143 Module 1 - Fluid and Electrolytes (PRACTICE QUESTIONS)

Which is considered an isotonic solution? A. 0.9% normal saline B. 0.45% normal saline C. Dextran in normal saline D. 3% NaCl

A. An isotonic solution is 0.9% normal saline (NaCl). Dextran in normal saline is a colloid solution, 0.45% normal saline is a hypotonic solution, and 3% NaCl is a hypertonic solution.

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? A. Extracellular fluid volume deficit B. Metabolic alkalosis C. Altered blood urea nitrogen (BUN) value D. Respiratory acidosis

A. Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. A cause of this loss is hemorrhage.

Clients diagnosed with hypervolemia should avoid sweet or dry food because it A. increases the client's desire to consume fluid. B. obstructs water elimination. C. can cause dehydration. D. can lead to weight gain.

A. The management goal in hypervolemia is to reduce fluid volume. For this reason, fluid is rationed and the client is advised to take a limited amount of fluid when thirsty. Sweet or dry food can increase the client's desire to consume fluid. Sweet or dry food does not obstruct water elimination or cause dehydration. Weight regulation is not part of hypervolemia management except to the extent it is achieved on account of fluid reduction.

The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults? A. Hypervolemia B. Hypovolemia C. Dehydration D. Fluid volume excess

C. The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances.

Which electrolyte is a major cation in body fluid? A. Bicarbonate B. Potassium C. Phosphate D. Chloride

B. Potassium is a major cation that affects cardiac muscle functioning. Chloride, bicarbonate, and phosphate are anions.

A patient's electrocardiogram reveals a prolonged P-R interval and ST segment depression. The nurse should review laboratory results for which electrolyte imbalance? 1. Hypokalemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypernatremia

Answer: 2 Explanation: 1. Prolongation of the PR interval is not an ECG finding associated with hypokalemia. 2. Cardiovascular manifestations of hyperkalemia include prolonged P-R interval; flat or absent P wave; slurring of QRS; tall peaked T wave; and ST segment depression. 3. Hypocalcemia causes prolongation of the QT interval and a long ST segment. 4. Cardiovascular manifestations of hypernatremia include hypertension and tachycardia.

The nurse is concerned that a patient's arterial blood carbon dioxide level is increasing because this can contribute to the development of which electrolyte imbalance? 1. Hyperkalemia 2. Hypokalemia 3. Hypercalcemia 4. Hypocalcemia

Answer: 1 Explanation: 1. A rise in arterial blood carbon dioxide is a diagnostic indicator of acidosis. Acidosis contributes to hyperkalemia because excess hydrogen ions shift into the cells, forcing potassium out into the serum. The nurse should be concerned about the patient developing hyperkalemia. 2. Acidosis does not contribute to the development of hypokalemia. 3. Acidosis does not contribute to the development of hypercalcemia. 4. Acidosis does not contribute to the development of hypocalcemia.

A client with hypervolemia asks the nurse by what mechanism the sodium-potassium pump will move the excess body fluid. What is the nurse's best answer? A. Free flow B. Active transport C. Passive osmosis D. Passive elimination

B. Active transport is the physiologic pump maintained by the cell membrane that results in the movement of fluid from an area of lower concentration to one of higher concentration. Active transport requires adenosine triphosphate (ATP) for energy. The sodium-potassium pump actively moves sodium against the concentration gradient out of the cell, and fluid follows. Passive osmosis does not require energy for transport. Free flow is the natural transport of water. Passive elimination is a filter process carried out in the kidneys.

A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider? A. Works as a customer service representative B. Ingests alcohol occasionally C. Takes high doses of vitamin D D. Follows a high-fiber eating plan

C. Hypercalcemia can affect many organ systems and symptoms occur when the calcium level acutely rises. Hypercalcemia crisis refers to an acute rise in the serum calcium level. Severe thirst and polyuria are often present. Additional findings include muscle weakness, nausea, and bone pain. Excessive ingestion of vitamin D supplements may cause excessive absorption of calcium. Therefore, the nurse would report this finding to the health care provider. The client's symptoms are not associated with occasional alcohol intake, a high-fiber eating plan, or the client's employment status. These findings would not need to be reported.

An elderly client takes 40 mg of furosemide twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use? A. Hyperkalemia B. Hypophosphatemia C. Hypokalemia D. Hypernatremia

C. Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium-losing diuretics, such as furosemide, can induce hypokalemia. Hyperkalemia refers to increased potassium levels. Loop diuretics can bring about lower sodium levels, not hypernatremia. Furosemide does not affect phosphorus levels.

The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? A. Rapid respiration B. Low heart rate C. Elevated blood pressure D. Subnormal temperature

C. Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.

Which solution is hypotonic? A. Lactated Ringer solution B. 5% NaCl C. 0.9% NaCl D. 0.45% NaCl

D. Half-strength saline is hypotonic. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A 5% NaCl solution is hypertonic.

A client with excess fluid volume and hyponatremia is in a *comatose* state. What are the nursing considerations concerning fluid replacement? A. Restrict fluids and salt for 24 hours. B. Monitor the serum sodium for changes hourly. C. Correct the sodium deficit rapidly with salt. D. Administer small volumes of a hypertonic solution.

D. In clients with normal or excess fluid volume, hyponatremia is usually treated effectively by restricting fluid with clients who are not neurologically impaired. When the serum sodium concentration is overcorrected (exceeding 140 mEq/L) too rapidly or in the presence of hypoxia or anoxia, the client can develop neurological symptoms. However, if neurologic symptoms are severe (e.g., seizures, delirium, coma), or if the client has traumatic brain injury, it may be necessary to administer small volumes of a hypertonic sodium solution with the goal of alleviating cerebral edema. Incorrect use of these fluids is extremely dangerous, because 1 L of 3% sodium chloride solution contains 513 mEq (mmol/L) of sodium and 1 L of 5% sodium chloride solution contains 855 mEq (mmol/L) of sodium. The recommendation for hypertonic saline administration in clients with craniocerebral trauma is between 0.10 to 1.0 mL of 3% saline per kilogram of body weight per hour.

A client being treated for a chronic illness has a serum potassium level of 2.9 mEq/L (2.9 mmol/L). Which assessment finding(s) will the nurse expect to assess in the client? Select all that apply. A. muscle weakness B. hyperactive reflexes C. leg cramps D. anorexia E. paresthesias

A, C, D, E. A normal serum potassium level ranges from 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Clinical signs and symptoms of a low potassium level include anorexia, leg cramps, paresthesias, muscle weakness, and hypoactive reflexes. Hyperactive reflexes are associated with a low calcium or magnesium level.

The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A. A 52-year-old with diarrhea B. A 72-year-old with a total knee repair C. A 65-year-old with a myocardial infarction D. A 7-year-old with a fracture tibia

A. Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? A. Lactated Ringer's solution B. Half-normal saline solution C. 5% dextrose and normal saline solution D. 10% dextrose in water

A. Lactated Ringer's solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn't give half-normal saline solution because it's hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the *need for further teaching*? A. I can use laxatives and enemas but only once a week. B. I will take a potassium supplement daily as prescribed. C. I will be sure to buy frozen vegetables when I grocery shop. D. A good breakfast for me will include milk and a couple of bananas.

A. The client is experiencing hypokalemia, most likely due to the diagnosis of bulimia. Hypokalemia is defined as a serum potassium concentration <3.5 mEq/L (3.5 mmol/L), and usually indicates a deficit in total potassium stores. Clients diagnosed with bulimia frequently suffer increased potassium loss through self-induced vomiting and misuse of laxatives, diuretics, and enemas; thus, the client should avoid laxatives and enemas. Prevention measures may involve encouraging the client at risk to eat foods rich in potassium (when the diet allows), including fruit juices and bananas, melon, citrus fruits, fresh and frozen vegetables, lean meats, milk, and whole grains. If the hypokalemia is caused by abuse of laxatives or diuretics, client education may help alleviate the problem.

A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. Which factors contribute to this phenomenon? Select all that apply. A. Decreased kidney mass B. Increased conservation of sodium C. Increased total body water D. Decreased renal blood flow E. Decreased excretion of potassium

ANS: A, D, E. Dehydration in older adults is common as a result of decreased kidney mass, decreased glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability to conserve sodium, decreased excretion of potassium, and a decrease of total body water.

The nurse is providing care for a client with chronic obstructive pulmonary disease. When describing the process of respiration, the nurse explains to a newly licensed nurse how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing which process? A. Diffusion B. Osmosis C. Active transport D. Filtration

ANS: A. Diffusion is the natural tendency of a substance to move from an area of higher concentration to one of lower concentration. It occurs through the random movement of ions and molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the pulmonary capillaries and alveoli and the tendency of sodium to move from the extracellular fluid compartment, where the sodium concentration is high, to the intracellular fluid, where its concentration is low. Osmosis occurs when two different solutions are separated by a membrane that is impermeable to the dissolved substances; fluid shifts through the membrane from the region of low solute concentration to the region of high solute concentration until the solutions are of equal concentration. Active transport implies that energy must be expended for the movement to occur against a concentration gradient. Movement of water and solutes occurring from an area of high hydrostatic pressure to an area of low hydrostatic pressure is filtration.

A client has questioned the nurse's administration of intravenous (IV) normal saline, asking, Wouldn't sterile water be a more appropriate choice than saltwater? Under what circumstances would the nurse administer electrolyte-free water intravenously? A. Never, because it rapidly enters red blood cells, causing them to rupture. B. When the client is severely dehydrated, resulting in neurologic signs and symptoms C. When the client is in excess of calcium and/or magnesium ions D. When a client's fluid volume deficit is due to acute or chronic kidney disease

ANS: A. IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure, electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes them to rupture.

The nurse is evaluating a newly admitted client's laboratory results, which include several values that are outside of reference ranges. Which of the following alterations would cause the release of antidiuretic hormone (ADH)? A. Increased serum sodium B. Decreased serum potassium C. Decreased hemoglobin D. Increased platelets

ANS: A. Increased serum sodium causes increased osmotic pressure, increased thirst, and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect ADH release.

The nurse is caring for a client who has been involved in a motor vehicle accident. The client's labs indicate a minimally elevated serum creatinine level. The nurse should further assess which body system for signs of injury? A. Renal B. Cardiac C. Pulmonary D. Nervous

ANS: A. Serum creatinine is a sensitive measure of renal function. It is not an indicator of cardiac, pulmonary, or nervous system impairments.

The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The nurse should prioritize assessment for what health problem? A. Diminished deep tendon reflexes B. Tachycardia C. Cool, clammy skin D. Acute flank pain

ANS: A. To gauge a client's magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.

A client with hypokalemia is to receive intravenous (IV) potassium replacement. Which action should the nurse take when administering potassium intravenously? Select all that apply. A. Administer potassium by IV push. B. Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration. C. Monitor complete blood count during potassium infusion. D. Follow the facility policy for infusion of potassium. E. Report a reduced urinary output to the health care provider.

ANS: B, D, E. Potassium should be administered by an infusion pump and should never be given by IV push to avoid rapid replacement. Because potassium is excreted by the kidneys, BUN, serum creatinine, and urinary output should be assessed prior to and during administration of IV potassium. Abnormal laboratory results or decreased or absent urinary output should be reported to the health care provider. Because potassium administration does not affect blood cells, the complete blood count does not need to be monitored during administration of potassium. The nurse should check facility policy on the administration of IV potassium to ensure safe care.

The community health nurse is performing a home visit to an 80-year-old client recovering from hip surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry mucous membranes. When asked about fluid intake, the client states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurse's best response? A. I will need to have your medications adjusted, so you will need to be readmitted to the hospital for a complete workup. B. Limiting your fluids can create imbalances that can result in confusion, so let's try adjusting the timing of your fluids. C. It is normal to be a little confused following surgery, and it is safe not to urinate at night. D. Confusion and bladder issues are a normal consequence of aging, so I am not too concerned.

ANS: B. In older adult clients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the older adult. There is no specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in older adults.

The nurse caring for a client post colon resection is assessing the client on the second postoperative day. The nasogastric tube remains patent and is draining moderate amounts of greenish fluid. Which assessment finding would suggest that the client's potassium level is too low? A. Diarrhea B. Paresthesias C. Increased muscle tone D. Joint pain

ANS: B. Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and arrhythmias. The client would not have diarrhea because increased bowel motility is inconsistent with hypokalemia. Joint pain is not a symptom of hypokalemia, nor is increased muscle tone.

A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client with increased intracranial pressure. This solution will increase the number of dissolved particles in the client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described with which of the following terms? A. Hydrostatic pressure B. Osmosis and osmolality C. Diffusion D. Active transport

ANS: B. Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.

The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The client reports tingling in the lips and fingers. The client also reports an intermittent spasm in the wrist and hand and exhibits increased muscle tone. Which electrolyte imbalance should the nurse first suspect? A. Hypophosphatemia B. Hypocalcemia C. Hypermagnesemia D. Hyperkalemia

ANS: B. Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety.

The nurse is caring for a client with a diagnosis of pancreatitis. The client was admitted from a homeless shelter and is a vague historian. The client appears malnourished and on day 3 of the client's admission, total parenteral nutrition (TPN) has been started. Why should the nurse start the infusion of TPN slowly? A. Clients receiving TPN are at risk for hypercalcemia if calories are started too rapidly. B. Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. C. Malnourished clients who receive fluids too rapidly are at risk for hypernatremia. D. Clients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate.

ANS: B. The nurse identifies clients who are at risk for hypophosphatemia and monitors them. Because malnourished clients receiving parenteral nutrition are at risk when calories are introduced too aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of phosphorus into the cells. Clients receiving TPN are not at risk for hypercalcemia or hypernatremia if calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration.

One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric. The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will help to achieve what goal? A. Distinguish hyponatremia from hypernatremia. B. Evaluate pituitary gland function. C. Distinguish reduced renal blood flow from decreased renal function. D. Provide an effective treatment for hypertension-induced oliguria.

ANS: C. If a client is not secreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a client with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.

The nurse is performing an admission assessment on a 79-year-old client newly admitted for end-stage liver disease. What principle should guide the nurse's assessment of the client's skin turgor? A. Overhydration is common among healthy older adults. B. Dehydration causes the skin to appear spongy. C. Inelastic skin turgor is a normal part of aging. D. Skin turgor cannot be assessed in clients over the age of 70.

ANS: C. Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older clients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.

The nurse is assessing the client for the presence of a Chvostek sign. Which electrolyte imbalance would a positive Chvostek sign indicate? A. Hypermagnesemia B. Hyponatremia C. Hypocalcemia D. Hyperkalemia

ANS: C. The nurse can induce Chvostek sign by tapping the client's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek sign. Both hypomagnesemia and hypocalcemia may be indicated by a positive Chvostek sign.

The nurse is called to a client's room by a family member who voices concern about the client's status. On assessment, the nurse finds the client tachypneic, lethargic, weak, and exhibiting a diminished cognitive ability. The nurse also identifies 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this client's signs and symptoms? A. Hypocalcemia B. Hyponatremia C. Hyperchloremia D. Hypophosphatemia

ANS: C. The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, arrhythmias, and coma. A high chloride level is accompanied by a high sodium level and fluid retention. With hypocalcemia, tetany would be expected to occur. There would not be edema with hyponatremia. Signs or symptoms of hypophosphatemia are mainly neurologic.

A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? A. Maintain a low-sodium diet. B. Encourage the use of over-the-counter calcium supplements. C. Ensure the client has sufficient potassium intake. D. Encourage fluid intake.

ANS: C. Thiazide diuretics, such as hydrochlorothiazide, cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake, and increased fluid intake does not reduce the client's risk for electrolyte disturbances.

When planning the care of a client with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur? A. Active transport of hydrogen ions across the capillary walls B. Pressure of the blood in the renal capillaries C. Action of the dissolved particles contained in a unit of blood D. Hydrostatic pressure resulting from the pumping action of the heart

ANS: D. Hydrostatic pressure is the pressure created by the weight of fluid against the wall that contains it. In the body, hydrostatic pressure in blood vessels results from the weight of fluid itself and the force resulting from cardiac contraction. This pressure causes water and electrolytes from the arterial capillary bed to pass into the interstitial fluid, in this instance, as a result of the pumping action of the heart; this process is known as filtration. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal filtration.

The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? A. Hypertension B. Kussmaul respirations C. Increased DTRs D. Shallow respirations

ANS: D. If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also kidney disease. This type of client is associated with decreased DTRs, not increased DTRs.

A client comes into the emergency department (ED) by ambulance with a hip fracture after slipping and falling while at home. The client is alert and oriented but anxious and reports thirst. The client's pupils are equal and reactive to light and accommodation, and the heart rate is elevated. An indwelling urinary catheter is inserted, and 40 mL of urine is present. What is the nurse's most likely explanation for the client's urinary output? A. The client urinated prior to arrival to the ED and will probably not need to have the urinary catheter kept in place. B. The client likely has a traumatic brain injury, lacks antidiuretic hormone, and needs vasopressin. C. The client is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output. D. The client is having a sympathetic reaction, which has stimulated the renin- angiotensin-aldosterone system, which results in diminished urine output.

ANS: D. In response to the acute stress of falling at home, the sympathetic nervous system is activated. Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is most likely causing the lower urine output. The client urinating prior to arrival to the ED is unlikely; the fall and hip injury would make the ability to urinate difficult. No assessment information indicates the client has a head injury or heart failure.

The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion. The plan of care includes assessment of specific gravity every four hours. The results of this test will allow the nurse to assess which aspect of the client's health? A. Nutritional status B. Potassium balance C. Calcium balance D. Fluid volume status

ANS: D. Specific gravity measures the density of urine compared with water and can assess the ability of the kidneys to excrete or conserve water. Therefore, specific gravity will detect if the client has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

Baroreceptors in the left atrium and in the carotid and aortic arches respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect? A. Decrease in the release of aldosterone B. Increase of filtration in the Loop of Henle C. Decrease in the reabsorption of sodium D. Decrease in glomerular filtration

ANS: D. Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased sympathetic stimulation.

The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain, and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing which electrolyte imbalance? A. Hypernatremia B. Hypomagnesemia C. Hypophosphatemia D. Hypercalcemia

ANS: D. The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The client's presentation is inconsistent with hypophosphatemia.

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance? A. Metabolic alkalosis B. Hypermagnesemia C. Hypercalcemia D. Hypovolemia

ANS: D. Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

A patient in the intensive care unit has low blood pressure. If the patient's baroreceptors are functioning appropriately, what will the nurse assess in this patient? 1. Reduced urine output 2. Weak hand grasps 3. Decreased level of consciousness 4. Peripheral edema

Answer: 1 Explanation: 1. Arterial baroreceptors are in the arch of the aorta and carotid sinus. These receptors detect arterial pressure changes. When they sense a decrease in arterial blood pressure, they signal the autonomic nervous system, which will cause peripheral vasoconstriction to raise the blood pressure. Vasoconstriction of the renal arteries decreases glomerular filtration, which will reduce the urine output. 2. Weak hand grasps may or may not occur in the patient with hypotension and are not associated with baroreceptor response. 3. Decreased level of consciousness (LOC) is not always present in patients with hypotension. Decreased LOC is not related to baroreceptor response. 4. Peripheral edema may or may not be seen in patients with low blood pressure. Peripheral edema is not related to baroreceptor response.

Which patient would the nurse expect to have the least amount of body fluid? 1. A 75-year-old woman with a body mass index (BMI) in the obese range 2. A 23-year-old female with history of type 1 diabetes 3. A 72-year-old male who had a myocardial infarction at age 50 4. A 16-year-old male who plays football on his high school team

Answer: 1 Explanation: 1. Fat cells contain little water, so obese individuals have less fluid. Women have more body fat than men, so they have less fluid. Older patients tend to have reduced body water. 2. Since this female is young, she will have more body fluid than older females. Diabetes is not a factor. 3. Since this older adult is male, he tends to have more body fluid than women at that age. 4. This patient is young and male, which tends to increase fluid level. The fact that he plays football is not a factor.

The nurse caring for a patient receiving digoxin plans to monitor which electrolyte because of increased risk of digitalis toxicity? 1. Potassium 2. Chloride 3. Calcium 4. Sodium

Answer: 1 Explanation: 1. In patients receiving digoxin therapy, low serum potassium levels can increase the risk for development of dysrhythmias. 2. Chloride levels do not increase risk for digitalis toxicity. 3. Calcium levels do not increase risk for digitalis toxicity. 4. Sodium levels do not increase risk for digitalis toxicity.

A patient comes into the emergency department with complaints of feeling weak, confused, and having abdominal cramps after spending several hours in the hot sun attending a baseball game. The patient's blood pressure is 96/58 mm Hg. The nurse would conduct additional assessment for which condition? 1. Hyponatremia 2. Hypercalcemia 3. Hypernatremia 4. Hypocalcemia

Answer: 1 Explanation: 1. Manifestations of hyponatremia include hypotension, confusion, headache, lethargy, seizures, decreased muscle tone, muscle twitching, tremors, vomiting, diarrhea, and cramping. The patient is complaining of feeling weak and confused with abdominal cramps, which are symptoms associated with hyponatremia. The blood pressure of 96/58 mm Hg is another indication of hyponatremia. Because of these findings and the patient history, the nurse should assess for additional symptoms of hyponatremia. 2. The symptoms and the patient history do not suggest hypercalcemia. 3. Manifestations of hypernatremia include hypertension, thirst, nausea, and vomiting. Hypernatremia would be unlikely in the patient with this history. 4. These symptoms and this history do not support a diagnosis of hypocalcemia.

A patient admitted with hyperphosphatemia is to be treated with the administration of intravenous fluids. Which fluid would the nurse anticipate providing? 1. 0.9% normal saline 2. Lactated Ringer's solute 3. 5% dextrose and 0.25% normal saline 4. 5% dextrose and water

Answer: 1 Explanation: 1. Treatment of hyperphosphatemia is directed at lowering serum levels. This is accomplished by either administering agents that bind phosphate in the gastrointestinal tract or administering an intravenous solution with saline, since saline promotes the renal excretion of phosphate. The intravenous solution of choice for this patient would be 0.9% normal saline. 2. Lactated Ringer's solution does not provide the most benefit to this patient. 3. 5% dextrose and 0.25% normal saline is not the best fluid choice as it has insufficient amounts of an essential ingredient. 4. 5% dextrose and water is not the best fluid choice as it lacks an essential ingredient.

A hospitalized patient has a phosphorus level of 4.8 mg/dL. The nurse would review this patient's history for the presence of which conditions? Select all that apply. 1. Chronic kidney failure 2. Hyperthyroidism 3. Recent cardiac surgery 4. Alcoholism 5. Treatment for gram-negative sepsis

Answer: 1, 2 Explanation: 1. Hyperphosphatemia is predominantly associated with chronic kidney failure. 2. Hyperthyroidism can precipitate hypocalcemia, which leads to hyperphosphatemia. 3. Cardiac surgery is associated with hypophosphatemia. 4. Alcoholism is associated with hypophosphatemia. 5. Gram-negative sepsis is associated with hypophosphatemia.

The nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The nurse would anticipate interventions to be necessary for which values? 1. Calcium 8 mg/dL 2. Potassium 3 mEq/L 3. Sodium 142 mEq/L 4. Phosphate 1.8 mEq/L 5. Magnesium 2.1 mEq/L

Answer: 1, 2 Explanation: 1. The normal range for serum calcium is 9 to 11 mg/dL. A low value may indicate need for intervention. 2. The normal range for potassium is 3.5 to 5.3 mEq/L. A low value would indicate need for supplementation. 3. The normal range for serum sodium is between 135 to 145 mEq/L. 4. The normal range for serum phosphate is 1.7 to 2.6 mEq/L. 5. The normal range for serum magnesium is 1.5 to 2.5 mEq/L.

The nurse is assessing for the presence of Trousseau sign. Which findings would the nurse evaluate as indicating this sign is present? 1. The fingers hyperflex. 2. The thumb flexes toward the palm. 3. The fingers hyperextend. 4. The thumb hyperextends. 5. The hand makes a fist.

Answer: 2, 3 Explanation: 1. Flexion of the fingers does not indicate positive Trousseau sign. 2. Flexion of the thumb toward the palm indicates a positive Trousseau sign. 3. Hyperextension of the fingers indicates a positive Trousseau sign. 4. Hyperextension of the thumb does not indicate a positive Trousseau sign. 5. Fisting of the hand does not indicate a positive Trousseau sign.

A patient's laboratory report indicates critically low serum calcium levels. The nurse would conduct further assessment for which conditions? Select all that apply. 1. Disruption of the parathyroid glands 2. Decreased supply of vitamin D 3. Low levels of calcitonin 4. Insufficient levels of calcitriol 5. Insufficient levels of calcidiol

Answer: 1, 2, 4, 5 Explanation: 1. Parathyroid hormone is essential to the release of calcium from bony tissue into the blood and the conversion of calcidiol to calcitriol. 2. If insufficient amounts of vitamin D are present, calcium absorption in the intestine is reduced. 3. Low levels of calcitonin would result in high calcium levels. 4. Calcitriol is the active form of vitamin D, which causes the small intestine to absorb more calcium. Insufficient levels of calcitriol would result in low serum calcium levels. 5. Calcidiol converted to calcitriol. Insufficient levels would result in low calcium levels.

A patient has a serum calcium level of 11 mg/dL. The nurse would review this patient's medical record for which conditions? Select all that apply. 1. History of taking thiazide diuretics 2. Diagnosis of hyperparathyroidism 3. Diagnosis of acute pancreatitis 4. Low serum magnesium level 5. Long-term bed rest

Answer: 1, 2, 5 Explanation: 1. Hypercalcemia may result from use of thiazide diuretics. 2. Primary hyperparathyroidism is associated with hypercalcemia. 3. The diagnosis acute pancreatitis is associated with hypocalcemia. 4. A low serum magnesium level often occurs with hypocalcemia. 5. Immobility can cause hypercalcemia.

Laboratory testing reveals a patient's serum osmolality to be 240 mOsm/kg. The nurse would assess for which conditions? Select all that apply. 1. Excessive infusion of D5W 2. Dehydration 3. Hyperglycemia 4. Syndrome of inappropriate ADH (SIADH) 5. Acute kidney injury

Answer: 1, 4 Explanation: 1. Excessive D5W IV intake will result in decreased serum osmolality. 2. Dehydration results in increased serum osmolality. 3. Hyperglycemia results in increased serum osmolality. 4. SIADH will result in decreased serum osmolality. 5. Acute kidney injury results in decreased urine osmolality.

The nurse notes that a patient's serum albumin level is elevated. Which other lab result should the nurse review? 1. Potassium 2. Calcium 3. Sodium 4. Chloride

Answer: 2 Explanation: 1. Changes in albumin level should not change potassium level. 2. Ionized calcium is the calcium used in physiological activities such as neuromuscular activity. The concentration of ionized calcium is inversely proportional to the albumin concentration, so the higher the serum albumin, the lower the plasma ionized calcium. 3. Albumin level does not affect sodium level. 4. Chloride level is not affected by albumin level.

A patient with a history of heart failure is admitted with dehydration, malnutrition, and fatigue. The nurse learns that the patient has been taking multiple doses of a thiazide diuretic. The nurse would review laboratory reports for which electrolyte imbalance? 1. Hypernatremia 2. Hypophosphatemia 3. Hypocalcemia 4. Hypermagnesemia

Answer: 2 Explanation: 1. Hypernatremia is not associated with dehydration. 2. Hypophosphatemia is associated with malnourished states and is a relatively common imbalance in the high-acuity patient. Other conditions that can cause hypophosphatemia include those disorders that cause hypercalcemia, such as taking thiazide diuretics. 3. Thiazide diuretics can cause hypercalcemia. 4. Dehydration, malnutrition, and fatigue are not directly linked to hypermagnesemia.

A patient's temperature has been elevated for the past 24 hours. The nurse should monitor which electrolyte? 1. Phosphorous 2. Sodium 3. Potassium 4. Magnesium

Answer: 2 Explanation: 1. It is unlikely that temperature elevation will affect phosphorus levels. 2. With an elevated temperature, there can be a loss of water and sodium through diaphoresis. The nurse should assess the patient's sodium level. 3. It is unlikely that temperature elevation will affect potassium level. 4. It is unlikely that temperature level will affect magnesium level.

The nurse is planning the care of a patient in the intensive care unit. With regard to maintaining adequate fluid volume for this patient, the nurse realizes that interventions should be planned to reduce the risk of which condition? 1. Retention of potassium 2. Retention of sodium 3. Loss of calcium 4. Loss of magnesium

Answer: 2 Explanation: 1. Most intensive care patients experience a reduced potassium level and do not retain potassium. As retention of a different electrolyte occurs, potassium is excreted by the kidney. 2. Under normal situations, the regulation of water is through the thirst mechanism. In the intensive care unit, however, many patients have altered levels of consciousness and will not have this mechanism in place. Because of this, hypernatremia or retention of sodium is a common electrolyte imbalance in these types of patients. 3. Calcium balance is not typically associated with fluid volume. 4. Magnesium balance is not typically associated with fluid volume.

A patient with hypoxia is at risk for disruption of the sodium potassium pump. Which would the nurse expect if this occurs? 1. Decreased serum potassium 2. Cell death 3. Increase in the cells' ability to use active transport 4. Decreased extracellular fluid

Answer: 2 Explanation: 1. The amount of potassium in the extracellular fluids would increase. 2. Without the counterregulatory forces provided by the sodium potassium pump, cells will fill with fluid and will rupture and die. 3. Dysfunction of the sodium potassium pump will not increase the cells' ability to use active transport. 4. Since the cells can no longer hold fluid, the extracellular fluid component increases.

Potassium phosphate IV has been prescribed for a patient who has hypophosphatemia. Which nursing interventions are indicated when administering this medication? 1. Dilute the dose in 100 mL of normal saline (NS) and administer over 20 minutes. 2. Monitor the patient for respiratory distress. 3. Monitor for the development of hypotension. 4. Ensure that pharmacy has mixed the medication with a local anesthetic.

Answer: 2 Explanation: 1. The dose should be diluted in 500 mL of 0.45 NS and given over 6 hours. 2. Replacement of phosphorus may cause respiratory changes. The patient should be monitored for respiratory distress. 3. Hypotension is not an expected effect of phosphorus replacement. 4. There is no indication that mixing this medication with a local anesthetic is required.

A patient is admitted with bleeding from the gastrointestinal tract. The nurse plans interventions to support the balance of which fluid volume compartment? 1. Transcellular 2. Intravascular 3. Interstitial 4. Intracellular

Answer: 2 Explanation: 1. Transcellular fluid is cerebrospinal fluid, peritoneal fluid, and synovial fluid. 2. Intravascular fluid is one extracellular compartment that consists of plasma. In the case of bleeding, the fluid compartment that will be affected first will be the intravascular fluid. 3. Interstitial fluid is found between the cells. 4. Intracellular fluid is that fluid found within the cells.

The nurse is assessing the effectiveness of fluid replacement therapy in a patient who has a fluid volume deficit. Which assessment findings would indicate the therapy is effective? Select all that apply. 1. Blood pressure 90/48 mm Hg 2. Weight gain of 2 pounds since yesterday 3. Urine output increase to 40 mL per hour 4. Tenting of skin 5. Serum osmolality of 284 mOm/kg

Answer: 2, 3, 5 Explanation: 1. Low blood pressure indicates that the therapy has not been effective. 2. Increase in weight of 2 pounds in 1 day indicates a change in fluid balance. 3. Increase in urine output indicates improvement of fluid balance status. 4. Tenting of skin indicates poor skin turgor and fluid volume deficit. 5. Normal serum osmolality is 280-300 mOsm/kg. Presence of normal serum osmolality indicates normal fluid volume status.

A patient's potassium and calcium levels are below the normal range. The nurse should check for a decreased level of which other electrolyte? 1. Phosphorous 2. Sodium 3. Magnesium 4. Chloride

Answer: 3 Explanation: 1. The phosphorous level might be elevated since phosphorous has an inverse relationship to calcium. 2. Sodium level will not be affected. 3. Because magnesium is mainly excreted in the feces and a small amount is excreted through the urine, these mechanisms of excretion and conservation are similar to those of potassium and calcium. If the patient's potassium and calcium levels are low, the patient might also demonstrate a low magnesium level since magnesium balance is closely related to potassium and calcium balance.

A patient's BUN/creatinine ratio is 13:1. How would the nurse interpret this finding? 1. The patient is hypervolemic. 2. Renal tubule dysfunction may be present. 3. The patient is normovolemic. 4. The patient's glomerular filtration rate is decreased.

Answer: 3 Explanation: 1. A BUN/creatinine ratio of 13:1 does not indicate hypervolemia. 2. There is no information that supports this interpretation. 3. The normal ratio of BUN to creatinine is 10:1 to 20:1. Based on this value alone, the nurse would evaluate this patient as normovolemic. 4. There is not enough information to make this determination.

A patient is demonstrating tremors and a positive Chvostek's sign even though the serum calcium level is low normal. The nurse would review the medical record for which electrolyte imbalance? 1. Low phosphate 2. Low potassium 3. Low magnesium 4. Elevated sodium

Answer: 3 Explanation: 1. A positive Chvostek's sign is associated with hyperphosphatemia. 2. Potassium levels are not associated with a positive Chvostek's sign. 3. The symptoms associated with a low magnesium level are similar to those seen in a low calcium level. Therefore, the nurse should suspect that the patient is experiencing a low magnesium level since tremors and a positive Chvostek's sign are also seen with a low calcium level. 4. Sodium level is not associated with a positive Chvostek's sign.

While assessing a high-acuity patient, the nurse learns the patient has a history of arthritis. Which question would provide the most information regarding potential impact on the patient's fluid and electrolyte balance? 1. How well are you able to take care of your daily needs? 2. How well do you sleep? 3. How often do you take nonsteroidal anti-inflammatory medications? 4. Does your arthritis affect mostly your hands or your feet and legs?

Answer: 3 Explanation: 1. Ability to take care of activities of daily living (ADLs) would not have much impact on fluid and electrolyte balance. 2. Sleep has little relationship to fluid and electrolyte balance. 3. One question asked during the nursing history that relates to fluid and electrolyte assessment is if the patient is taking or receiving any medications that can alter the fluid and electrolyte balance. One such type of medication is nonsteroidal anti-inflammatory drugs (NSAIDs). The patient has arthritis and could be taking NSAIDs on a regular basis. Therefore, the nurse should assess the patient's frequency of taking this category of medication, which could impact the fluid and electrolyte status. 4. The body part affected by arthritis would not have an impact on fluid and electrolyte status.

A patient admitted to the intensive care unit has been taking high levels of magnesium supplements. The nurse would add which information to this patient's plan of care? 1. Test for presence of Chvostek's sign. 2. Monitor for sudden decrease in respiratory rate. 3. Monitor for cardiac dysrhythmias. 4. Monitor for hyperthermia.

Answer: 3 Explanation: 1. Chvostek's sign is positive in hypomagnesemia. 2. A low respiratory rate can be seen with a low magnesium level. 3. Cardiac dysrhythmias have been associated with abnormal magnesium levels. 4. Magnesium does not affect temperature.

The nurse is preparing intravenous fluids for a patient whose serum sodium is 156 mmol/L. Which types of fluid would the nurse select? 1. 10% dextrose in water 2. Lactated Ringer's 3. 0.45% normal saline 4. 5% dextrose and 0.45% normal saline

Answer: 3 Explanation: 1. Hypertonic solutions such as 10% dextrose in water are not used to treat hypernatremia. 2. Lactated Ringer's is an isotonic solution and would not be effective when treating hypernatremia. 3. To effectively treat hypernatremia, the patient will need to be provided with hypotonic intravenous fluids. The fluid 0.45% normal saline is a hypotonic fluid. 4. Hypertonic fluids such as 5% dextrose and 0.45% normal saline would not be used to treat hypernatremia.

When assessing the patient's edema of the lower extremities, the nurse notes that it takes 3 minutes before the 8-mm indentation created by applying pressure above the ankles disappears. This information should be documented as being which type of pitting edema? 1. +2 2. +1 3. +4 4. +3

Answer: 3 Explanation: 1. Indentations that are 4 mm and disappear within 10 to 15 seconds would be considered +2 pitting edema. 2. Indentations that are 2 mm and disappear rapidly would be considered +1 pitting edema. 3. Indentations that are 8mm and disappear after 2 to 5 minutes would be considered +4 pitting edema. 4. Indentations that are 6 mm and disappear within 1 to 2 minutes would be considered +3 pitting edema.

Which laboratory value would require that the nurse closely monitor a patient's cardiac rhythm? 1. Chloride 94 mEq/L 2. Calcium 2.2 mmol/L 3. Potassium 3.3 mEq/L 4. Phosphate 3 mg/dL

Answer: 3 Explanation: 1. This chloride level is slightly lower than normal but would not cause cardiac rhythm disturbances. 2. This normal calcium level would not be implicated in cardiac rhythm disturbances. 3. Both high and low potassium levels can adversely affect cardiac rhythm. 4. This normal phosphate level would not adversely affect cardiac rhythm.

After reviewing a patient's laboratory values, the nurse determines the patient is experiencing fluid volume deficit. Which laboratory value would the nurse cite as supporting this determination? 1. Serum sodium 140 mEq/L 2. Urine specific gravity of 1.003 3. Urine osmolality 330 mOsm/kg 4. Serum potassium 4.3 mEq/L

Answer: 3 Explanation: 1. This serum sodium level is within normal limits and would not help determine the patient's hydration status. 2. Low urine specific gravity develops in conditions that cause fluid volume excess. 3. Normal urine osmolality is 280 to 320 mOsm/kg. The urine osmolality will increase during fluid volume deficit because the kidneys retain water. This is the laboratory value that indicates the patient is experiencing fluid volume deficit. 4. This normal serum potassium level would not help determine if the patient is experiencing a fluid volume deficit.

Which findings would the nurse evaluate as indication that a pregnant female is hypovolemic? Select all that apply. 1. Flat neck veins 2. Bilateral adventitious lung sounds 3. Flat hand veins when dependent 4. Sunken eyes 5. Tenting of the skin

Answer: 3, 4, 5 Explanation: 1. Flat neck veins are normal and do not indicate hypovolemia. Distended neck veins indicate hypervolemia. 2. Adventitious lung sounds indicate hypervolemia. 3. If hand veins remain flat when in the dependent position, the nurse should suspect that the patient is hypovolemic. 4. Eyes that are sunken in their sockets may indicate hypovolemia. 5. Tenting of the skin reveals poor skin turgor, which can be a result of hypovolemia. This finding is not reliable in older adults.

A patient has a serum calcium level of 7.9 mg/dL. Which nursing interventions would be appropriate for this patient? Select all that apply. 1. Treat tachycardia. 2. Monitor for the development of hypertension. 3. Place on seizure precautions. 4. Strain all urine. 5. Reorient as indicated.

Answer: 3, 5 Explanation: 1. Bradycardia is the expected result of this calcium level. 2. Hypotension is the expected effect of this calcium level. 3. A serum calcium level of less than 8.5 mg/dL is indicative of hypocalcemia. Nursing interventions appropriate for the patient would include monitoring the patient for seizures. 4. Straining urine is associated with the possibility of kidney stones. This calcium level is not associated with kidney stone development. 5. This calcium level indicates hypocalcemia. Reduced cognitive ability is a common finding associated with hypocalcemia. The nurse should reorient this patient as needed.

A patient who was admitted to the intensive care unit has a magnesium level of 8.4 mg/dL. The nurse would prepare for which interventions? Select all that apply. 1. Maintenance of strict bedrest 2. Administration of insulin 3. Observation for fluid volume excess 4. Intravenous administration of magnesium 5. Initiation of dialysis

Answer: 3, 5 Explanation: 1. While ambulation may not be indicated for this patient due to changes in neuromuscular function, strict bedrest is not required. The patient may be able to sit on the side of the bed, use a bedside commode, or sit in a bedside chair. 2. Insulin is not used in the treatment of hypermagnesemia. It may be used in the treatment of hyperkalemia. 3. The nurse must plan to observe for findings associated with the common complication of fluid volume excess. 4. This magnesium level is elevated, so additional magnesium is not indicated. 5. Dialysis may be required to remove magnesium in severe cases.

A patient being treated for fluid volume excess has blood glucose elevation. The nurse would review the patient's medication history for which medication? 1. Furosemide (Lasix) 2. Spironolactone (Aldactone) 3. Potassium chloride (K-Dur) 4. Hydrochlorothiazide (Esidrix)

Answer: 4 Explanation: 1. Furosemide does not cause hyperglycemia. 2. Spironolactone does not result in hyperglycemia. 3. Potassium supplements do not cause hyperglycemia. 4. Hydrochlorothiazide has hyperglycemia as a major side effect.

A patient is receiving several units of packed red blood cells over several days to replace the blood lost during an active gastrointestinal bleed. The nurse would assess this patient for findings associated with which electrolyte imbalance? 1. Hyponatremia 2. Hypercalcemia 3. Hypokalemia 4. Hypomagnesaemia

Answer: 4 Explanation: 1. Blood is administered with normal saline so hypernatremia would be a more likely condition. 2. Blood administration is not a primary cause of hypercalcemia. 3. Blood transfusion is not a likely cause of hypokalemia. 4. Hypomagnesaemia can be induced by the administration of large amounts of stored blood because stored blood is preserved with citrate. Citrate is added to stored blood as a preservative.

The nurse is planning the care of a 50-year-old patient with the risk of developing fluid volume deficit. Which assessment finding would have the greatest contribution to this risk? 1. Loose bowel movement one per day 2. First-degree steam burn on hand and forearm 3. Temperature of 99.6°F 4. Diuretic therapy two doses per day

Answer: 4 Explanation: 1. Diarrhea does contribute to fluid volume deficit, but one loose bowel movement per day does not constitute diarrhea. 2. Burns also can cause a fluid volume deficit, but it is unlikely that a first-degree burn on the hand and forearm will produce a significant amount of fluid loss. 3. Fever does increase fluid loss, but this is a low-grade temperature so the effect would be minimal. 4. The patient receiving two doses of diuretic therapy per day is at risk for high volumes of urine output that could increase the risk of developing a fluid volume deficit.

A patient diagnosed with chronic renal failure has a magnesium level of 6 mg/dL. Which history data would the nurse evaluate as contributing to this electrolyte imbalance? 1. The patient had an episode of nasal congestion last week and took decongestant. 2. The patient had a recent sprain injury treated with rest and compression wrapping. 3. The patient has been trying to reduce intake of caffeine-containing fluids. 4. The patient has been taking over-the-counter laxative for chronic constipation.

Answer: 4 Explanation: 1. Taking a decongestant would not contribute to hypermagnesemia. 2. A sprain injury treated with rest and compression would not cause hypermagnesemia. 3. Reduction of caffeine-containing beverages would not contribute to hypermagnesemia. 4. Many over-the-counter laxatives contain magnesium. Chronic overuse of these laxatives may result in hypermagnesemia.

A patient in the intensive care unit has developed gastrointestinal hemorrhage. The nurse would prepare to fluid resuscitate this patient with which intravenous fluid? 1. 5% dextrose and 0.45% normal saline 2. 2.5% dextrose 3. 0.45% normal saline 4. 0.9% normal saline

Answer: 4 Explanation: 1. The solution 5% dextrose and 0.45% normal saline is a hypertonic solution and is not the best choice for expanding the patient's blood volume. 2. The 2.5% dextrose is a hypotonic solution and would not help expand the patient's blood volume. 3. The 0.45% normal saline is a hypotonic solution and would not help expand the patient's blood volume. 4. The patient needs an isotonic solution to expand the blood volume. The appropriate intravenous solution is 0.9% normal saline.

A patient with fluid volume excess has a hemoglobin level of 9 mg/dL. How would the nurse explain the more likely cause of this laboratory value? 1. An undiagnosed bleeding disorder exists. 2. The patient has chronic anemia. 3. The patient has iron deficiency anemia. 4. Plasma dilution has occurred due to excess fluid.

Answer: 4 Explanation: 1. While this may be the case, it is not the most likely reason for this lab value. 2. While this may be the case, it is not the most likely reason for this lab value. 3. While this may be the case, it is not the most likely reason for this lab value. 4. Since this patient has fluid volume excess, the most likely etiology of a low hemoglobin level is plasma dilution from excess extracellular fluid volume.

A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? A. hydrochlorothiazide B. furosemide C. spironolactone D. metolazone

B. Furosemide is the only loop diuretic choice. Hydrochlorothiazide and metolazone are thiazide diuretics that block sodium reabsorption. Spironolactone is a potassium-sparing diuretic that prevents sodium absorption.

A patient with diabetes insipidus presents to the emergency room for treatment of dehydration. The nurse knows to review serum laboratory results for which of the diagnostic indicators? A. Sodium level of 137 mEq/L B. Sodium level of 150 mEq/L C. Potassium level of 3.8 mEq/L D. Potassium level of 6 mEq/L

B. Hypernatremia (normal serum sodium is 135 to 145 mEq/L) is consistent with increased fluid loss and dehydration in diabetes insipidus.

A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into convulsions or a coma. What is the level of serum sodium at which a client can experience these side effects? A. 148 mEq/L B. 114 mEq/L C. 130 mEq/L D. 135 mEq/L

B. Hyponatremia occurs when the serum sodium level dips below 135 mEq/L. When serum sodium levels fall below 115 mEq/L, mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, personality changes, convulsions, or coma can occur. A serum sodium level of 148 mEq/L would indicate hypernatremia. Normal serum concentration levels range from 135 to 145 mEq/L.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result? A. Serum creatinine level of 0.4 mg/dl B. Serum sodium level of 124 mEq/L C. Serum blood urea nitrogen (BUN) level of 8.6 mg/dl D. Hematocrit of 52%

B. In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn't affected by the client's fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

Oncotic pressure refers to the A. amount of pressure needed to stop the flow of water by osmosis. B. osmotic pressure exerted by proteins. C. excretion of substances such as glucose through increased urine output. D. number of dissolved particles contained in a unit of fluid.

B. Oncotic pressure is a pulling pressure exerted by proteins such as albumin. Osmolality refers to the number of dissolved particles contained in a unit of fluid. Osmotic diuresis occurs when urine output increases as a result of excretion of substances such as glucose. Osmotic pressure is the amount of pressure needed to stop the flow of water by osmosis.

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client's symptoms are most likely associated with which electrolyte imbalance? A. Hyperkalemia B. Hypercalcemia C. Hypokalemia D. Hypocalcemia

B. The normal reference range for serum calcium is 8.6 to 10.2 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client's other laboratory findings are within their normal ranges, so the client doesn't have hypernatremia, hypochloremia, or hypokalemia.

A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned? A. Phosphorus B. Potassium C. Calcium D. Iron

C. Calcium deficiency is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension. Electrocardiogram findings associated with hypocalcemia include prolonged QT interval and lengthened ST.

With which condition should the nurse expect that a decrease in serum osmolality will occur? A. Influenza B. Hyperglycemia C. Kidney failure D. Uremia

C. Failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. sodium 137 mEq/L (137 mmol/L) potassium 4.6 mEq/L (4.6 mmol/L) chloride 94 mEq/L (94 mmol/L) calcium 12.9 mg/dL (3.2 mmol/L) What laboratory value is of highest concern to the nurse? A. chloride 94 mEq/L (94 mmol/L) B. potassium 4.6 mEq/L (4.6 mmol/L) C. calcium 12.9 mg/dL (3.2 mmol/L) D. sodium 137 mEq/L (137 mmol/L)

C. More than 99% of the body's calcium is found in the skeletal system. Hypercalcemia, or calcium levels exceeding 10.2 mg/dL (2.5 mmol/L), can be a dangerous imbalance. The client presents with anorexia, nausea and vomiting, constipation, abdominal pain, bone pain, and confusion. The listed sodium, potassium, and chloride levels are within normal limits.

At which serum sodium concentration might convulsions or coma occur? A. 142 mEq/L (142 mmol/L) B. 145 mEq/L (145 mmol/L) C. 130 mEq/L (130 mmol/L) D. 140 mEq/L (140 mmol/L)

C. Normal serum concentration level ranges from 135 to 145 mEq/L (135-145 mmol/L). When the level dips below 135 mEq/L (135 mmol/L), hyponatremia occurs. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L (mmol/L) are within the normal range.

An adult client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next? A. Be prepared to administer a sodium chloride IV. B. Be prepared to administer a lactated Ringer's IV. C. Consider sodium restriction with discontinuation of salt tablets. D. Continue to monitor client with another appointment.

C. The client's symptoms of feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy suggest hypernatremia. The client needs to be evaluated with serum blood tests soon; a later appointment will delay treatment. It is necessary to restrict sodium intake. Salt tablets and a sodium chloride IV will only worsen this condition. A Lactated Ringer's IV is not used with hypernatremia. A hypotonic solution IV may be a part of the treatment, but not along with the salt tablets.

A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment? A. respiratory rate B. bowel sounds C. neuromuscular function D. electrocardiogram (ECG) results

D. Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the client's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.

The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? A. Hallucinations B. Headache C. Nausea D. Confusion

D. Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur. General manifestations of hyponatremia include poor skin turgor, dry mucosa, headache, decreased saliva production, orthostatic fall in blood pressure, nausea, vomiting, and abdominal cramping. Neurologic changes, including altered mental status, status epilepticus, and coma, are probably related to cellular swelling and cerebral edema associated with hyponatremia. Hallucinations are associated with increased serum sodium concentrations.

A nurse evaluates a client's laboratory results. What is a factor that may be affecting an increase in serum osmolality? A. hyponatremia B. diuretic use C. overhydration D. free water loss

D. Osmolality measures the solute concentration per kilogram in blood and urine. Water loss in the serum would increase the solute concentration. Free water loss is a factor increasing serum osmolality. Diuretic use, overhydration, and hyponatremia are factors decreasing serum osmolality.

The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be A. 145 mEq/L (145 mmol/L) B. 135 mEq/L (135 mmol/L) C. 125 mEq/L (125 mmol/L) D. 155 mEq/L (155 mmol/L)

D. The client is experiencing signs and symptoms (S/S) of hypernatremia. Hypernatremia is a serum sodium concentration >145 mEq/L (>145 mmol/L). A cause of hypernatremia is near drowning in seawater (which contains a sodium concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst, elevated body temperature, swollen and dry tongue and sticky mucous membranes, hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia, elevated pulse, and elevated blood pressure.

The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? A. Kidney and liver B. Pancreas and stomach C. Heart and lungs D. Lungs and kidney

D. The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.