Evolve Lessons - Assess of Acid-Base, Fluid, & Electrolytes

The nurse is providing care to a patient who is diagnosed with end-stage renal disease. Which clinical manifestation assessed by the nurse indicates the patient is experiencing hyperphosphatemia? A. Decreased blood pressure B. Anorexia C. Irritated and itchy eyes D. Confusion

Rationales: A. Decreased blood pressure, or hypotension, is a clinical manifestation of hypophosphatemia, not hyperphosphatemia. B. Anorexia is a clinical manifestation of hypophosphatemia, not hyperphosphatemia C. (Correct) In patients who have end-stage renal disease, hyperphosphatemia will cause calcium phosphate crystals to form in soft tissues, causing itching or irritated eyes. D. Confusion is a clinical manifestation of hypophosphatemia, not hyperphosphatemia.

Which clinical manifestation does the nurse anticipate when assessing a patient who is experiencing respiratory alkalosis? A. Dyspnea B. Tachypnea C. Hypertension D. Hypotension

Rationales: A. Dyspnea is a clinical manifestation the nurse anticipates for a patient who is experiencing respiratory acidosis, not alkalosis. B. (Correct) Tachypnea is a clinical manifestation the nurse anticipates for a patient who is experiencing respiratory alkalosis. C. Hypertension is not a clinical manifestation the nurse anticipates for a patient who is experiencing respiratory alkalosis. D. Hypotension is not a clinical manifestation the nurse anticipates for a patient who is experiencing respiratory alkalosis.

A patient who received an excessive volume of hypotonic IV fluid has developed the signs and symptoms of hypotonic FVE. Which neurologic clinical manifestations are consistent with this fluid imbalance? A. Seizures B. Paralysis C. Tingling sensations in the lower extremities D. Confusion E. Facial numbness

Rationale: A. (Correct) Decreased level of consciousness, including confusion, seizures, and coma can result from hypotonic FVE, due to cerebral edema and increased intracranial pressure. B. Paralysis is not a clinical manifestation associated with hypotonic FVE. It is most commonly caused by injury to the spinal cord. C. Tingling sensations in the lower extremities is not a clinical manifestation associated with hypotonic FVE. It is most commonly caused by disorders involving peripheral circulation or peripheral nerves. D. (Correct) Decreased level of consciousness, including confusion, seizures, and coma can result from hypotonic FVE, due to cerebral edema and increased intracranial pressure. E. Facial numbness is not a clinical manifestation associated with hypotonic FVE. It is most commonly caused by disorders other neurological disorders, such as stroke.

A patient with vomiting and diarrhea has developed rapid onset isotonic fluid volume deficit. The patient can be expected to have which lab data results? A. Elevated RBC B. Increased BUN and Creatinine C. Low serum osmolality D. Decreased urine specific gravity E. Decreased urine osmolality

Rationale: A. (Correct) Elevated RBC levels show fluid volume deficit that developed rapidly. Increased RBC indicates a concentration of blood cells and too little circulating fluid. B. (Correct) The increased BUN and Creatinine are a result of too little fluid passing through the kidneys. C. A low serum osmolality is seen in hypotonic fluid volume excess, or hyponatremia. D. Urine specific gravity typically elevates in isotonic FVD from increased concentration of solutes in the urine. While urine specific gravity provides supportive data during data clustering, it is not considered a reliable indicator of FVD. E. Isotonic FVD would result in reduced urine output that is more concentrated (has increased urine osmolality).

A patient has developed edema. Which descriptions are accurate regarding this manifestation? A. Caused by excessive fluid in the interstitial space. B. Develops when fluid moves into the intravascular space faster than it is absorbed. C. Dependent edema occurs in the sacral area of patient on bedrest. D. Edematous tissue is quite fragile. E. Increased circulating plasma proteins are a major cause.

Rationale: A. (Correct) It is caused by fluid moving into the interstitial area at a faster rate than it is reabsorbed into the intravascular space. B. It develops when fluid moves into the interstitial space faster than it can be absorbed. C. (Correct) When the patient is bedbound, edema can often be found in the sacral area of the lower back. D. (Correct) Where edema is present, the cells are pushed apart and away from nearby capillaries, making the affected tissue fragile. E. Decreased circulating plasma proteins are one of the four major causes of edema formation.

The nurse has been assigned to an adult patient with isotonic fluid volume deficit and performing her shift assessment on the patient. The nurse can anticipate which clinical findings? A. Hypotension B. Flat neck veins when supine C. Confusion D. Low urine output E. Slow, thready pulse

Rationale: A. (Correct) The patient with either type of FVD can develop hypotension related to decreased circulating volume. B. (Correct) The patient with either type of FVD typically develops flat neck veins when lying in a supine position. C. Confusion in a patient with FVD typically suggests hypertonic FVD due to cellular dehydration, which causes neurologic changes. D. (Correct) The patient with either type of FVD can develop decreased urine output (oliguria) related to diminished cardiac output caused by decreased circulating fluid volume. E. The patient with either type of FVD can develop a rapid, weak, and thready pulse related to decreased cardiac output caused by decreased circulating fluid volume.

An acutely ill patient is brought into the urgent treatment center by a family member. Which patient assessments would suggest a significant fluid volume deficit? A. Hypertension B. Elevated serum BUN and creatinine C. Rapid, weak, thready pulse D. Weight loss of 0.5 kg over the past 2 days E. Dry, cracked lips and furrows on the tongue

Rationale: A. A patient with FVD would more likely have hypotension (low blood pressure). B. (Correct) Elevated serum BUN and creatinine can occur from too little fluid passing through the kidneys. C. (Correct) A pulse that is rapid (tachycardia) and also weak and thready suggests significant FVD. D. A rapid loss of 1 kg or greater within a period of 24 hours is significant. E. (Correct) Mucous membranes and the tongue can become very dry and cracked with significant FVD.

The nurse suspects that a patient has developed a hypertonic fluid volume deficit from receiving a large volume of hypertonic IV fluids. The nurse should expect to see which lab test result? A. Decreased urine specific gravity B. Decreased hematocrit levels C. Increased BUN and Creatinine D. Low RBC count E. Elevated serum osmolality

Rationale: A. Fluid volume deficit often (but not always) causes increased urine specific gravity. B. Decreased hematocrit levels may occur with a fluid volume excess that develops rapidly. C. (Correct) Increased BUN and creatinine are indicators of poor renal function or low fluid volume. D. Low RBC without accompanying blood loss can indicate fluid volume excess that develops rapidly. E. (Correct) Elevated serum osmolality indicates hypertonic fluid volume deficit or hypernatremia.

The nurse is assessing a patient with fluid volume deficit (FVD). Which clinical manifestation would suggest that the patient is experiencing hypertonic FVD? A. Hypotension B. Oliguria C. The patient has become confused D. Dry mucous membranes

Rationale: A. Hypotension can occur for many reasons. In patients with FVD it occurs because of reduced circulating fluid volume and can occur in either type of FVD. B. When present in patients with FVD, oliguria (low urine output) can occur with both types. C. (Correct) The patient with hypertonic FVD develops neurological clinical manifestations due to brain cell dysfunction, when water shifts out of the brain cells, shrinking them. This does not occur in patients with isotonic FVD. D. Dry mucous membranes occur with interstitial fluid is diminished. It can occur with either type of FVD.

The nurse is evaluating the ABG results for a patient who is suspected of having an acid-base imbalance. The ABG analysis indicates a decreased pH, an increased PaCO2, and a normal HCO3-. Which conclusion by the nurse is accurate? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Rationales: A. (Correct) A decreased pH, an increased PaCO2, and a normal HCO3- indicate that the patient is experiencing respiratory acidosis. B. A decreased pH, an increased PaCO2, and a normal HCO3- does not indicate respiratory alkalosis. C. A decreased pH, an increased PaCO2, and a normal HCO3- does not indicate metabolic acidosis. D. A decreased pH, an increased PaCO2, and a normal HCO3- does not indicate metabolic alkalosis.

During the morning patient assessment the nurse finds bounding peripheral pulses and jugular venous distention. The nurse is aware that these are clinical manifestations caused by what type of fluid imbalance? A. Increased interstitial fluids B. Increased circulating volume C. Increased intracellular volume D. Increased transcellular volume

Rationale: A. Increased interstitial fluids causes dependent edema, which develops when fluid shifts into the interstitial space faster than it can be reabsorbed. B. (Correct) The bounding peripheral pulses and jugular venous distention are caused by increased circulating fluid volume, which occurs when excessive fluid is retained in the cardiovascular system. C. Increased intracellular volume pertains to an increase of fluid within cells. This occurs with hypotonic FVE, resulting in cerebral edema or pulmonary edema if allowed to progress. D. Transcellular fluid is contained within epithelial-lined spaces, such as cerebrospinal fluid. It would not cause the patient's manifestations.

A patient has developed neurologic manifestations related to hypertonic fluid volume deficit. The nurse is aware that these manifestations are caused by what underlying problem? A. Decreased serum osmolality causes water to shift out of brain cells by osmosis. B. Decreased intracellular osmolality causes water to shift into the brain cells by osmosis. C. Increased intracellular osmolality causes sodium to shift into the brain cells by osmosis. D. Increased serum osmolality causes water to shift out of brain cells by osmosis

Rationale: A. Increased serum osmolality causes water to shift out of brain cells by osmosis. As water shifts out of the cells, they shrink and become dysfunctional, causing neurologic manifestations B. Increased serum osmolality causes water to shift out of brain cells by osmosis. As water shifts out of the cells, they shrink and become dysfunctional, causing neurologic manifestations C. Increased serum osmolality causes water to shift out of brain cells by osmosis. As water shifts out of the cells, they shrink and become dysfunctional, causing neurologic manifestations. D. (Correct) As water shifts out of the cells, they shrink and become dysfunctional, causing neurologic manifestations.

A patient has developed edema as a result of fluid volume excess. The nurse is aware that the underlying cause of this fluid imbalance is which primary cause of edema? A. Increased capillary permeability B. Obstruction of lymphatic drainage C. Decreased circulating plasma proteins D. Increased hydrostatic pressure

Rationale: A. Leakage of fluids into the interstitial space secondary to increased capillary permeability is associated with inflammation rather than fluid volume excess. B. Leakage of fluids into the interstitial space secondary to obstruction of lymphatic drainage is often seen in patients who have had surgeries for cancer in which the regional lymph nodes have been surgically removed. C. Decrease circulating plasma proteins may occur with severe liver injury, causing decreased production of albumin. It is not a problem of fluid volume excess. D. (Correct) Increased hydrostatic pressure is the pressure exerted against vessel walls as blood rushes through the vasculature. As pressure increases with fluid volume excess, fluid leaves the blood vessels, entering the interstitial spaces.

A nurse is asked to assess a patient for fluid volume deficit. The patient reports that he has lost 10 kg of total body weight in the last 48 hours due to vomiting and diarrhea. Based on the relationship between volume and weight, about how much fluid has this patient lost? A. 1 liter of fluid B. 5 liters of fluid C. 10 liters of fluid D. 15 liters of fluid

Rationale: A. The principles states that 1 liter of fluid weighs 1 kg; therefore, if the patient has lost 10 kg of total body weight, around 10 liters of fluid have been lost, not 1 liter. B. The principles states that 1 liter of fluid weighs 1 kg; therefore, if the patient has lost 10 kg of total body weight, around 10 liters of fluid have been lost, not 5 liters. C. (Correct) The principles states that 1 liter of fluid weighs 1 kg; therefore, if the patient has lost 10 kg of total body weight, around 10 liters of fluid have been lost. D. The principles states that 1 liter of fluid weighs 1 kg; therefore, if the patient has lost 10 kg of total body weight, around 10 liters of fluid have been lost, not 15 liters.

The nurse is admitting a patient with a fluid imbalance. During the patient interview, what questions would be appropriate for the nurse to ask to obtain fluid balance information? A. "What type of fiber-containing food do you eat during a typical day?" B. "Have you lost or gained weight recently?" C. "Do you have a history of renal disease or diabetes mellitus?" D. "Have you noticed swelling of your hands and feet?" E. "Do you have any food allergies?"

Rationale: A. This question focuses on dietary fiber and would provide important information on possible causes of constipation; however, it is not likely going to provide information on fluid balance. B. (Correct) Weight gain or loss, especially when rapid and unintentional would support a fluid imbalance. C. (Correct) Patients with renal diseases and diabetes mellitus are at increased risk for development of fluid imbalance. D. (Correct) The presence of swelling (edema) in hands and especially feet and ankles may indicate dependent edema, which would support the presence of a fluid imbalance. E. While this is an important question, it is unlikely to provide information about fluid imbalance

A patient presents to the emergency department (ED) with a serum phosphate concentration of 3.1 mEq/L. Which should the nurse assess this patient for based on this laboratory value? A. Tetany B. Hyperreflexia C. Decreased deep tendon reflexes D. Muscle cramps E. Shallow respirations

Rationales: A. (Correct) A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. The nurse should assess for tetany, a clinical manifestation of hypocalcemia caused by hyperphosphatemia. B. (Correct) A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. The nurse should assess for hyperreflexia, a clinical manifestation of hypocalcemia caused by hyperphosphatemia. C. A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. Decreased deep tendon reflexes occur with hypercalcemia or hypermagnesemia; therefore, the nurse would not assess for this clinical manifestation. D. (Correct) A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. The nurse should assess for muscle cramps, a clinical manifestation of hypocalcemia caused by hyperphosphatemia. E. A serum phosphate concentration greater than 2.6 mEq/L indicates hyperphosphatemia. Shallow respirations occur with hypophosphatemia or hypermagnesemia; therefore, the nurse would not assess for this clinical manifestation.

The nurse is providing care to a patient whose serum potassium level is 5.2 mEq/L. Which clinical manifestation should the nurse monitor the patient for during the assessment? A. Bradycardia B. Hyperactive deep tendon reflexes C. Lethargy D. Emesis

Rationales: A. (Correct) A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. The nurse should monitor for bradycardia, a clinical manifestation associated with this electrolyte imbalance. B. A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. Hyperactive deep tendon reflexes are associated with hypocalcemia and hypomagnesemia, not hyperkalemia. C. A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. Lethargy is a clinical manifestation associated with hyponatremia, hyponatremia, hypercalcemia, or hypermagnesemia, not hyperkalemia. D. A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. Emesis is not a clinical manifestation associated with hyperkalemia.

A patient presents with muscle twitching and tetany. Ten minutes after hospital admission, the patient experiences a seizure. Which acid-base imbalance should the nurse suspect? A. Metabolic alkalosis B. Metabolic acidosis C. Respiratory alkalosis D. Respiratory acidosis

Rationales: A. (Correct) Clinical manifestations associated with metabolic alkalosis include muscle twitching and tetany that may progress to seizure. B. Muscle twitching, tetany, and seizure are not clinical manifestations associated with metabolic acidosis. C. Muscle twitching, tetany, and seizure are not clinical manifestations associated with respiratory alkalosis. D. Muscle twitching, tetany, and seizure are not clinical manifestations associated with respiratory acidosis

The nurse is conducting a health history assessment for a patient who is diagnosed with hypermagnesemia. Which questions should the nurse in the assessment interview? A. "What type of laxatives do you use?" B. "Have you had diarrhea recently?" C. "Do you use over the counter antacids?" D. "Do you have lactose intolerance?" E. "Do you take a prescribed diuretic?"

Rationales: A. (Correct) Some laxatives are high in magnesium; therefore, this question is appropriate for the nurse to include when conducting a health history interview assessment for a patient with hypermagnesemia. B. Diarrhea increases potassium excretion and, if chronic, also increases calcium and magnesium excretion; asking about diarrhea is not an appropriate assessment question during the health history interview for a patient who presents with hypermagnesemia C. (Correct) Some over the counter antacids are high in magnesium; therefore, this question is appropriate for the nurse to include when conducting a health history interview assessment for a patient with hypermagnesemia D. Asking the patient about lactose intolerance is not an appropriate assessment question during the health history interview for a patient who presents with hypermagnesemia. E. Loop diuretics cause hypokalemia and sometimes hypomagnesemia, not hypermagnesemia; therefore, this is not an appropriate assessment question during the health history interview for a patient who presents with hypermagnesemia.

The nurse is assessing a patient who is diagnosed with respiratory acidosis. Which cardiovascular finding does the nurse anticipate when assessing the cardiovascular system? A. Tachycardia B. Dysrhythmia C. Hypotension D. Dyspnea E. Confusion

Rationales: A. (Correct) Tachycardia is an expected cardiovascular assessment finding for the patient who is experiencing respiratory acidosis. B. (Correct) Dysrhythmia is an expected cardiovascular assessment finding for the patient who is experiencing respiratory acidosis. C. Hypotension is not an expected cardiovascular assessment finding for a patient who is experiencing respiratory acidosis. D. Dyspnea is a respiratory, not cardiovascular, assessment finding that is expected for a patient who is experiencing respiratory acidosis. E. Confusion is a neurological, not cardiovascular, assessment finding that is expected for a patient who is experiencing respiratory acidosis.

Which nursing actions should the nurse perform when analyzing an ABG during the assessment process for a patient who is suspected of having an acid-base imbalance? A. Examining oxygenation status B. Evaluating the pH C. Assessing PaCO2 and HCO3- D. Monitoring the potassium E. Determining compensation

Rationales: A. (Correct) The first step the nurse performs when analyzing an ABG is to examine the oxygenation status to determine if the patient is experiencing hypoxemia. B. (Correct) The second step the nurse performs when analyzing an ABG is to evaluate the pH to determine if the patient is acidotic or alkalotic. C. (Correct) The third step the nurse performs when analyzing an ABG is to assess PaCO2 and HCO3- values. This allows the nurse to determine whether the underlying issue is metabolic or respiratory in nature. D. Potassium level is not a criterion that is used to assess an ABG. E. (Correct) The final step the nurse performs when analyzing an ABG is to determine compensation.

A patient presents to the emergency department with severe bilateral lower extremity weakness and shallow respirations. Heart rate and rhythm are normal and the patient is alert. Which laboratory test should the nurse anticipate based on the current data? A. Serum potassium B. Urine specific gravity C. Serum sodium D. Serum calcium

Rationales: A. (Correct) The nurse would anticipate a serum potassium concentration test for this patient. Hypokalemia causes bilateral quadriceps muscle weakness that may ascend to weaken the respiratory muscles. B. A urine specific gravity is used to assess sodium imbalances. C. Serum sodium imbalances cause decreased level of consciousness. D. Calcium imbalances alter neuromuscular excitability and do not cause respiratory muscle weakness.

Which assessment finding causes the nurse to suspect that a patient is experiencing metabolic acidosis? A. Dyspnea B. Kussmaul respirations C. Polyuria D. Muscle twitching

Rationales: A. Dyspnea is an assessment finding that would cause the nurse to suspect respiratory, not metabolic, acidosis. B. (Correct) Kussmaul respirations are frequent, deep breaths that constitute a compensatory mechanism in an effort to breathe out more carbon dioxide. This is an assessment finding that would cause the nurse to suspect that the patient is experiencing metabolic acidosis. C. Polyuria is an assessment finding that would cause the nurse to suspect metabolic alkalosis, not acidosis. D. Muscle twitching is an assessment finding that would cause the nurse to suspect metabolic alkalosis, not acidosis.

Which clinical manifestations should the nurse anticipate when assessing a patient who is diagnosed with hypernatremia? A. Hyperactive deep tendon reflexes B. Confusion C. Thirst D. Lethargy E. Seizures

Rationales: A. Hyperactive deep tendon reflexes are a clinical manifestation the nurse would anticipate for a patient diagnosed with hypocalcemia or hypomagnesemia, not hypernatremia. B. (Correct) Confusion is a clinical manifestation the nurse would anticipate for a patient diagnosed with hypernatremia because osmotic shifts cause brain cells to shrivel. C. (Correct) Thirst is a clinical manifestation the nurse would anticipate for a patient diagnosed with hypernatremia. D. (Correct) Lethargy is a clinical manifestation the nurse would anticipate for a patient diagnosed with hypernatremia. E. (Correct) Seizures are a clinical manifestation the nurse would anticipate for a patient diagnosed with severe hypernatremia.

The nurse is providing care to a patient with the following ABG values: pH 7.30, PaCO2 40 mm Hg, and HCO3- 20 mEq/L. Which should the nurse document in the medical record regarding this ABG? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Rationales: A. The nurse would not document respiratory acidosis in the patient's medical record based on these ABG findings. B. The nurse would not document respiratory alkalosis in the patient's medical record based on these ABG findings. C. (Correct) Metabolic acidosis is characterized by a decreased pH, a normal PaCO2, and a decreased HCO3-. This is appropriate terminology for the nurse to document in the patient's medical record based on the ABG analysis. D. The nurse would not document metabolic alkalosis in the patient's medical record based on these ABG findings.

Which should the nurse assess for in all patients who are experiencing an acid-base imbalance? A. Urine output B. ABG analysis C. Vital signs D. Bowel sounds E. Skin turgor

Rationales: A. Urine output is not an assessment parameter for all patients who are suspected of having an acid-base imbalance. B. (Correct) All patients who are suspected of experiencing an acid-base imbalance will require an ABG analysis. C. (Correct) All patients who are suspected of experiencing an acid-base imbalance will require a vital signs assessment. D. Auscultating bowel sounds is not an assessment parameter for all patients who are suspected of having an acid-base imbalance. E. Skin turgor is not an assessment parameter for all patients who are suspected of having an acid-base imbalance.

Which test should the nurse anticipate for a patient with hyperkalemia? A. Urine specific gravity B. Serum calcium C. Electrocardiogram D. Urine osmolality

Rationales: A. Urine specific gravity is a laboratory test used to assess and monitor sodium imbalances, not hyperkalemia. B. A serum calcium concentration is used to assess and monitor patients who are experiencing a calcium imbalance such as hypocalcemia and hypercalcemia. This laboratory test would not be useful to monitor a patient with hyperkalemia who is experiencing cardiac dysrhythmia. C. (Correct) An electrocardiogram (ECG) should be anticipated for a patient with hyperkalemia in order to diagnose and monitor cardiac dysrhythmias. D. Urine osmolality is a laboratory test that might be used for a patient experiencing sodium imbalances, not hyperkalemia.

Which neurological assessment, performed by tapping the side of the face, should the nurse perform for a patient with risk factors for hypocalcemia? A. Level of consciousness exam B. Trousseau sign C. Electrocardiogram D. Chvostek sign

Rationales: A. While a level of consciousness exam is an appropriate neurological assessment to conduct for a patient with documented hypocalcemia, this test is not administered by tapping on the side of the patient's face. B. Trousseau sign is a neurological assessment used to monitor for hypocalcemia. However, the assessment is performed using a blood pressure cuff to assess for spasm of the hand and wrist muscles. C. An electrocardiogram is a cardiovascular diagnostic tool, not a neurological assessment. D. (Correct) Chvostek sign is a neurological assessment that is performed by tapping the side of the face over the facial nerve. A positive Chvostek sign, spasm of the facial muscle, indicates increased neuromuscular excitability, consistent with hypocalcemia.