller clamp on the IV tubing to prevent the solution from running freely through the tubing once it is attached to the IV bag. The nurse would next uncap the proximal (spike) end of the tubing, attach it to the IV bag, and then squeeze the drip chamber to half-fill it. Next, the roller clamp is opened slowly, and the fluid is allowed to flow through the tubing in a controlled fashion to prevent air from remaining in parts of the tubing. Finally, the distal end of the tubing is uncapped and attached to the client.

The nurse is calculating a client's fluid intake for a 24-hour period. The client suffers from chronic kidney disease, is on hemodialysis, and urinates about 100 mL a day. The client is on a fluid restriction of 750 mL per day. The client drank 4 oz of tea and 4 oz of orange juice for breakfast, 4 oz of water at 1200 and at 1700 when taking his medications, and 4 oz of iced tea at lunch and dinner. At 0800 and again at 1400, the client received his intravenous antibiotics in 50 mL of normal saline. How many mL of fluid does the client have left to drink for the day?

30 mL Rationale: The hemodialysis client has severe renal insufficiency and requires fluid restriction. Clients receiving hemodialysis are limited to a fluid intake resulting in a gain of no more than 0.45 kg (1 lb) per day on the days between dialysis and a daily intake of 500 to 750 mL plus the volume lost in urine. The client consumed a total of 24 oz of fluid (8 oz at breakfast, 8 oz with medications, and 4 oz at lunch and 4 oz at dinner). This equals 720 mL (1 oz = 30 mL). The client also received a total of 100 mL of intravenous fluid (50 mL at 0800 and 50 mL at 1400). The total fluid intake is 820 mL. The client voids approximately 100 mL of urine a day so add that to the prescribed daily intake (750 plus 100 equals 850 allowable daily fluid intake). So if the client took in 820 mL and is allowed 850 mL, subtract 820 from 850. The client may drink 30 mL more fluid on this day.

The nurse reviews a client's arterial blood gas results and notes that the pH is 7.30 (7.30), the Paco2 is 52 mm Hg (50 mm Hg), and the HCO3 is 22 mEq/L (22 mmol/L). The nurse interprets these results as indicating which condition? 1) Metabolic acidosis, compensated 2) Respiratory alkalosis, compensated 3) Metabolic alkalosis, uncompensated 4) Respiratory acidosis, uncompensated

4 Rationale:Normal pH is 7.35 to 7.45. In a respiratory condition, the pH and the Paco2 will exhibit opposite effects; in this case, the pH is low and the Paco2 is increased. In an acidotic condition, the pH is decreased. Therefore, the values identified in the question indicate a respiratory acidosis. Compensation occurs when the pH returns to a normal value. Because the pH is not within the normal range, the condition is uncompensated.

The nurse has a prescription to obtain an arterial blood sample from a client. Prior to the procedure the nurse assesses the adequacy of the client's radial artery by performing the Allen's test. In which order would the Allen's test be performed? Place in correct order of priority. All options must be used. 1. Apply pressure over the ulnar and radial arteries simultaneously. 2. Release pressure from the ulnar artery while compressing the radial artery. 3. Ask the client to open and close the hand repeatedly. 4. Assess the color of the extremity distal to the pressure point. 5. Explain the procedure to the client. 6. Document the findings.

5, 1, 3, 2, 4, 6 Rationale:The Allen's test is performed before obtaining an arterial blood specimen from the radial artery to determine the presence of collateral circulation and the adequacy of the ulnar artery. Failure to determine the presence of adequate collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The nurse first would explain the procedure to the client. To perform the test, the nurse applies direct pressure over the client's ulnar and radial arteries simultaneously. While applying pressure, the nurse asks the client to open and close the hand repeatedly; the hand would blanch. The nurse then releases pressure from the ulnar artery while compressing the radial artery and assesses the color of the extremity distal to the pressure point. If pinkness fails to return within 6 to 7 seconds, the ulnar artery is insufficient, indicating that the radial artery would not be used for obtaining a blood specimen. Finally, the nurse documents the findings. Other sites, such as the brachial or femoral artery, can be used if the radial artery is deemed inadequate.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? -Weight loss and dry skin -Flat neck and hand veins and decreased urinary output -An increase in blood pressure and increased respirations -Weakness and decreased central venous pressure (CVP)

An increase in blood pressure and increased respirations Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either fluid volume excess or deficit.

A client has been diagnosed with metabolic alkalosis as a result of excessive antacid use. The nurse monitoring this client would expect to note which signs/symptoms? -Disorientation and dyspnea -Decreased respiratory rate and depth -Drowsiness, headache, and tachypnea -Tachypnea, dizziness, and paresthesias

Decreases respiratory rate and depth Rationale: A client with metabolic alkalosis is likely to exhibit decreased respiratory rate and depth as a compensatory mechanism. A client with metabolic acidosis would display the symptoms noted in option 3. The client with respiratory acidosis and the client with respiratory alkalosis would display the symptoms noted in options 1 and 4, respectively.

The nurse is providing care to a client with the following arterial blood gas results: pH of 7.50, Pao2 of 90 mm Hg, Paco2 of 40 mm Hg, and bicarbonate of 35 mEq/L. When the nurse notifies the primary health care provider about these levels, the nurse would anticipate receiving from the PHCP which prescription for this client? -Obtain a serum alcohol level. -Obtain a serum salicylate level. -Discontinue nasogastric suctioning. -Discontinue the client's fentanyl patch.

Discontinue nasogastric suctioning Rationale: The arterial blood gas (ABG) results indicate metabolic alkalosis, as the pH and bicarbonate are elevated. Nasogastric suctioning may cause metabolic alkalosis by decreasing the acid components in the stomach. Excess alcohol ingestion and salicylate toxicity may cause metabolic acidosis. Fentanyl (an opioid) may cause respiratory acidosis.

The nurse is caring for a client in the early stages of disseminated intravascular coagulation (DIC). At this stage, what medication would the nurse expect to be prescribed? -Heparin -Platelets -Antibiotic -Clotting factors

Heparin Rationale: During the early phase of DIC, anticoagulants (especially heparin) are given to limit clotting and prevent the rapid consumption of circulating clotting factors and platelets. Antibiotics are given when sepsis is suspected in an attempt to prevent DIC from occurring.

A client is determined by blood gas analysis to be in respiratory alkalosis. Which electrolyte disorder would the nurse monitor for that could accompany the acid-base imbalance? -Hypokalemia -Hypercalcemia -Hypochloremia -Hypernatremia

Hypokalemia Rationale: Clinical manifestations of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. The clinical picture does not include hypercalcemia, hypochloremia, or hypernatremia.

The nurse is reading a primary health care provider's (PHCP's) progress notes in the client's record and reads that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse plans to make a notation that insensible fluid loss occurs through which type of excretion? -Urinary output -Wound drainage -Integumentary output -The gastrointestinal tract

Integumentary output Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most likely caused this serum phosphorus level? -Malnutrition -Renal insufficiency -Hypoparathyroidism -Tumor lysis syndrome

Malnutrition Rationale: The normal serum phosphorus (phosphate) level is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client is experiencing hypophosphatemia. Causative factors relate to malnutrition or starvation and the use of aluminum hydroxide-based or magnesium-based antacids. Renal insufficiency, hypoparathyroidism, and tumor lysis syndrome are causative factors of hyperphosphatemia.

A client with diabetes mellitus is most likely to experience which type of acid-base imbalance as a complication of the disorder? -Metabolic acidosis -Metabolic alkalosis -Respiratory acidosis -Respiratory alkalosis

Metabolic Acidosis Rationale:Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises while the cells of the body use all available glucose and then break down glycogen and fat for fuel. The by-products of fat metabolism are acidotic, leading to the complication called diabetic ketoacidosis. The acid-base disorders in the remaining options are unlikely to occur in diabetes mellitus unless there is another existing disorder.

The nurse is caring for a client with hyperglycemia and diabetic ketoacidosis (DKA) who now has developed Kussmaul's respirations. The nurse plans care, understanding that the purpose of this type of breathing is to correct what imbalance? -Metabolic acidosis -Metabolic alkalosis -Respiratory acidosis -Respiratory alkalosis

Metabolic acidosis Rationale: Kussmaul's respirations cause respiratory compensation in an attempt to correct metabolic acidosis by exhaling carbon dioxide. This breathing pattern is very deep and rapid and is the respiratory system's attempt to correct metabolic acidosis by exhaling carbon dioxide.

A client is being treated for metabolic acidosis with medication therapy and other measures. The nurse would plan to monitor the results of which electrolyte, which could dramatically decline with effective treatment of the acidosis? -Sodium -Potassium -Magnesium -Phosphorus

Potassium Rationale: The serum potassium level tends to rise with metabolic acidosis. This is because potassium moves out of the cells and into the bloodstream. When acidosis is corrected with treatment, the potassium will shift back into the cellular compartment. This can cause a rapid drop in the serum potassium level. Because of the effects of potassium on the heart, this electrolyte needs to be monitored closely while the client is treated.

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the laboratory value? Select all that apply. -U waves -Widened T wave -Prominent U wave -Prolonged QT interval -Prolonged ST segment

Prolonged QT interval Prolonged ST segment Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9 mg/dL (2.25 mmol/L) indicates hypocalcemia. Electrocardiographic changes that occur in a client with hypocalcemia include a prolonged QT interval and prolonged ST segment. A shortened ST segment and a widened T wave occur with hypercalcemia. ST depression and prominent U waves occur with hypokalemia.

An anxious client is experiencing respiratory alkalosis from hyperventilation caused by anxiety. The nurse would take which action to help the client experiencing this acid-base disorder? -Put the client in a supine position. -Provide emotional support and reassurance. -Withhold all sedative or antianxiety medications. -Tell the client to breathe deeply but more rapidly.

Provide emotional support and reassurance Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication if it is prescribed. The client would try to breathe more slowly. Lying supine provides no benefit to the client and may cause problems with breathing.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation -Sustained tissue damage -Requires nasogastric suction -Has a history of Addison's disease -Uric acid level of 9.4 mg/dL (559 mmol/L)

Requires nasogastric suction The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5 mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia.

The nurse is admitting to the hospital a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe, the client will be at risk for which acid-base imbalance? -Metabolic acidosis -Metabolic alkalosis -Respiratory acidosis -Respiratory alkalosis

Respiratory Acidosis Rationale:Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, leading to respiratory acidosis and ventilatory failure as the paralysis develops. Therefore, the remaining options are incorrect.

The nurse is caring for a client who is experiencing metabolic alkalosis. Knowing the risks of this imbalance, the nurse plans to protect the client's safety by carefully implementing which prescribed precaution? -Contact isolation -Seizure precautions -Bleeding precautions -Neutropenic precautions

Seizure Precautions Rationale: The client with metabolic alkalosis is at risk for tetany and seizures. The nurse would maintain client safety by using seizure precautions with this client. The remaining options are unnecessary in the care of the client experiencing metabolic alkalosis.

The nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply. -ST depression -Prominent U wave -Tall peaked T waves -Prolonged ST segment -Widened QRS complexes

Tall peaked T waves Widened QRS complexes Rationale:The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Electrocardiographic changes associated with hyperkalemia include flat P waves, prolonged PR intervals, widened QRS complexes, and tall peaked T waves. ST depression and a prominent U wave occur in hypokalemia. A prolonged ST segment occurs in hypocalcemia.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? -The client with colitis -The client with Cushing's syndrome -The client who has been overusing laxatives -The client who has sustained a traumatic burn

The client who has sustained a traumatic burn The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level higher than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. Clients who experience cellular shifting of potassium in the early stages of massive cell destruction, such as with trauma, burns, sepsis, or metabolic or respiratory acidosis, are at risk for hyperkalemia. The client with Cushing's syndrome or colitis and the client who has been overusing laxatives are at risk for hypokalemia.

Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)? -The client who is taking diuretics -The client with hyperaldosteronism -The client with Cushing's syndrome -The client who is taking corticosteroids

The client who is taking diuretics Rationale: The normal serum sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A serum sodium level of 130 mEq/L (130 mmol/L) indicates hyponatremia. Hyponatremia can occur in the client taking diuretics. The client taking corticosteroids and the client with hyperaldosteronism or Cushing's syndrome are at risk for hypernatremia.