Medical Surgical Nursing: Fluid, Electrolyte, and Acid-Base Imbalances

The nurse finds polyuria, soft flabby muscles, and an irregular pulse in a patient who has a blood glucose level of 165 mg/dL and who is on is on intravenous dextrose therapy. Which changes are observed in the patient's electrocardiogram? Select all that apply. 1 Loss of P wave 2 Prolonged QRS 3 Peaked T waves 4 Presence of U wave 5 ST segment depression

2, 4, 5 When the potassium levels in the blood are low, it is known as hypokalemia. Symptoms include fatigue, nausea, excessive urination, and muscle weakness. Hypokalemia alters the resting membrane potential, resulting in hyperpolarization and changes in electrolytes. Prolonged QRS complex, presence of a U wave, and ST segment depression are caused by hyperpolarization, which is found in hypokalemia. Loss of the P wave and peaked T waves are both seen in hyperkalemia. Test-Taking Tip: Recall the symptoms of hypokalemia and use your knowledge to eliminate the wrong options. Text Reference - p. 296

A patient has the following arterial blood gas results: pH 7.16, PaCO2 80 mm Hg, PaO2 46 mm Hg, HCO3- 24 mEq/L, and SaO2 81%. The nurse recognizes that the results represent: 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3 The pH is less than 7.35, indicating acidosis. This eliminates metabolic and respiratory alkalosis as possibilities. Because the PaCO2 is high at 80 mm Hg (normal range is 35 to 45 mm Hg) and the metabolic measure of HCO3- is normal (range is 22 to 28 mEq/L), the patient is in respiratory acidosis, not alkalosis. Text Reference - p. 303

The nurse needs to add potassium chloride 10 mEq to an intravenous (IV) of lactated Ringer's solution. Available are multidose vials containing 5 mEq KCl in 10 mL of solution. How many milliliters of KCl should be added to the IV bag? 1. 2 mL 2. 5 mL 3. 10 mL 4. 20 mL

4 Using ratio and proportion, multiply 5 by x and multiply 10 × 10 to yield 5x = 100. Divide 100 by 5 to yield 20 mL. Text Reference - p. 298

Which value of blood pH indicates acidosis? 1. 7.25 2. 7.35 3. 7.45 4. 7.55

1 A pH below 7.35 indicates acidosis; thus a pH of 7.25 a sign of acidosis. Normal blood pH lies between 7.35 and 7.45. A pH of 7.55 indicates alkalosis. Text Reference - p. 302

While caring for a patient who had a pituitary tumor removed, which finding should be reported immediately to the primary health care provider? 1 Excessive thirst 2 Calcium level of 8.6 mg/dL 3 Potassium level of 3.5 mEq/L 4 Urine output of 300 mL in eight hours

1 A patient who has had surgery on the pituitary gland is at risk for diabetes insipidus. Excessive thirst is an indicator of inadequate antidiuretic hormone (ADH) synthesis or release. The nurse should monitor the urine output closely and notify the primary health care provider of excessive thirst. One would expect large volumes of urine in the absences of ADH production. A urine output of 300 mL in eight hours would not be alarming. The calcium and potassium levels are at the low end of normal. The nurse should continue to monitor these electrolytes. Text Reference - p. 294

A patient with blood pressure of 160/90 mm Hg has pedal edema. Which process of transport of molecules would be in action? 1 Osmosis 2 Diffusion 3 Active transport 4 Facilitated diffusion

1 A patient with blood pressure of 160/90 mm Hg has hypertension and develops pedal edema due to excess sodium in the blood. This leads to movement of water down the gradient. Therefore, the water from the blood vessels moves from higher concentrations to lower concentration across the semipermeable membrane with the help of osmotic pressure and leads to accumulation of water in the extracellular spaces. Diffusion, active transport, and facilitated diffusion involve the movement of molecules from lower concentrations to higher concentrations. Text Reference - p. 287

Which phosphate level would the nurse be likely to find in the patient who has alcohol withdrawal symptoms? 1 1.4 mg/dL 2 2.4 mg/dL 3 3.8 mg/dL 4 4.8 mg/dL

1 Alcohol withdrawal can result in hypophosphatemia. Phosphate levels of less than 2.4 mg/dL indicate hypophosphatemia. The nurse would be likely to find the patient's phosphate level at 1.4 mg/dL. Phosphate levels of 2.4, 3.8, and 4.8 mg/dL indicate hyperphosphatemia. The patient with symptoms of alcohol withdrawal does not have hyperphosphatemia. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect. Text Reference - p. 301

A patient sustains a soft tissue injury to the ankle, and a large amount of edema develops. What nursing intervention will relieve edema associated with this injury? 1 Elevating the extremity 2 Massaging the ankle every 1-2 hours 3 Applying a warm compress to the ankle 4 Applying warm saline soaks to the extremity

1 Elevation promotes good venous return, allowing extracellular fluid to flow more readily away from the edematous area. In addition, ice or a cold compress helps ease edema and pain. Warm saline soaks, massage of the extremity, and warm compresses will increase venous circulation and congestion, thereby worsening the edema, as well as the pain. Text Reference - p. 293

A patient is diagnosed with Cushing syndrome. What manifestation does the nurse anticipate while assessing this patient? 1 Dyspnea 2 Dry mouth 3 Weight loss 4 Restlessness

1 Excess extracellular volume may result from fluid retention during Cushing syndrome. This shift of fluid into the interstitial spaces leads to blockage of air spaces (pulmonary edema) resulting in dyspnea, crackles, and peripheral edema. Dry mouth, weight loss, and restlessness are the common manifestations resulting from extracellular fluid depletion. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Text Reference - p. 292

The nurse anticipates that treatment of the patient with severe hyperphosphatemia includes: 1 Insulin infusion 2 Fluid restriction 3 Calcium supplements 4 Loop diuretic therapy

1 For severe hyperphosphatemia, hemodialysis or an insulin and glucose infusion can decrease levels rapidly. Fluid restriction, calcium supplements, and diuretic therapy are not treatment options for hyperphosphatemia. Text Reference - p. 301

The nurse is caring for a patient with hyponatremia related to excess fluid. Which of these interventions is appropriate initially? 1 Fluid restriction 2 Administration of hypotonic intravenous (IV) fluids 3 Administration of a cation-exchange resin 4 Oral doses of sodium chloride three times a day

1 In hyponatremia that is caused by water excess, fluid restriction often is all that is needed to treat the problem. Small amounts of IV hypertonic saline solution (3%) may be given if severe symptoms, such as seizures, develop. Treatment of hyponatremia associated with abnormal fluid loss includes fluid replacement with sodium-containing solutions. Administration of oral sodium chloride is not appropriate. Text Reference - p. 296

A patient sustains multiple injuries in a motor vehicle accident and is hypovolemic due to hemorrhage. Blood transfusions are given to replace the lost blood. The nurse finds that the patient has now developed laryngeal stridor, dysphagia, and numbness and tingling around the mouth. What could be the reason for these new manifestations? 1 The patient has developed hypocalcemia 2 The patient has developed fluid overload 3 The patient has developed anemia 4 The patient has developed a hemolytic reaction

1 Laryngeal stridor, dysphagia, and numbness and tingling around the mouth after multiple blood transfusions can be attributed to hypocalcemia. Blood and blood products have citrate in them, which can bind with calcium in the body and make it unavailable. Multiple blood transfusions have thus caused hypocalcemia. This usually manifests as laryngeal stridor, dysphagia, and numbness and tingling around the mouth. Such symptoms are not caused by fluid overload, which manifests as edema. Anemia can be the result of hemorrhage but does not present with laryngeal stridor and dysphagia. There are chances of hemolytic reactions, because the patient is receiving multiple transfusions. However, a hemolytic reaction manifests as severe anaphylaxis, so the patient is not having a hemolytic reaction. Text Reference - p. 300

A nurse is providing postoperative care for a patient. The primary health care provider assesses the patient and advises the nurse to stop all intravenous fluids except for continuous maintenance fluids. Which fluid will the nurse administer as a maintenance fluid? 1 0.45% NaCl 2 Lactated Ringer's solution 3 5% dextrose in 0.9% saline 4 25% albumin solution

1 Maintenance fluids are hypotonic solutions because the body's daily losses are hypotonic. The nurse should therefore administer 0.45% NaCl, which is hypotonic. Lactated Ringer's solution is an isotonic solution and is not used as a maintenance fluid, because it tends to expand the extracellular compartment. Five percent dextrose in 0.9% saline is a hypertonic solution that expands intravascular volume and replaces extracellular fluid losses; 25% albumin solution is a plasma expander and not used as a maintenance fluid. Text Reference - p. 308

The arterial blood gas analysis shows a partial pressure of carbon dioxide (PaCO2) of 43 mm Hg and pH of 5.1 in a patient with diabetes. What would be the patient's diagnosis? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

1 Metabolic acidosis is characterized by increased levels of acid in the blood. As a result, pH of the blood decreases. The normal range of pH of blood is 7.35 to 7.45, and the normal value of partial pressure of carbon dioxide (PaCO2) lies between 35 and 45 mm Hg. The patient's numbers indicate metabolic acidosis. Metabolic alkalosis is manifested by an increased pH. A decreased pH and elevated PaCO2 indicate respiratory acidosis. Respiratory alkalosis is manifested by increased plasma pH and decreased PaCO2. Text Reference - p. 304

A patient has been treated successfully for dehydration. The nurse would expect: 1 Oral intake balances output. 2 Oral intake is less than output. 3 Oral intake is greater than output. 4 No significant difference in fluid balance.

1 Oral intake should equal output if fluid balance has been restored and dehydration has been corrected. Less intake than output would result in dehydration. Greater intake than output may indicate decreased renal function or impaired ability to excrete urine. Text Reference - p. 292

Which treatment could be a possible reason for a cancer patient to have a serum phosphate level of 5.4 mg/dL? 1 Chemotherapy 2 Insulin therapy 3 Total parenteral nutrition 4 Phosphate-binding antacids

1 Phosphate levels greater than 4.4 mg/dL indicate hyperphosphatemia. Chemotherapy drugs increase the patient's phosphate levels. Insulin therapy decreases the phosphate levels to less than 2.4 mg/dL. Patients with total parenteral nutrition have decreased phosphate levels. Phosphate-binding antacids remove phosphates from the body, resulting in hypophosphatemia. Text Reference - p. 301

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? 1 Weakness 2 Paresthesia 3 Facial spasms 4 Muscle tremors

1 Signs of hypercalcemia are lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia. Text Reference - p. 299

What is the pH of urine excreted by the kidneys as a compensatory response? 1. 8 2. 9 3. 10 4. 11

1 The average pH of urine excreted by the kidneys is 6. As a compensatory response, the kidneys excrete urine with a pH ranging from 4 to 8. Text Reference - p. 303

When assessing the patient with a multilumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? 1 Administer oxygen 2 Notify the health care provider 3 Rapidly administer more intravenous (IV) fluid 4 Reposition the patient to the right side

1 The cap off the central line could allow entry of air into the circulation. For an air embolus, the priority is to administer oxygen; next, the catheter is clamped and the patient is positioned on the left side with the head down. Then the health care provider is notified. Test-Taking Tip: Being emotionally prepared for an examination is key to your success. Proper use of this text over an extended period of time ensures your understanding of the mechanics of the examination and increases your confidence about your nursing knowledge. Your lifelong dream of becoming a nurse is now within your reach! You are excited, yet anxious. This feeling is normal. A little anxiety can be good because it increases awareness of reality; but excessive anxiety has the opposite effect, acting as a barrier and keeping you from reaching your goal. Your attitude about yourself and your goals will help keep you focused, adding to your strength and inner conviction to achieve success. Text Reference - p. 311

Which serum potassium results best support the rationale for administering a stat dose of potassium chloride 20 mEq in 250 mL of normal saline over two hours? 1 3.1 mEq/L 2 3.9 mEq/L 3 4.6 mEq/L 4 5.3 mEq/L

1 The normal range for serum potassium is 3.5 to 5.0 mEq/L. This intravenous (IV) prescription provides a substantial amount of potassium. Thus the patient's potassium level must be low. The only low value shown is 3.1 mEq/L; 3.9 mEq/L, 4.6 mEq/L, and 5.3 mEq/L are not low values. Text Reference - p. 296

The nurse receives a health care provider's prescription to change a patient's intravenous (IV) from D5½ normal saline (NS) with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory value on this same patient best supports the rationale for this IV prescription change? 1 Sodium 136 mEq/L, potassium 4.5 mEq/L 2 Sodium 145 mEq/L, potassium 4.8 mEq/L 3 Sodium 135 mEq/L, potassium 3.6 mEq/L 4 Sodium 144 mEq/L, potassium 3.7 mEq/L

1 The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV prescription decreases the amount of potassium and increases the amount of sodium. For this prescription to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. Text Reference - p. 296

While caring for a patient with encephalitis, the nurse suspects that the patient has developed respiratory alkalosis. Which finding in the patient supports the nurse's suspicion? 1 Bicarbonate ion concentration, 18 mEq/L, partial pressure of carbon dioxide, 30 mm Hg 2 Bicarbonate ion concentration, 22 mEq/L, partial pressure of carbon dioxide, 35 mm Hg 3 Bicarbonate ion concentration, 24 mEq/L, partial pressure of carbon dioxide, 43 mm Hg 4 Bicarbonate ion concentration, 26 mEq/L, partial pressure of carbon dioxide, 45 mm Hg

1 The normal range of bicarbonate (HCO3-) ion concentration in blood is 22 to 26 mEq/L and the normal range of partial pressure of carbon dioxide (PaCO2) is 35 to 45 mm Hg. When the respiratory center is stimulated, patients with encephalitis will hyperventilate. This condition causes a decrease in partial pressure of carbon dioxide, resulting in decreased carbonic acid concentration. Because the laboratory reports show a decreased partial pressure of carbon dioxide and bicarbonate ion concentration, the nurse suspects respiratory alkalosis. Test-Taking Tip: Encephalitis is an inflammatory condition of brain, wherein the brain's key functions may get altered. Use this tip in answering the question. Text Reference - p. 304

Which is a normal value of the anion gap? 1 14 mmol/L 2 15 mmol/L 3 16 mmol/L 4 17 mmol/L

1 The normal range of the anion gap is 10 to14 mmol/L. Anion gap values of 15, 16, and 17 mmol/L are abnormal. Text Reference - p. 305

A diabetic patient fasting before surgery reports feeling dizzy and deep rapid breathing. A nurse observes that the patient has developed Kussmaul respirations. What condition is the patient most likely experiencing? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

1 The patient has been fasting and complains of dizziness. The patient has likely developed diabetic ketoacidosis, a type of metabolic acidosis. Kussmaul respiration is deep, rapid breathing that develops in response to metabolic acidosis. This type of breathing is a compensatory mechanism to excrete excess carbon dioxide from the lungs. Metabolic alkalosis occurs when there is a loss of acid or a gain in bicarbonate. It is not associated with Kussmaul respiration. Respiratory acidosis results when the person hypoventilates and carbonic acid accumulates in the blood. Respiratory alkalosis occurs when the person hyperventilates. Text Reference - p. 303

While taking a patient's blood pressure, a nurse notices that a carpal spasm occurs. To diagnose a possible cause for the carpal spasm, the nurse should expect the primary health care provider to prescribe which level? 1 Calcium 2 Sodium 3 Potassium 4 Magnesium

1 Trousseau's sign (carpal spasm when blood pressure cuff is inflated for a few minutes) is indicative of hypocalcemia. It does not occur with changes in sodium, potassium, or magnesium levels. The nurse should expect the primary health care provider to prescribe a calcium level be drawn. Text Reference - p. 300

Which electrolyte changes can be identified by Trousseau's sign? 1 Hypocalcemia 2 Hypercalcemia 3 Hypermagnesemia 4 Hyperphosphatemia

1 Trousseau's sign refers to carpal spasms induced by inflating a blood pressure cuff on the arm. Hypocalcemia can be identified by Trousseau's sign. Hypercalcemia, hypermagnesemia, and hyperphosphatemia cannot be identified by Trousseau's sign. Text Reference - p. 300

A nurse is caring for a patient who reports diarrhea and vomiting for the past five days. As a result, the patient has developed severe hypokalemia. The primary health care provider prescribes IV potassium chloride (KCl) treatment. How can the nurse ensure the safety of the patient when administering IV KCl? Select all that apply. 1 Continuously monitor cardiac function 2 Check hourly for the presence of phlebitis at the IV site 3 Monitor the urine output 4 Assess for signs of tetany 5 Assess for laryngeal spasms

1, 2, 3 IV potassium chloride (KCl) is administered to treat hypokalemia. IV administration of KCl may cause rapid changes in potassium levels, which may adversely affect the heart. Therefore, the patient should be under continuous cardiac monitoring. KCl is an irritant and may cause phlebitis and infiltration, leading to necrosis and sloughing. So the nurse should frequently check the IV site for phlebitis and infiltration. KCl is administered when the urine output is at least 0.5 mL/kg of body weight per hour. The urine output should hence be monitored to check for its adequacy. Tetany and laryngeal spasms occur when there are low levels of calcium. They are not related to potassium levels. Text Reference - p. 298

The primary health care provider concludes that a patient has metabolic alkalosis. Which signs in the patient help the primary health care provider to reach this conclusion? Select all that apply. 1 Tremors 2 Vomiting 3 Tachycardia 4 Epigastric pain 5 Numbness of limbs

1, 2, 3 Tremors, vomiting, and tachycardia are signs of metabolic alkalosis. Epigastric pain and numbness of limbs are signs of respiratory alkalosis. Text Reference - p. 305

A nurse is teaching the nursing assistants the importance of performing accurate weighings. Which content should be included? Select all that apply. 1 Calibrate the scale before using 2 Weigh patient with same garments each day 3 Weigh the patient at the same time each day 4 Empty the Foley catheter after weight obtained 5 Teach the patient the importance of daily weighings 6 If bed scale used, weigh with same number of linens on the bed

1, 2, 3, 6 In many settings the nursing assistant weighs the patient. Accurate weighings help determine medical treatment. It is essential to teach these health care providers the importance of calibrating the scale before using, weighing the patients with the same garments and at the same time each day, and if using a bed scale, documenting and weighing with the same number of linens and pillows on the bed. The drains, including the Foley catheter, should be drained before weighing. If the patient does not have an indwelling catheter, the weight should be obtained after the patient voids. Teaching the patient the importance of weighing daily is a nurse function and should not be delegated to the nursing assistant. Text Reference - p. 292

A nurse is caring for a patient with malignant lung cancer who experiences weakness, lethargy, depressed reflexes, and bone pain. The nurse suspects the patient may have hypercalcemia. Which changes in the electrocardiogram indicate hypercalcemia? Select all that apply. 1 Shortened ST segment 2 Elongation of ST segment 3 Shortened QT interval 4 Prolonged QT interval 5 Flattened or inverted T wave

1, 3 Hypercalcemia may result from malignancies. Bone destruction due to tumor invasion may cause a release of calcium, leading to high levels of calcium in the blood. This causes altered transmembrane potentials affecting conduction time, and is manifested as a shortened ST segment and QT interval. An elongated ST segment and a prolonged QT interval are manifestations of hypocalcemia. A flattened or inverted T wave is a manifestation of hypokalemia. Text Reference - p. 299

The dehydrated patient is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions? Select all that apply. 1 Lung sounds 2 Bowel sounds 3 Blood pressure (BP) 4 Serum sodium level 5 Serum potassium level

1, 3, 4 BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions. Bowel sounds and serum potassium level do not need to be monitored frequently. Text Reference - p. 309

A nurse has been caring for a patient with a high fever and diarrhea for the past five days. Which clinical manifestations suggest extracellular fluid volume deficit? Select all that apply. 1 Restlessness 2 Peripheral edema 3 Concentrated urine 4 Dry mucous membranes 5 Jugular venous distention

1, 3, 4 Hypovolemia or extracellular fluid deficit occurs when there is excess loss of body fluid, as can often occur after prolonged diarrhea. Its clinical manifestations include restlessness, concentrated urine, and dry mucous membranes. Dehydration may make the patient restless. Urine may be concentrated due to low urine output. The mucous membranes get dry because of fluid deficit. Peripheral edema and jugular venous distention are signs of extracellular volume excess caused by abnormal retention of fluids. Text Reference - p. 292

When the nurse is caring for a patient with a central venous access device, which nursing interventions are important to maintain a safe, functioning device? Select all that apply. 1 Change the catheter dressing regularly. 2 Monitor the heart rate and blood pressure. 3 Change the injection caps at regular intervals. 4 Cleanse around the catheter insertion site. 5 Measure and record oral intake and output

1, 3, 4 Nursing management of central venous access devices is important in keeping the devices safe and functioning and in reducing risk of infection. The catheter dressing and the injection caps should be regularly changed, and the catheter site should be regularly cleansed; these steps keep the site free from infection. Flushing is an important intervention to maintain the patency of the catheter and prevent occlusion. Monitoring vital parameters and assessing intake and output are general measures that are not specific to the care of central venous access devices. Text Reference - p. 311

The nurse is reviewing the mechanisms of acid-base buffers in the body. The kidneys act as an acid-base buffer by which of these mechanisms? Select all that apply. 1 Eliminating excess H+ 2 Excreting excess water 3 Eliminating excess CO2 4 Reabsorbing additional HCO3- 5 Reabsorbing additional sodium ions

1, 4 As a compensatory mechanism, the pH of the urine can decrease to 4 or increase to 8. To compensate for acidosis, the kidneys can reabsorb additional HCO3- and eliminate excess H+. Thus, the pH of the blood increases and the pH of the urine decreases. Text Reference - p. 303

On assessment, the nurse finds that a patient has a headache, increased blood pressure, peripheral edema, dyspnea, and jugular venous distention. The symptoms indicate excess fluid volume. Which causes of excess fluid volume might the nurse find in the patient? Select all that apply. 1 Heart failure 2 Hemorrhage 3 Diabetic insipidus 4 Long-term use of corticosteroids 5 Syndrome of inappropriate antidiuretic hormone (SIADH

1, 4, 5 Excess volume of fluid can accumulate in illnesses such as heart failure and SIADH, or due to long-term use of corticosteroids. In heart failure, the heart is unable to pump adequate blood to the body, resulting in pooling of blood in the periphery. In SIADH, abnormal levels of ADH cause reabsorption of water from the kidneys, leading to water retention in the body. Long-term use of corticosteroids causes altered homeostatic regulation of sodium and water, resulting in excess fluid volume. Hemorrhage and diabetic insipidus cause a deficit in fluid volume. Text Reference - p. 292

The nurse is caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? 1 Fully compensated respiratory alkalosis 2 Partially compensated respiratory acidosis 3 Normal acid-base balance with hypoxemia 4 Normal acid-base balance with hypercapnia

2 A low pH (normal 7.35-7.45) indicates acidosis. In the patient with a respiratory disease such as COPD, the patient retains carbon dioxide (normal 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2. Text Reference - p. 306

Which condition is an example of a mixed acid-base disorder? 1 Hypoxia and respiratory alkalosis 2 Septicemia and metabolic alkalosis 3 Sedative overdose and respiratory acidosis 4 Diabetic ketoacidosis and metabolic acidosis

2 A mixed acid-base disorder is a condition in which two or more disorders that affect the acid-base balance are present at the same time. Septicemia causes respiratory alkalosis, which causes acid-base imbalance. Metabolic alkalosis also affects the acid-base balance. Thus, septicemia and metabolic alkalosis are examples of a mixed acid-base disorder. Hypoxia causes respiratory alkalosis. Overdose of sedatives causes respiratory acidosis. Diabetic ketoacidosis results in metabolic acidosis. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Text Reference - p. 305

The patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid were removed. What intravenous (IV) solution may be used to pull fluid into the intravascular space after the paracentesis? 1 0.9% sodium chloride 2 25% albumin solution 3 Lactated Ringer's solution 4 5% dextrose in 0.45% saline

2 After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question. Text Reference - p. 309

A 68-year-old patient was admitted with abdominal pain, nausea, and severe diarrhea. Based on this information, the nurse assesses this patient for which primary acid-base imbalance? 1 Metabolic alkalosis 2 Metabolic acidosis 3 Respiratory alkalosis 4 Respiratory acidosis

2 Because gastric secretions are rich in hydrochloric acid, the patient with severe diarrhea will lose significant amounts of bicarbonate and is at increased risk for metabolic acidosis and a fall in pH. Metabolic alkalosis, respiratory alkalosis, and respiratory acidosis will not occur as a result of increased loss of bicarbonate. STUDY TIP: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage. Text Reference - p. 304

What amount of plasma is present in the body of a patient who weighs 55 kg? Record your answer using two decimal places. ____________ L

2 Extracellular fluid accounts to one-third of the body water, and plasma represents 20 percent of the extracellular fluid. Therefore, a patient weighing 55 kg has 30.3 L of total body water and about 10 L of extracellular fluid, and plasma represents 20 percent of the extracellular fluid, which equals approximately 2 L. Test-Taking Tip: Plasma is the component of extracellular fluid. Extracellular fluid accounts to one third of the body fluids and plasma accommodates 20 percent of extracellular fluid. Derive the correct answer by focusing on the details provided. Text Reference - p. 286

A patient reports weight gain, diarrhea, headache, nausea, and vomiting. The patient's blood pressure is 140/90 mm Hg. The patient's previous health records reveal primary hypoaldosteronism. Which medication may be beneficial for the patient? 1 Amiloride 2 Conivaptan 3 Propranolol 4 Sodium polystyrene sulfonate

2 Hyponatremia is decreased sodium levels in the body. Hyponatremia can be manifested by weight gain, diarrhea, headache, nausea, vomiting, and elevated blood pressure. Conivaptan blocks the activity of antidiuretic hormone and results in increased urine output without loss of electrolytes, thereby improving the patient's hyponatremia. Amiloride, propranolol, and sodium polystyrene sulfate treat hypokalemia, but not hyponatremia. Test-Taking Tip: Recall the clinical manifestations of hyponatremia and drugs used to treat hyponatremia to answer this question accurately. Text Reference - p. 296

Which statement made by the student nurse regarding the hypothalamic-pituitary regulation needs correction? 1 "Consumption of water is less during stress." 2 "Dry mouth is the measuring tool for fluid deficit." 3 "Morphine facilitates antidiuretic hormone release." 4 "Osmoreceptors in the hypothalamus stimulate thirst."

2 Hypothalamic-pituitary regulation helps to maintain water balance in the body. A dry mouth is not considered to be a tool to measure fluid deficit in the body. Stress and other social and psychologic factors affect thirst. Medications such as morphine and nicotine stimulate secretion of antidiuretic hormones that prevent urinary elimination of water. Osmoreceptors in the hypothalamus maintain body fluid osmolality, which also stimulates thirst. Text Reference - p. 289

The nurse finds that the patient with renal disease is irritable and has an irregular pulse. ECG changes suggest severe hyperkalemia. What should be the first nursing intervention? 1 Stop all sources of dietary potassium 2 Administer intravenous calcium gluconate 3 Administer ion-exchange resins 4 Administer intravenous insulin with glucose

2 In the case of severe hyperkalemia, manifested by irritation, irregular pulse, and changes in ECG findings, the nurse should act immediately to prevent cardiac arrest. The nurse should administer intravenous calcium gluconate to reverse the membrane potential effects of extracellular fluid (ECF) potassium. Administering ion-exchange resins (to increase elimination of potassium) and intravenous insulin with glucose (to force potassium from ECF to intracellular fluid [ICF]) can be done once the patient is stable. Stopping all sources of dietary potassium is an important measure when hyperkalemia is mild. Text Reference - p. 297

The nurse is caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should be withheld until consulting with the health care provider? 1 Antibiotics 2 Loop diuretics 3 Bronchodilators 4 Antihypertensives

2 Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus, administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing health care provider should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range. Text Reference - p. 296

A patient has been admitted for dehydration. What is a priority nursing intervention? 1 Reorient the patient hourly 2 Perform daily weights 3 Provide continuous oxygen saturation monitoring 4 Restrict sodium intake to 2 grams per day

2 Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate that the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. The nurse would recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water. This patient is not disoriented, and that is not a common assessment finding in the patient with dehydration. Continuous oxygen saturation monitoring is not indicated. Sodium intake does not need to be restricted. Text Reference - p. 292

The nurse is teaching a caregiver for an older adult patient with dementia about fluid balance maintenance at home. Which statement made by the caregiver indicates that he or she requires further education? 1 "I should increase fluids and lower dietary sodium." 2 "I should provide fluids when the patient feels thirsty." 3 "I should assist the patient when holding utensils and cups." 4 "I should request the patient to pass urine before going to bed."

2 Mental status alterations are a common problem in old age and may lead to decreased ability to express thirst and obtain fluids. Therefore, older patients are always encouraged to drink fluids and also to decrease dietary sodium in the diet. Musculoskeletal changes such as stiffness of the hands and fingers may lead to an inability to hold containers. The patient should make a habit of urinating before bed to decrease the chance of nocturia. Text Reference - p. 291

After performing gastric suctioning on a patient who has ingested pesticides, the nurse suspects that the patient has developed metabolic alkalosis. Which finding supports the nurse's suspicion? 1 pH, 7, partial pressure of carbon dioxide (PaCO2), 34 mm Hg 2 pH, 10, partial pressure of carbon dioxide (PaCO2), 52 mm Hg 3 pH, 8.3, partial pressure of carbon dioxide (PaCO2), 44 mm Hg 4 pH, 7.2, partial pressure of carbon dioxide (PaCO2), 38 mm Hg

2 Metabolic alkalosis is manifested by increased plasma pH and partial pressure of carbon dioxide (PaCO2). Normal pH of the blood ranges from 7.35 to 7.45 and the normal range of PaCO2 in blood ranges from 35 to 45 mm Hg. The laboratory findings of pH 10 and PaCO2 of 52 mm Hg support the nurse's suspicion. A pH of 7 and PaCO2 of 34 mm Hg do not indicate metabolic alkalosis. A pH of blood of 8.3 is higher than normal and indicates alkalinity, and a PaCO2 of 44 mm Hg is normal. A pH value of 7.2 and a PaCO2 value of 38 mm Hg are normal. Test-Taking Tip: Gastric suctioning may lead to acid-base imbalance in the body. Using this tip may help you in selecting the right answer. Text Reference - p. 304

After reviewing the patient's arterial blood gas analysis report, the primary health care provider concludes that the patient has respiratory acidosis. Which findings made the primary health care provider reach this conclusion? 1 pH, 7.4, partial pressure of carbon dioxide (PaCO2), 44, bicarbonate ion (HCO3-), 26 2 pH, 7.2, partial pressure of carbon dioxide (PaCO2), 47, bicarbonate ion (HCO3-), 25 3 pH, 7.36, partial pressure of carbon dioxide (PaCO2), 41, bicarbonate ion (HCO3-), 23 4 pH, 7.42, partial pressure of carbon dioxide (PaCO2), 42, bicarbonate ion (HCO3-), 24

2 Patients with respiratory acidosis have increased concentration of carbon dioxide (PaCO2) in the blood and decreased blood pH, whereas the bicarbonate ion concentration (HCO3-) is normal. The normal value ranges of pH, PaCO2, and HCO3- are 7.37 to 7.45, 35 to 45 mm Hg, and 22 to 26 mEq/L, respectively. Thus, a pH value of 7.2, PaCO2 of 47, and HCO3- concentration of 25 indicate respiratory acidosis in the patient Text Reference - p. 304

Which condition may precipitate respiratory acidosis? 1 Severe vomiting 2 Severe pneumonia 3 Pulmonary embolism 4 Diabetic ketoacidosis

2 Pneumonia is an inflammatory condition that causes hypoventilation, which results in increased concentration of carbon dioxide in blood and precipitates respiratory acidosis. Severe vomiting may cause loss of strong acids from the body, resulting in metabolic alkalosis. A pulmonary embolism causes hyperventilation, resulting in respiratory alkalosis. Diabetic ketoacidosis causes accumulation of ketone bodies in the body, resulting in metabolic acidosis. Text Reference - p. 304

While documenting the arterial blood gas values of a group of patients, the nurse suspects a patient to have respiratory alkalosis. Which patient's findings support the nurse's suspicion? 1 Patient A 2 Patient B 3 Patient C 4 Patient D

2 Respiratory alkalosis is characterized by an increased pH and decreased carbon dioxide concentration (PaCO2) in blood. The normal values of blood pH, partial pressure of carbon dioxide (PaCO2), and bicarbonate ion (HCO3-) are between 7.35 and 7.45, 35 and 45 mm Hg, and 22 and 26 mEq/L, respectively. The increased pH and decreased PaCO2 in patient B are indicators of respiratory alkalosis. Test-Taking Tip: Respiratory alkalosis is caused by hyperventilation. Text Reference - p. 304

A nurse reviews a patient's blood gas results: pH 7.15, PaO2 40 mm Hg, PaCO2 70 mm Hg, and HCO3 25 mEq/L. The nurse suspects hypoxia and what other condition? 1 Metabolic acidosis 2 Respiratory acidosis 3 Respiratory alkalosis 4 Compensating respiratory acidosis

2 This patient is not breathing effectively and therefore has a buildup of carbon dioxide in the form of carbonic acid. This places the patient in an acidotic state, because the pH is less than 7.35. Metabolic and respiratory alkalosis are therefore eliminated as possibilities. Because the PaCO2 is high at 70 mm Hg (normal range is 35 to 45 mm Hg) and the metabolic measure of HCO3- is normal at 25 mEq/L (normal range is 22 to 28 mEq/L), the patient is in respiratory acidosis. The patient is not compensated, because the HCO3- is still within normal range. If the HCO3- were increased, this would be an indication of compensation. Text Reference - p. 303

The surgical-unit nurse notes that a patient has an intravenous (IV) prescription for 0.9% normal saline (NS) with 20 mEq KCl/L at 100 mL/hr. The nurse regulates the IV flow rate at how many drops (gtt) per minute, noting that the tubing has a drop factor of 10 drops/mL? 1 15 gtt/minute 2 17 gtt/minute 3 19 gtt/minute 4 21 gtt/minute

2 Use the following formula to calculate the rate of IV solutions: Volume × drop factor, divided by time (in minutes). Multiply 100 by 10 to yield 1000 and divide this by 60 to yield 16.6 or 17 gtt/minute (because the nurse cannot count a fraction of a drop). Text Reference - p. 298

While performing patient teaching regarding hypercalcemia, which statements are appropriate? Select all that apply. 1 Have the patient restrict fluid intake to less than 2000 mL/day. 2 Renal calculi may occur as a complication of hypercalcemia. 3 Weight-bearing exercises can help keep calcium in the bones. 4 The patient should increase daily fluid intake to 3000 to 4000 mL. 5 Treatment of heartburn can be managed best with Tums as needed.

2, 3, 4 A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Weight-bearing exercise does enhance bone mineralization. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Text Reference - p. 299

When administering intravenous (IV) potassium chloride (KCl) to a patient to correct hypokalemia, which interventions are important? Select all that apply. 1 IV KCl can be added to a hanging IV bag. 2 KCl should never be given via IV push or bolus. 3 KCl must always be diluted before administering. 4 IV site should be regularly assessed for infiltration. 5 IV KCl should be administered at a rate of 50 mEq/h.

2, 3, 4 IV KCl is given to correct hypokalemia. IV KCl should never be given via IV push or as a bolus. IV KCl must never be given in a concentrated form; it should always be diluted before administration. The nurse should check the IV site regularly, because KCl can irritate the veins, causing phlebitis and infiltration. The solution should not be added to a hanging IV bag; following this rule lowers the risk of a bolus dose being given. The rate of IV administration of KCl should not exceed 10 to 20 mEq/h. The solution should be administered by infusion pump so that correct doses are administered at the correct rate. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know. Text Reference - p. 298

A patient has been prescribed IV potassium chloride (KCl) for the treatment of hypokalemia. What precautions should the nurse take to prevent severe complications related to KCl administration? Select all that apply. 1 Administer KCl as an IV push or as a bolus 2 Turn IV bags containing KCl upside down and upright several times prior to administration 3 Never add KCl to an existing IV bag 4 Dilute KCl before administering 5 Ascertain an adequate urine output prior to administration

2, 3, 4, 5 Severe hypokalemia can be treated by administering KCl. IV bags containing KCl should be inverted several times to ensure dilution of the drug and prevent accidental bolus delivery. Adding KCl to a hanging IV bag may cause accidental bolus delivery and lead to cardiac complications. It can cause severe cardiac complications and so should not be given undiluted. KCl is given to patients who have a urine output of at least 0.5 mL/kg of body weight per hour. This ensures timely clearance of unused potassium. KCl should never be administered as IV bolus or push because it can affect the cardiac function. Text Reference - p. 298

What does the nurse infer from a patient who reports abdominal cramping and diarrhea and has a serum potassium level of 6.8 mEq/L? Select all that apply. 1 The patient is on insulin therapy. 2 The patient is on a potassium-sparing diuretic. 3 The patient is on β-adrenergic agonist therapy. 4 The patient is on an aldosterone receptor blocker. 5 The patient is on an angiotensin-converting enzyme inhibitor.

2, 3, 5 Potassium levels greater than 5.0 mEq/L indicate hyperkalemia. This can manifest as abdominal cramping and diarrhea. Potassium-sparing diuretics, β-adrenergic agonist therapy, and angiotensin-converting enzyme inhibitors increase the potassium levels in the body. This results in hyperkalemia. Insulin and aldosterone receptor blockers decrease potassium levels. Text Reference - p. 296

It is especially important for the nurse to assess for which clinical manifestation(s) in a patient with primary hypoparathyroidism? Select all that apply. 1 Anorexia 2 Easy fatigability 3 Depressed reflexes 4 Circumoral numbness 5 Positive Trousseau's sign

2, 4, 5 Primary hypoparathyroidism can result in a lack of parathyroid hormone, leading to hypocalcemia. Manifestations of low serum calcium levels include easy fatigability, depression, anxiety, confusion, numbness and tingling in extremities and the region around the mouth, hyperreflexia, muscle cramps, positive Chvostek's and Trousseau's signs, and others. Anorexia and depressed reflexes are manifestations of hypercalcemia. Text Reference - p. 300

A nurse is assessing a patient's weight in order to evaluate fluid volume status. The patient's weight on the day of admission was 60 kg. On day 2, the weight is 62 kg. What is the quantity of fluid retention in the patient? Record your answer using a whole number and no punctuation. _______ mL

2000 An increase in 1 kg is equal to 1000 mL of fluid retention. The patient has gained 2 kg, which is equal to 2000 mL of fluid retention. Text Reference - p. 292

A person weighing 100 kg has 40 L of intracellular fluid. What amount of intracellular fluid does a 60 kg individual have? Record your answer using one decimal place. ____________ L

24.0 Intracellular fluid constitutes approximately 40 percent of the body weight of an adult. The person weighing 60 kg would have approximately 24 liters of intracellular fluid, because 60 kg x 40/100 x 40/100 = 24.0 L. Text Reference - p. 286

After reviewing the laboratory reports of four patients, the primary health care provider orders the nurse to prepare one of the patients for mechanical ventilation. Which patient's reports indicate the need for this intervention? 1 Patient A 2 Patient B 3 Patient C 4 Patient D

3 A need for mechanical ventilation arises when the patient is not able to breathe properly. This is manifested by decreased oxygen and increased carbon dioxide in blood. The normal partial pressure of carbon dioxide (PaCO2) value lies between 35 and 45 mm Hg, and the normal range of blood pH is 7.35 to 7.45. Patient C has an increased concentration of carbon dioxide in the blood and a low pH, which indicate that the patient has difficulty breathing and requires mechanical ventilation. Text Reference - p. 304

A patient asks why the primary health care provider prescribed a b-type natriuretic peptide (BNP). Which response by the nurse is accurate? 1 It is a diagnostic procedure to rule out urine retention. 2 It is a blood test that is elevated in patients with hyponatremia. 3 It is a blood test that shows if there is excess fluid in the heart. 4 It is an x-ray that helps determine the presence of stomach ulcers

3 BNP is a hormone that is produced when the atrial pressure increases. This blood test is used to diagnose the severity and treatment outcomes of congestive heart failure (CHF). The atrial pressure increases because of increased venous return and hypernatremia. The test gives no information to rule out urine retention or the presence of stomach ulcers. A serum sodium level is needed to determine hyponatremia. Text Reference - p. 290

Shortly after having a central IV catheter inserted into the subclavian vein, the patient experiences shortness of breath, anxiety, and restlessness. What is the highest priority for the nurse? 1 Administering a sedative 2 Advising the patient to relax 3 Auscultating the breath sounds 4 Obtaining an arterial blood gas analysis

3 Because this is an acute episode, the nurse should first listen to the patient's lungs to see whether anything has changed. In this situation the probability is high that the patient sustained a pneumothorax during the subclavian IV catheter insertion procedure. The patient will need oxygen, and the care provider should be notified of the findings. Administering a sedative is not appropriate. Advising the patient to relax does provide reassurance, but the anxiety and restlessness are probably due to hypoxia. Obtaining an arterial blood gas analysis would likely be the next nursing action. Text Reference - p. 311

What is the function of a buffer? 1 To excrete weak acids 2 To secrete hydrogen ions 3 To convert strong acids to weak acids 4 To convert ammonia to ammonium ions

3 Buffers convert strong acids to weak acids. Excretion of weak acids, secretion of hydrogen ions into the renal tubule, and conversion of ammonia to ammonium ions takes place in the kidneys. Text Reference - p. 303

The nurse is caring for a patient with fluid imbalance related to a deficit. Which action by the nurse provides comfort to the patient? 1 Providing tube feeding to the patient 2 Supplementing water to the patient with nasogastric suction 3 Helping the patient to apply moisturizer and use moisturizing soaps 4 Weighing the patient regularly while the drainage bags are attached

3 Fluid imbalance leads to abnormal homeostasis. It also leads to breakdown of skin, so a patient with fluid imbalance should practice proper skin care by applying lotion and moisturizing soaps. Tube feeding may be recommended for the patient with severe fluid imbalance. The patient on nasogastric suction should either consume ice cubes, or the nasogastric tube should be irrigated with isotonic saline solution. Consumption of water may increase the loss of electrolytes. The nurse has to remove or detach the drainage bags before weighing a patient. Text Reference - p. 293

The student nurse is educating a patient regarding skin care management. What statement made by the student requires correction? 1 "Avoid extreme temperatures." 2 "Apply moisturizers even at night." 3 "Wash hands and legs frequently with soap." 4 "Change your position regularly while at rest."

3 Good skin care management is essential to prevent fluid loss. The patient should limit the use of soap to prevent the skin from drying. The nurse should advise the patient to either take precautions or to avoid extreme temperatures to avoid dehydration of the skin. Regular skin care by applying moisturizers and changing positions while at rest help to maintain skin hydration and may prevent skin breakdown. Text Reference - p. 293

A patient is diagnosed with Guillain-Barren syndrome. Which complication does the nurse anticipate? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3 Guillain-Barren syndrome is a disease of the respiratory system that causes hypoventilation. Hypoventilation increases the concentration of carbonic acid, which results in respiratory acidosis. Metabolic acidosis, metabolic alkalosis, and respiratory alkalosis are not caused by Guillain-Barren syndrome. Text Reference - p. 304

The nurse is caring for a patient diagnosed with heat stroke and with a urine output of 4000 mL per day. What is the most appropriate nursing action? 1 Transfusing blood 2 Applying moisturizer regularly 3 Administrating lactated Ringer's solution 4 Administrating supplementary water in enteric formula

3 Heat stroke and an increased amount of urine output of about 4000 mL leads to a deficit in extracellular fluid volume, causing dehydration. Administering lactated Ringer's solution to maintain fluid and electrolyte balance is beneficial. Blood transfusions are performed only when the fluid loss is due to blood loss. Moisturizers are applied to patients with dry skin to prevent the fluid loss. Tube feeding is preferred in the patient with severe extracellular fluid loss. The patient on tube feeding must be thereby supplemented with water added to the enteric formula. Text Reference - p. 291

Which protein regulates the pH of blood? 1 Albumin 2 Globulin 3 Hemoglobin 4 Alpha acid glycoprotein

3 Hemoglobin shifts chloride ions in and out of red blood cells in exchange for bicarbonate ions, which helps to regulate blood pH. Albumin, globulin, and alpha acid lipoprotein are plasma proteins that help transport of lipids, minerals, and vitamins. Text Reference - p. 303

Which is the clinical manifestation of metabolic acidosis? 1 Seizures 2 Hypoventilation 3 Rapid respirations 4 Ventricular fibrillation

3 Metabolic acidosis is manifested by deep and rapid respirations called Kussmaul's respirations. Seizures, hypoventilation with hypoxia, and ventricular fibrillation are signs of respiratory acidosis. Text Reference - p. 305

A patient has the following arterial blood gas results: pH 7.32; PaCO2 56 mm Hg; HCO3- 24 mEq/L. The nurse determines that these results indicate: 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3 Respiratory acidosis (carbonic acid excess) occurs whenever a person experiences hypoventilation. Hypoventilation leads to a buildup of CO2, resulting in an accumulation of carbonic acid in the blood. Carbonic acid dissociates, liberating H+, and there is a decrease in pH. The patient is not experiencing metabolic acidosis. These results are not indicative of metabolic alkalosis or respiratory alkalosis (because the pH is high). Text Reference - p. 303

Which electrolyte imbalance is associated with sickle cell anemia? 1 Increased calcium levels 2 Increased potassium levels 3 Increased phosphate levels 4 Increased magnesium levels

3 Sickle cell anemia leads to increased concentration of phosphates in the body, thus causing hyperphosphatemia. Hypercalcemia, or increased calcium levels, is associated with hyperparathyroidism. Hyperkalemia, or increased potassium levels, is associated with tumor-lysis syndrome. Hypermagnesemia, or increased magnesium levels, is associated with diabetic ketoacidosis. Text Reference - p. 301

A patient is admitted with alcohol abuse. Laboratory data reveals a phosphate level of 1.8 mg/dL. Which assessment finding is consistent with this data? 1 Seizure activity 2 Diarrhea 3 Weakness 4 Tetany

3 Signs of hypophosphatemia include weakness, confusion, coma, and diminished reflexes. Seizure activity, diarrhea, and tetany are not associated with this electrolyte imbalance. Text Reference - p. 301

A 71-year-old patient is admitted with nausea and vomiting. Which manifestations would the nurse assess to check for the presence of dehydration? Select all that apply. 1 Hypertension 2 Bradypnea 3 Urine output 10 mL/hr 4 Tachycardia 5 Sunken eyes

3, 4, 5 Decreased urine output below 30 mL/hour, tachycardia, and sunken eyes are all signs of dehydration. Dehydration will cause hypotension and would increase, not decrease, respiratory rate. Text Reference - p. 292

A nurse is assessing a patient with hyperkalemia. Which changes in the electrocardiogram might the nurse find? Select all that apply. 1 Flattened T wave 2 Prolonged QRS 3 Loss of P wave 4 Tall, peaked T wave 5 ST segment depression

3, 4, 5 Hyperkalemia causes a decrease in cardiac depolarization, leading to a flattening of the P wave. High potassium levels lead to rapid repolarization, evident as tall T waves and ST segment depression. T waves are flattened and QRS is prolonged in hypokalemia. Text Reference - p. 297

A patient weighing 60 kg with diabetes mellitus is excreting 3500 mL of urine per day. What is the amount of weight lost by the patient in 24 hours? Record your answer using one decimal place. ____________ kg 00:00:27 Question Answer Confidence Buttons

3.5 A sudden change in body weight is an indicator of fluid imbalance. One liter of water weighs one kg. Therefore, a patient of 60 kg with diabetes mellitus who is excreting 3500 mL of urine per day would lose 3.5 kg. This sudden change of weight is due to polyuria, which further leads to fluid imbalance. Text Reference - p. 286

The nurse is caring for an older patient who is receiving intravenous (IV) fluids postoperatively. During the 8 AM assessment of this patient, the nurse notes that the IV solution, which was prescribed to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4 AM. What is the priority nursing intervention? 1 Notify the health care provider and complete an incident report. 2 Slow the rate to keep the vein open until the next bag is due at noon. 3 Obtain a new bag of IV solution to maintain patency of the site. 4 Listen to the patient's lung sounds and assess respiratory status.

4 After four hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and the nurse should assess the patient's respiratory status and lung sounds as the priority action and then notify the health care provider for further prescriptions. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care. Text Reference - p. 292

Which statement is true regarding magnesium? 1 A decrease in magnesium levels decreases blood pressure. 2 Magnesium is the most abundant intracellular cation present in the body. 3 The majority of the magnesium in the human body is present in extracellular fluid. 4 Alterations in serum magnesium levels profoundly affect neuromuscular excitability and contractility.

4 Alterations in serum magnesium levels profoundly affect neuromuscular excitability and contractility because magnesium directly acts on the myoneural junction. A decrease in blood magnesium levels increases the blood pressure. Magnesium is the second most abundant intracellular cation. The majority of the body's magnesium is present in the bones. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Text Reference - p. 301

Which treatment strategy would be beneficial in a patient with a blood sodium level of 170 mEq/L who experiences intense thirst, agitation, and decreased alertness? 1 Intravenous furosemide 2 Intravenous cation-exchange resin 3 Intravenous phosphate-binding agent 4 Intravenous 0.45% sodium chloride saline solution

4 Hypernatremia is a condition in which water shifts out of the cells into the extracellular fluid, resulting in dehydration. Therefore, the patient with hypernatremia would experience intense thirst, agitation, and decreased alertness. To reduce dehydration, fluid should be replaced by administering hypotonic intravenous fluids such as 5% dextrose in water or 0.45% sodium chloride saline solution. Administering intravenous furosemide may help treat hypercalcemia. A cation-exchange resin may be administered to treat hyperkalemia. A phosphate-binding agent may be administered to treat hyperphosphatemia. Text Reference - p. 295

The nurse is preparing to administer intravenous (IV) potassium chloride (KCl) to a patient. Which action should the nurse perform to ensure the patient's safety? 1 Give KCl via IV push. 2 Add KCl to the hanging IV bag. 3 Give IV KCl in concentrated amounts. 4 Invert IV bags containing KCl several times

4 Hypokalemia is characterized by a decreased concentration of potassium in the body. Therefore, KCl should be administered to maintain normal potassium levels. Inverting the IV bags containing KCl several times ensures even distribution of KCl medication in the bag. The nurse should administer KCl through an infusion pump, not by IV push, to ensure that it is administered at an accurate rate. The nurse should not add KCl to the hanging IV bag because this would result in administering a bolus dose. The nurse will give IV KCl in diluted forms, rather than in concentrated amounts, to ensure the patient's safety. Text Reference - p. 298

When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? 1 Fluid movement from the blood vessels into the cells 2 Fluid movement from the interstitial spaces into the cells 3 Fluid movement from the blood vessels into interstitial spaces 4 Fluid movement from the interstitial space into the blood vessels

4 In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect, and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing on the NCLEX examination, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point. Text Reference - p. 292

An 82-year-old patient is admitted with pneumonia. The nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because 1 Older adults are at an increased risk of impaired renal function. 2 Older adults have an impaired level of consciousness and need to be reminded to drink fluids. 3 Older adults are more likely than younger adults to lose extracellular fluid during severe illnesses. 4 Small losses of fluid are more significant because body water accounts for only about 50% of body weight in older adults.

4 Older adults, with less muscle mass and more fat content, have less body water than younger adults. In the older adult, body water content averages 45% to 55% of body weight, leaving them at a higher risk for fluid-related problems than young adults. Text Reference - p. 291

The nurse preparing to administer a dose of potassium phosphate would hold the medication after noting which laboratory value? 1 Sodium 133 mEq/L 2 Magnesium 1.8 mEq/L 3 Potassium 5.2 mEq/L 4 Calcium 6.4 mg/dL

4 Phosphorus and calcium have inverse or reciprocal relationships, meaning that when calcium levels are high, phosphorus levels tend to be low. Therefore, administration of phosphorus will reduce a patient's already abnormally low calcium level, which can result in life-threatening complications. Potassium phosphate will not have any effect on sodium, magnesium, or potassium levels. Text Reference - p. 301

Which is a manifestation of respiratory acidosis? 1 Diarrhea 2 Nausea 3 Abdominal pain 4 Ventricular fibrillation

4 Respiratory acidosis causes compensatory hyperkalemia, which leads to ventricular fibrillation. Diarrhea, nausea, and abdominal pain are manifestations of metabolic acidosis. Test-Taking Tip: Have confidence in your initial response to an item because it more than likely is the correct answer. Text Reference - p. 305

Which condition is manifested by hyperreflexia? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

4 Respiratory alkalosis is manifested by hyperreflexia. Metabolic acidosis is manifested by abdominal pain and Kussmaul respirations. Tachycardia, anorexia, and muscle cramps are the manifestations of metabolic alkalosis. Headache, seizures, and hypotension are the manifestations of respiratory acidosis. Test-Taking Tip: If you can eliminate any responses as incorrect based on your knowledge, you will not be guessing randomly but will be exercising "informed guessing." Text Reference - p. 305

What concentration of bicarbonate ion in blood is an indicator of a compensatory response in patients with respiratory acidosis? 1 24 mEq/L 2 25 mEq/L 3 26 mEq/L 4 27 mEq/L

4 The bicarbonate ion concentration in blood increases as a compensatory response in patients with respiratory acidosis. The normal range of bicarbonate ion is 22 to 26 mEq/L. Therefore, 27 mEq/L indicates a compensatory response. Test-Taking Tip: You have at least a 25 percent chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses. Text Reference - p. 304

The nurse is caring for a 92-year-old patient who has dehydration. The nurse would instruct the unlicensed assistive personnel (UAP) to report which finding? 1 Ambulation in the hallway without assistance 2 Temperature 97.1o F 3 Frequent use of the urinal 4 Urine output of 350 mL in 24 hours

4 The minimal urine output necessary to maintain kidney function is 30 mLs per hour, or 720 mL per 24 hours. The nurse should be notified of a decrease in urine output so that additional fluid volume-replacement therapy can be instituted. Ambulation is encouraged. The temperature is normal. Frequent use of the urinal would not indicate dehydration. Text Reference - p. 292

What is the normal range of blood pH? 1 7.05 to 7.15 2 7.15 to 7.25 3 7.25 to 7.35 4 7.35 to 7.45

4 The normal range of blood pH is 7.35 to 7.45. A pH less than 7.35 indicates acidosis. Text Reference - p. 302

The nurse is caring for a patient admitted with dehydration because of nausea and vomiting. The nurse anticipates which acid-base imbalance based on this information? 1 Respiratory acidosis 2 Respiratory alkalosis 3 Metabolic acidosis 4 Metabolic alkalosis

4 The nurse is caring for a patient admitted with dehydration because of nausea and vomiting. The nurse anticipates which acid-base imbalance based on this information? 1 Respiratory acidosis 2 Respiratory alkalosis 3 Metabolic acidosis 4 Metabolic alkalosis

The nurse needs to add potassium chloride (KCl) 40 mEq to an intravenous (IV) solution of 0.9% sodium chloride. The multidose vial contains 10 mEq KCl in 5 mL of solution. How many milliliters of KCl should the nurse add to the IV bag? 1. 2 mL 2. 5 mL 3. 10 mL 4. 20 mL

4 Using ratio and proportion, multiply 10 by x and multiply 40 × 5 to yield 10x = 200. Divide 200 by 10 to yield 20 mL. Text Reference - p. 298

The nurse is recording a patient weight of 68 kg in the ward. How much interstitial fluid is estimated to be present there? Record your answer using one decimal place. ____________ L

8.6 About 70 percent of the extracellular fluid is found in the interstitial space and the extracellular fluid comprises about 33 percent of the total body water amount. The total body water amount represents about 55 percent of the body weight. The patient weighs 68 kg and has approximately 37.4 L of total body water and extracellular fluid is 33 percent of that amount, which equals12.3 L. Seventy percent of the extracellular fluid is 12.3 x 70/100 = 8.6 L.(((68 kg x 55/100) x 33/100) x 70/100) = 8.6 L Text Reference - p. 286