Fluid and Electrolytes questions
Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function? A. Assessing dietary intake B. Decreasing fluid intake C. Providing limited physical activity D. Turning, coughing, and deep breathing
A. Assessing dietary intake Assessing dietary intake provides a foundation for the client's usual practices and may help determine if the client is prone to constipation or diarrhea. Limited physical activity may contribute to constipation due to decreased peristalsis. Turning, coughing and deep breathing help promote gas exchange. Fluid intake should be increased to aid bowel elimination.
A client had a 2 kg weight loss in one day. The nurse realizes this change in weight is due to: 1. fluid loss. 2. poor appetite. 3. medications. 4. bed rest.
ANS: 1 A weight loss of more than 0.5 kg over 24 hours generally is the result of fluid loss and not of body mass. The client would not lose 2 kgs of body weight because of poor appetite, medications, or bed rest
An elderly client is demonstrating new signs of confusion. Which of the following should the nurse consider when caring for this client? 1. Assess for signs of elevated sodium level. 2. Restrict fluids. 3. Administer prescribed diuretic medication. 4. Monitor daily weights.
ANS: 1 Elderly clients who develop a new onset of confusion should have their serum sodium levels checked for an elevated serum sodium level. Restricting fluids, administering diuretics, and monitoring daily weights are all interventions appropriate for a client with a low-serum sodium level.
A client is diagnosed with chronic renal failure. Which of the following electrolytes should the nurse monitor for this client? 1. Hydrogen 2. Phosphorus 3. Calcium 4. Vitamin D
ANS: 1 The kidneys contribute to the regulation of electrolyte levels. Two electrolytes regulated by the kidneys are hydrogen and bicarbonate. The kidneys do not directly influence a clients phosphorus level. The kidneys affect calcium by activation of vitamin D; however, the kidneys do not regulate calcium levels. Vitamin D is not an electrolyte.
After reviewing a clients most recent electrocardiogram, the nurse suspects the client is experiencing hyperkalemia. Which of the following did the nurse assess on the clients rhythm strip? (Select all that apply.) 1. Tall peaked T-waves 2. Short QRS complex 3. Dysrhythmias 4. Wide QRS complex 5. Bradycardia 6. Tachycardia
ANS: 1, 3 Tall peaked T-waves and dysrhythmias are seen on the electrocardiogram of a client experiencing hyperkalemia. The other choices are not seen with hyperkalemia.
Which of the following components of the arterial blood gas will the nurse focus when on determining a clients acid-base status? (Select all that apply.) 1. pH 2. PO2 3. PCO2 4. HCO3 5. O2 Sat 6. Hgb
ANS: 1, 3, 4 Interpretation of the clients acid-base status involves the evaluation of three components of the arterial blood gas: pH, PCO2 and HCO3-.. PO2 and O2 Sat are not used to evaluate the clients acid-base status. Hgb level is not a component of the arterial blood gas.
A client has a serum potassium level of 2.9 mEq/L. Which of the following should be done to assist this client? (Select all that apply.) 1. Implement continuous cardiac monitoring. 2. Check for an elevated ST segment. 3. Assess muscle strength, tone, and reflexes. 4. Monitor digoxin levels. 5. Monitor for seizure activity.
ANS: 1, 3, 4 Interventions for a patient with hypokalemia are continuous cardiac monitoring; assessing for flattening T-waves; monitoring for digoxin toxicity, which may cause dysrhythmias; and assessing muscle strength, tone, and reflexes. Seizure activity is a sign of a sodium imbalance.
A client is diagnosed with a serum calcium level of 11.2 mEq/L. Which of the following interventions would be appropriate for this client? (Select all that apply.) 1. Administer diuretics as prescribed. 2. Restrict fluids. 3. Administer intravenous fluids as prescribed. 4. Continuous cardiac monitoring. 5. Administer intravenous sodium as prescribed. 6. Change to a low fat diet.
ANS: 1, 3, 4, 5 Management of hypercalcemia is focused on removing calcium, which is accomplished by administering diuretics, administering intravenous fluids, and administering intravenous sodium. Continuous cardiac monitoring is needed for clients at risk for developing dysrhythmias. Restricting fluids and changing to a low-fat diet are not used to treat hypercalcemia.
A client is diagnosed with hyponatremia. Which of the following assessment findings would cause the nurse to become concerned? (Select all that apply.) 1. Confusion 2. Poor appetite 3. Restlessness 4. Lethargy 5. Seizures 6. Coma
ANS: 1, 3, 4, 5, 6 The change in osmolality that occurs with hyponatremia causes fluid to shift into the intracellular space. Signs and symptoms associated with an expanded intracellular compartment include confusion, restlessness, lethargy, seizures, and coma. Poor appetite is not an assessment finding of hyponatremia.
A client is demonstrating dizziness and lightheadedness upon standing. The nurse is concerned the client is experiencing postural hypotension when which of the following is assessed? 1. Lying BP 120/70 mmHg, P 70; standing BP 116/78 mmHg, P 78 2. Lying BP 116/64 mmHg, P 62; standing BP 94/58 mmHg, P 78 3. Lying BP 130/80 mmHg, P 84; standing BP 118/72 mmHg, P 90 4. Lying BP 126/74 mmHg, P 74; standing BP 108/62 mmHg, P 84
ANS: 2 A decrease in systolic blood pressure of more than 20 mmHg when going from lying to standing, along with an increase in heart rate of 10 beats per minute or a decrease in diastolic blood pressure of more than 10 mmHg, along with a 10 beats per minute increase in heart rate, is considered postural hypotension. The other vital sign measurements do not support the criteria for postural hypotension.
A client is diagnosed with fluid volume excess. Which of the following will the nurse most likely assess in this client? 1. Poor skin turgor 2. Jugular vein distention 3. Dry mouth 4. Increased heart rate
ANS: 2 Excess fluid in the intravascular space causes an elevation in blood pressure, and increased jugular venous pressure may be visible in distended neck veins. Poor skin turgor, dry mouth, and increased heart rate are findings consistent with fluid volume deficit.
The nurse assesses a client to have mild pitting edema of the lower extremities. The nurse would document this finding as being: 1. 0+. 2. 1+. 3. 2+. 4. 3+.
ANS: 2 Mild pitting edema is documented as being +1. No pitting edema would be documented as 0+. Moderate pitting edema would be documented as 2+. Moderately severe pitting edema would be documented as 3+.
Which of the following assessment techniques can the nurse use to determine if a client is experiencing hypocalcemia? (Select all that apply.) 1. Allen test 2. Chvosteks sign 3. Percussion of the abdomen 4. Auscultation of the lungs 5. Trousseaus sign 6. Palpation of the neck
ANS: 2, 5 Trousseaus sign is assessed by inflating a blood pressure cuff for up to 4 minutes and assessing for hand spasms as a sign of hypocalcemia. Chvosteks sign is done by tapping on the facial nerve and assessing for a spasm of the facial muscle on the same side as evidence of hypocalcemia. The Allens test, percussion of the abdomen, auscultation of the lungs, and palpation of the neck are not performed specifically for hypocalcemia.
A client has lost a significant amount of blood. The nurse realizes that the fluid compartment most effected with the blood loss will be: 1. intracellular. 2. interstitial. 3. intravascular. 4. transcellular.
ANS: 3 Intravascular fluid is the fluid in the bloodstream. Intracellular fluid is the fluid inside each cell. Interstitial fluid is the fluid between cells. Transcellular fluid is the fluid outside all of the other fluid compartments, and it includes cerebrospinal fluid, joint fluid, and fluid within the gastrointestinal tract.
A client has a serum sodium level of 129 mEq/L. The nurse should prepare to administer which of the following intravenous solutions? 1. Dextrose 5% and Lactated Ringer 2. Dextrose 5% and 0.45% Normal Saline 3. 0.9% Normal Saline 4. Dextrose 5% and 0.9% Normal Saline
ANS: 3 Normal saline (0.9%) is commonly provided to restore extracellular fluid volume and increase sodium levels. Dextrose 5% and Lactated Ringers, Dextrose 5% and 0.45% Normal Saline, and Dextrose 5% and 0.9% Normal Saline are hypertonic solutions, and they will move water from the cells into the bloodstream
A client begins rapid breathing and demonstrates anxiety after learning of a diagnosis of breast cancer. After a short while, the client complains of tingling lips and fingers. Which of the following should the nurse do to assist this client? 1. Provide oxygen. 2. Coach the client in the use of an incentive spirometer. 3. Help the client slow the respiratory rate or breathe into a paper bag. 4. Administer intravenous fluids.
ANS: 3 With the clients rapid respirations, too much carbon dioxide is being excreted. This leads to alkalosis. Symptoms of respiratory alkalosis include tingling of the lips and fingers. If the client is unable to control the respiratory rate, the nurse may have the client breathe into a paper bag, which forces the rebreathing of carbon dioxide. Providing oxygen, using an incentive spirometer, and intravenous fluids is not going to help correct the clients rapid respiratory rate and respiratory alkalosis.
A client is diagnosed with hypophosphatemia. The nurse realizes that this electrolyte imbalance is most likely associated with: 1. diabetes mellitus. 2. congestive heart failure. 3. arthritis. 4. chronic alcoholism.
ANS: 4 A diet deficient in phosphorous may cause hypophosphatemia and reduced absorption of phosphorous occurs with chronic alcoholism. Hypophosphatemia is not associated with diabetes mellitus, congestive heart failure, or arthritis.
The nurse is concerned that a client can become dehydrated when which of the following is assessed? 1. History of arthritis 2. Appendicitis diagnosis 3 years ago 3. Age 30 4. Obese female
ANS: 4 An adult female has 50% of body weight that is fluid. Adipose cells contain less fluid than other cells. Females have more fat cells than males. Overweight people have less body fluid than thin people. A history of arthritis and appendicitis does not predispose the client to dehydration.
.A client diagnosed with hypokalemia should have which of the following electrolytes also assessed? 1. Sodium 2. Calcium 3. Bicarbonate 4. Magnesium
ANS: 4 Clients with hypokalemia often have concurrent hypomagnesemia. Hypokalemia is resistant to treatment unless the hypomagnesemia is corrected. Sodium, calcium, and bicarbonate changes are not associated with hypokalemia.
A client diagnosed with chronic renal failure is experiencing muscle weakness, paresthesias, and depression. Which of the following do these assessment findings suggest to the nurse? 1. Hyperkalemia 2. Hyponatremia 3. Hypocalcemia 4. Hypermagnesemia
ANS: 4 Signs and symptoms of hypermagnesemia are similar to those seen with hypercalcemia and include paresthesias, muscle weakness, anorexia, nausea, diminished bowel sounds, and constipation. Confusion, depression, lethargy, and coma can also occur. Muscle weakness, paresthesias, and depression are not seen in hyperkalemia, hyponatremia, or hypocalcemia.
Which of the following statements provides the rationale for using a hypotonic solution for a patient with FVD? A. A hypotonic solution provides free water to help the kidneys eliminate the solute. B. A hypotonic solution supplies an excess of sodium and chloride ions. C. Excessive volumes are recommended in the early postoperative period. D. A hypotonic solution is used to treat hyponatremia.
Answer: A. A hypotonic solution provides free water to help the kidneys eliminate the solute. Hypotonic solutions provide free water, which helps the kidneys eliminate solute.
A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark's care. Which nursing intervention should be included the care plan of Mark for his patient? A. Administering I.V. and oral fluids B. Clustering necessary activities throughout the day C. Assessing color, odor, and amount of sputum D. Monitoring serum albumin and total protein levels
Answer: A. Administering I.V. and oral fluids The client's assessment findings would lead the nurse to suspect that the client is dehydrated. Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client with problems associated with impaired gas exchange or ineffective airway clearance. Monitoring albumin and protein levels is appropriate for clients experiencing inadequate nutrition. Clustering activities helps with energy conservation and promotes rest.
A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit? A. Assessing urinary intake and output B. Obtaining the client's weight weekly at different times of the day C. Monitoring arterial blood gas (ABG) results D. Maintaining I.V. therapy at the keep-vein-open rate
Answer: A. Assessing urinary intake and output For the client with fluid volume deficit, assessing the client's urine output (using a urometer if necessary) is essential to ensure an output of at least 30 ml/hour. The client should be weighed daily, not weekly, and at same time each day, usually in the morning. Monitoring ABGs is not necessary for this client. Rather, serum electrolyte levels would most likely be evaluated. The client also would have an I.V. rate at least 75 ml/hour, if not higher, to correct the fluid volume deficit.
Mrs. Waltraud is receiving digoxin and Lasix daily. Today, she complains of nausea, and her apical pulse is 130 and irregular. Which of the following nursing interventions is the most appropriate? A. Hold the digoxin and check the patient's potassium level. B. Remove the orange juice from the patient's tray. C. Identify the patient as high risk for hyperkalemia. D. Assess the patient for other signs of hypernatremia.
Answer: A. Hold the digoxin and check the patient's potassium level. Patient experiencing hypokalemia are at risk for digitalis toxicity. Nausea and irregular pulse are signs digitalis toxicity.
Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate? A. Instituting seizure precaution to prevent injury B. Instructing the client on the importance of preventing infection C. Avoiding the use of tight tourniquet when drawing blood D. Teaching the client the importance of early ambulation
Answer: A. Instituting seizure precaution to prevent injury Instituting seizure precaution is an appropriate intervention, because the client with hypomagnesemia is at risk for seizures. Hypophosphatemia may produce changes in granulocytes, which would require the nurse to instruct the client about measures to prevent infection. Avoiding the use of a tight tourniquet when drawing blood helps prevent pseudohyperkalemia. Early ambulation is recommended to reduce calcium loss from bones during hospitalization.
Magnesium reabsorption is controlled by: A. Loop of Henle B. glomerulus C. pituitary D. parathyroid hormone
Answer: A. Loop of Henle The Loop of Henle is responsible for magnesium reabsorption.
Marie Joy's lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated? A. Positive Trousseau's sign B. Positive Chvostek's sign C. Tetany D. Paresthesia
Answer: A. Positive Trousseau's sign In a client with hypocalcemia, a positive Trousseau's sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed. Chvostek's sign refers to twitching of the facial nerve when tapping below the earlobe. Paresthesia refers to the numbness or tingling. Tetany is a clinical manifestation of hypocalcemia denoted by tingling in the tips of the fingers around the mouth, and muscle spasms in the extremities and face.
A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be included in the care of plan for the client? A. Room temperature reduction B. Fluid restriction of 2,000 ml/day C. Axillary temperature measurements every 4 hours D. Antiemetic agent administration
Answer: A. Room temperature reduction For patient with hyperthermia, reducing the room temperature may help decrease the body temperature. Tepid baths, cool compresses, and cooling blanket may also be necessary. Antipyretics, and not antiemetics, are indicated to reduce fever. Oral or rectal temperature measurements are generally accepted and are more accurate than axillary measurements. Fluids should be encouraged, not restricted to compensate for insensible losses.
Lab tests revealed that patient Z's [Na+] is 170 mEq/L. Which clinical manifestation would nurse Natty expect to assess? A. Tented skin turgor and thirst B. Muscle twitching and tetany C. Fruity breath and Kussmaul's respirations D. Muscle weakness and paresthesia
Answer: A. Tented skin turgor and thirst Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. Typically, the client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous membranes, lethargy, and restlessness. Muscle weakness and paresthesia are associated with hypokalemia; fruity breath and Kussmaul's respirations are associated with diabetic ketoacidosis. Muscle twitching and tetany may be seen with hypercalcemia or hyperphosphatemia.
Nursing intervention for the patient with hyperphosphatemia include encouraging intake of: A. amphojel B. Fleets phospho-soda C. milk D. vitamin D
Answer: A. amphogel Administration of phosphate binders (amphogel and basagel) will reduce the serum phosphate levels.
When assessing a patient for signs of fluid overload, the nurse would expect to observe: A. bounding pulse B. flat neck veins C. poor skin turgor D. vesicular
Answer: A. bounding pulse Bounding pulse is a sign of fluid overload as more volume in the vessels causes a stronger sensation against the blood vessel walls. Flat neck veins and vesicular breath sounds are normal findings. Poor skin turgor is consistent with dehydration.
Which of the following is a gas component of the ABG measurement? A. carbon dioxide B. bicarbonate C. hydrogen D. pH
Answer: A. carbon dioxide The gases measured by ABGs are oxygen and carbon dioxide. Bicarbonate and hydrogen are ions; their ratio is measured in the pH.
Magnesium performs all of the following functions except: A. contributing to vasoconstriction B. assisting in cardiac muscle contraction C. facilitating sodium transport D. assisting in protein metabolism
Answer: A. contributing to vasoconstriction Magnesium contributes to vasodilation, not vasoconstriction.
Bicarbonate is lost during which of the following clinical conditions? A. diarrhea B. diuresis C. diaphoresis D. vomiting
Answer: A. diarrhea Bicarbonate is lost in diarrhea because the lower intestinal tract contains fluids rich in bicarbonate.
When teaching a patient about foods high in magnesium, the nurse would include: A. green vegetables B. butter C. cheese D. tomatoes
Answer: A. green vegetables Green vegetables are high in magnesium.
Aldosterone secretion in response to fluid loss will result in which one of the following electrolyte imbalances? A. hypokalemia B. hyperkalemia C. hyponatremia D. hypernatremia
Answer: A. hypokalemia Aldosterone is secreted in response to fluid loss. Aldosterone causes sodium reabsorption and potassium elimination, further exacerbating hypokalemia.
The majority of the body's water is contained in which of the following fluid compartments? A. intracellular B. interstitial C. intravascular D. extracellular
Answer: A. intracellular The intracellular compartment holds two-thirds of total body water. The extracellular compartment is the interstitial space plus the intravascular space. The extracellular compartment accounts for one-third of total body water.
When assessing a patient for metabolic alkalosis, the nurse would expect to find: A. low serum potassium B. changes in urine output C. hypotension D. increased CVP
Answer: A. low serum potassium Decreased serum potassium is a common symptom of metabolic alkalosis.
Maria, an 85-year-old patient with a feeding tube, has been experiencing severe watery stool. The patient is lethargic and has poor skin turgor, a pulse of 120, and hyperactive reflexes. Nursing interventions would include: A. measuring and recording intake and output and daily weights B. administering salt tablets and monitoring hypertonic parenteral solutions C. administering sedatives D. applying wrist restraints to avoid displacement of the feeding tube
Answer: A. measuring and recording intake and output and daily weights The patient is exhibiting signs of hypernatremia and dehydration. The most appropriate nursing intervention is to measure and record intake and output and daily weight.
Which of the following arterial blood gas (ABG) values indicates uncompensated metabolic alkalosis? A. pH 7.48, PaCO2 42, HCO3 30 B. pH 7.48, PaCO2 46, HCO3 30 C. pH 7.48, PaCO2 34, HCO3 20 D. pH 7.48, PaCO2 34, HCO3 26
Answer: A. pH 7.48, PaCO2 42, HCO3 30 Uncompensated metabolic alkalosis is indicated by ABG values of pH 7.48, PaCO2 42, and HCO3 30. B indicates metabolic alkalosis, partially compensated. C indicates respiratory alkalosis, partially compensated. D indicates respiratory alkalosis, uncompensated.
Chloride helps maintain acid-base balance by performing which of the following roles? A. participating in the chloride shift B. following sodium to maintain serum osmolarity C. maintaining the balance of cations in the ICF and ECF D. separating carbonic acid
Answer: A. participating in the chloride shift To maintain acid-base balance, chloride shifts into and out of red blood cells in exchange for bicarbonate.
The chief anion in the intracellular fluid (ICF) is: A. phosphorus B. potassium C. sodium D. chloride
Answer: A. phosphorus Phosphorus is the major ICF cation. Potassium and sodium are cations. Chloride is the chief anion found in the ECF.
The major cation in the ICF is: A. potassium B. sodium C. phosphorus D. magnesium
Answer: A. potassium Potassium is the major ICF cation. Sodium is the major ECF cation. Phosphorus is the major ICF anion. Magnesium is the second-most abundant cation in the ICF.
The intracellular compartment holds water and: A. proteins B. glucose C. sodium D. uric acid
Answer: A. proteins The intracellular compartment holds large amounts of water and proteins. Potassium, lipids, and nucleic acids are also components of the intracellular compartment.
The extracellular fluid space holds water, electrolytes, proteins and: A. red blood cells B. potassium C. lipids D. nucleic acids
Answer: A. red blood cells The extracellular space contains red blood cells, white blood cells, and platelets in addition to water, electrolytes, and proteins. Potassium, lipids, and nucleic acids are intracellular components.
The majority gastrointestinal reabsorption of water occurs in: A. small intestines B. the esophagus C. the colon D. the stomach
Answer: A. small intestines Approximately 85% to 95% of water absorption takes place in the small intestine. The colon absorbs only 500 to 100 cc.
Body fluids perform which of the following functions? A. transport nutrients B. transport electrical charges C. cushion the organs D. facilitate fat metabolism
Answer: A. transport nutrients Body fluids facilitate the transport of nutrients, hormones, proteins, and other molecules.
Calcium is absorbed in the GI tract under the influence of: A. vitamin D B. glucose C. HCl D. vitamin C
Answer: A. vitamin D Calcium is absorbed in the GI tract under the influence of vitamin D in its biologically active form.
John Reid is admitted in the hospital and is currently receiving hypertonic fluids. Nursing management for the client includes monitoring for all of the following potential complications except: A. water intoxication B. fluid volume excess (FVE) C. cellular dehydration D. cell shrinkage
Answer: A. water intoxication Water intoxication is a potential complication associated with hypotonic fluid administration. Other choice are potential complication of hypertonic fluid administration.
Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? Select all that apply. A. Clustering activities to allow uninterrupted periods of rest B. Maintaining correct body alignment at all times C. Monitoring intake and output, using a urometer if necessary D. Using a footboard or pillows to keep feet in correct position E. Performing active and passive range-of-motion exercises F. Weighing the client daily at the same time and in the same clothes
Answer: B, D, E Correct body alignment, preventing footdrop, and range-of-motion exercises will help prevent contractures. Clustering activities will help promote adequate rest. Monitoring intake and output and weighing the client will help maintain fluid and electrolyte balance.
When monitoring the daily weight of a patient with fluid volume deficit (FVD), the nurse is aware that fluid loss may be considered when weight loss begins to exceed: A. 0.25 lb B. 0.50 lb C. 1 lb D. 1 kg
Answer: B. 0.50 lb Weight loss of more than 0.50 lb. is considered to be fluid loss.
Normal venous blood pH ranges from: A. 6.8 to 7.2 B. 7.31 to 7.41 C. 7.35 to 7.45 D. 7.0 to 8.0
Answer: B. 7.31 to 7.41 Normal venous blood pH ranges from 7.31 to 7.41. Normal arterial blood pH ranges from 7.35 to 7.45.
Sodium levels are affected by the secretion of which of the following hormones? A. progesterone and aldosterone B. ADH and ACTH C. antidiuretic hormone and FSH D. ECF and aldosterone
Answer: B. ADH and ACTH The endocrine system secretes aldosterone and ADH to help regulate sodium levels. The pituitary secretes adrenocorticotropin hormone to help regulate sodium. A and C are reproductive hormones. ECF is not a hormone.
For a patient with hypomagnesemia, which of the following medications may become toxic? A. Lasix B. Digoxin C. calcium gluconate D. CAPD
Answer: B. Digoxin In hypomagnesemia, a patient on digoxin is likely to develop digitalis toxicity. Neither A nor C has toxicity as a side effect. CAPD is not a medication.
Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis? A. Administering sodium chloride I.V. B. Encouraging slow, deep breaths C. Preparing to administer sodium bicarbonate D. Administer low-flow oxygen therapy
Answer: B. Encouraging slow, deep breaths The client who is hyperventilating and subsequently develops respiratory alkalosis is losing too much carbon dioxide. Measures that result in the retention of carbon dioxide are needed. Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory alkalosis. Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis. Administering sodium bicarbonate is appropriate for treating metabolic acidosis, and administering sodium chloride is appropriate for metabolic alkalosis.
Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling? A. Inserting an indwelling Foley catheter B. Having the client perform Kegel exercises C. Keeping the skin clean and dry D. Using pads or diapers on the client
Answer: B. Having the client perform Kegel exercises Kegel exercises, which help strengthen the muscles in the perineal area, are used to maintain urinary continence. To perform these exercises, the client tightens pelvic floor muscles for 4 seconds 10 times at least 20 times each day, stopping and starting the urinary flow. Inserting an indwelling Foley catheter increases the risk for infection and should be avoided. The nurse should encourage the client to develop a toileting schedule based on normal urinary habits. However, suggesting bathroom use every 8 hours may be too long an interval to wait. Pads or diapers should be used only as a resort.
Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care? A. Stress-reduction techniques B. Home environment evaluation C. Skin-care measures D. Participation in activities of daily living
Answer: B. Home environment evaluation After discharge, the client is responsible for his own care and health maintenance management. Discharge includes assessing the home environment for determining the client's ability to maintain his health at home.
Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia? A. Muscle pain and acute rhabdomyolysis B. Hot, flushed skin and diaphoresis C. Soft-tissue calcification and hyperreflexia D. Increased respiratory rate and depth
Answer: B. Hot, flushed skin and diaphoresis Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are indicative of hypophosphatemia. Soft-tissue calcification and hyperreflexia are indicative of hyperphosphatemia. Increased respiratory rate and depth are associated with metabolic acidosis.
Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate? A. Potassium supplements B. Kayexalate C. Calcium gluconate D. Sodium tablets
Answer: B. Kayexalate The client's potassium level is elevated; therefore, Kayexalate would be ordered to help reduce the potassium level. Kayexalate is a cation-exchange resin, which can be given orally, by nasogastric tube, or by retention enema. Potassium is drawn from the bowel and excreted through the feces. Because the client's potassium level is already elevated, potassium supplements would not be given. Neither calcium gluconate nor sodium tablets would address the client's elevated potassium level.
Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client's blood gas values through improved ventilation and oxygen therapy, which is the client's primary stimulus for breathing? A. High PCO2 B. Low PO2 C. Normal pH D. Normal bicarbonate (HCO3)
Answer: B. Low PO2 A chronically elevated PCO2 level (above 50 mmHg) is associated with inadequate response of the respiratory center to plasma carbon dioxide. The major stimulus to breathing then becomes hypoxia (low PO2). High PCO2 and normal pH and HCO3 levels would not be the primary stimuli for breathing in this client.
Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client? A. Prevention of fluid volume excess B. Maintenance of adequate oxygenation C. Education about infection prevention D. Pain reduction
Answer: B. Maintenance of adequate oxygenation For the client with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. A fluid volume deficit resulting from fever and diaphoresis, not excess, is more likely for this client. No information regarding pain is provided in this scenario. Teaching about infection control is not appropriate at this time but would be appropriate before discharge.
A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order? A. Potassium B. Sodium bicarbonate C. Serum sodium level D. Bronchodilatora
Answer: B. Sodium bicarbonate Metabolic acidosis results from excessive absorption or retention of acid or excessive excretion of bicarbonate. A base is needed. Sodium bicarbonate is a base and is used to treat documented metabolic acidosis. Potassium, serum sodium determinations, and a bronchodilator would be inappropriate orders for this client.
A diet containing the minimum daily sodium requirement for an adult would be: A. a no-salt diet B. a diet including 2 gm sodium C. a diet including 4 gm sodium D. a 1500 calorie weight-loss diet
Answer: B. a diet including 2 gm sodium The minimum sodium requirement for adults is 2 gm daily. Most adults consume more than this because sodium is abundant in almost all foods.
Which of the following is not an appropriate nursing intervention for a patient with hypercalcemia? A. administering calcitonin B. administering calcium gluconate C. administering loop diuretics D. encouraging ambulation
Answer: B. administering calcium gluconate Calcium gluconate is used for replacement in deficiency states. Calcitonin and loop diuretics are used to lower serum calcium.
Nursing interventions for a patient with hypermagnesemia include administering calcium gluconate to: A. increase calcium levels B. antagonize the cardiac effects of magnesium C. lower calcium levels D. lower magnesium levels
Answer: B. antagonize the cardiac effects of magnesium In a patient with hypermagnesemia, administration of calcium gluconate will antagonize the cardiac effects of magnesium. Although calcium gluconate will raise serum calcium levels, that is not the purpose of administration. Calcium gluconate does not lower calcium or magnesium levels.
Chloride is absorbed in the: A. stomach B. bowel C. liver D. kidney
Answer: B. bowel Chloride is absorbed in the bowel, mainly the duodenum and jejunum
The respiratory system regulates acid-base balance by: A. increasing mucus production B. changing the rate and depth of respirations C. forming bicarbonate D. reabsorbing bicarbonate
Answer: B. changing the rate and depth of respirations Through changes in the rate and depth of respirations, acid-base balance is achieved via CO2 elimination and retention. Mucus production is not part of the pulmonary regulatory system. C and D are responses that refer to ways in which kidneys balance acids and bases.
Jomarick is diagnosed with FVD; which of the following nursing diagnoses might apply to his condition? A. altered urinary elimination B. decreased cardiac output C. increased cardiac output D. vomiting
Answer: B. decreased cardiac output Decreased cardiac output is a nursing diagnosis associated with isotonic FVD. Other appropriate nursing diagnoses include altered tissue perfusion, potential for injury, and ineffective breathing pattern.
The body's compensation of metabolic alkalosis involves: A. increasing the respiratory rate B. decreasing the respiratory rate C. increasing urine output D. decreasing urine output
Answer: B. decreasing the respiratory rate The body attempts to compensate for metabolic alkalosis by decreasing the respiratory rate and conserving carbon dioxide (an acid). Urine volume does not influence acid-base balance.
Osmotic pressure is created through the process of: A. osmosis B. diffusion C. filtration D. capillary dynamics
Answer: B. diffusion In diffusion, the solute moves from an area of higher concentration to one of lower concentration, creating osmotic pressure. Osmotic pressure is related to the process of osmosis. Filtration is created by hydrostatic pressure. Capillary dynamics are related to fluid exchange at the intravascular and interstitial levels.
Vien is receiving oral potassium supplements for his condition. How should the supplements be administered? A. undiluted B. diluted C. on an empty stomach D. at bedtime
Answer: B. diluted Oral potassium supplements are known to irritate gastrointestinal (GI) mucosa and should be diluted.
The physician has ordered IV replacement of potassium for a patient with severe hypokalemia. The nurse would administer this: A. by rapid bolus B. diluted in 100 cc over 1 hour C. diluted in 10 cc over 10 minutes D. IV push
Answer: B. diluted in 100 cc over 1 hour Potassium must be well diluted and given slowly because rapid administration will cause cardiac arrest.
The balance of anions and cations as it occurs across cell membranes is known as: A. osmotic activity B. electrical neutrality C. electrical stability D. sodium-potassium pump
Answer: B. electrical neutrality Electrical neutrality refers to a state in which the same number of positively charged ions and negatively charged ions are present on either side of the membrane. Osmotic activity refers to the attraction of a solute to a solvent. Sodium-potassium pump refers to the exchange of electrolytes.
Mr. Miyazaki who is diagnosed of bipolar disorder has been drinking copious amounts of water and voiding frequently. The patient is experiencing muscle cramps, twitching, and is reporting dizziness. the nurse checks lab work for: A. complete blood count results, particularly the platelets. B. electrolytes, particularly the serum sodium C. urine analysis, particularly for the presence of white blood cells D. EEG results
Answer: B. electrolytes, particularly the serum sodium The patient is exhibiting behavior that could lead to a sodium and water imbalance and is exhibiting signs of hyponatremia. The nurse would check the electrolytes with attention to the sodium level.
Which of the following diagnoses is most appropriate for a patient with hypo calcemia? A. constipation, bowel B. high risk for injury: bleeding C. airway clearance, ineffective D. high risk for injury: confusion
Answer: B. high risk for injury: bleeding A patient with hypocalcemia may bleed, since calcium is required for normal blood clotting. A and D are diagnoses appropriate for a patient with hypercalcemia. C is not associated with fluctuating calcium levels.
Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (SIADH)? A. hypotonic solution B. hypertonic solution C. isotonic solution D. normotonic solution
Answer: B. hypertonic solution When hyponatremia is severe, hypertonic solutions may be used but should be infused with caution due to the potential for development of CHF. In SIADH, isotonic and hypotonic solutions are not indicated, because urine output is minimal, so water is retained. this water retention dilutes serum sodium levels, making the patient hyponatremic and necessitating administration of hypertonic solutions to balance sodium and water. Normotonic solutions do not exist.
Dietary recommendations for a patient with a hypotonic fluid excess should include: A. decreased sodium intake B. increased sodium intake C. increased fluid intake D. intake of potassium-rich foods
Answer: B. increased sodium intake Hypotonic fluid volume excess (FVE) involves an increase in water volume without an increase in sodium concentration. Increased sodium intake is part of the management of this condition.
Which of the following conditions is an equal decrease of extracellular fluid (ECF) solute and water volume? A. hypotonic FVD B. isotonic FVD C. hypertonic FVD D. isotonic FVE
Answer: B. isotonic FVD Isotonic FVD involves an equal decrease in solute concentration and water volume.
Which of the following nursing diagnoses might apply to a patient with hypertonic FVE? A. ineffective airway clearance B. potential for decreased cardiac output C. ineffective breathing pattern D. potential for increased cardiac output
Answer: B. potential for decreased cardiac output Potential for decreased cardiac output is a nursing diagnosis associated with hypertonic FVE.
Disease of which of the following structures is most likely to affect electrolyte reabsorption? A. glomerulus B. renal tubules C. bladder D. renal pelvis
Answer: B. renal tubules The renal tubules are the site of electrolyte reabsorption. The glomerulus is the site of electrolyte filtration. The bladder is where the urine is stored. The renal pelvis is where urine travels as it moves from the collecting ducts to the ureter.
Which of the following clinical conditions exacerbates electrolyte excretion? A. nasogastric feedings B. use of surgical drains C. immobility from fractures D. chronic water drinking
Answer: B. use of surgical drains Surgical drains will cause a fluid loss, and electrolytes are eliminated along with the fluid.
Alexander has hypotonic FVE; which of the following findings would the nurse expect to assess in the patient? A. poor skin turgor and increased thirst B. weight gain and thirst C. interstitial edema and hypertension D. hypotension and pitting edema
Answer: B. weight gain and thirst Weight gain and thirst are symptoms of hypotonic FVE; other symptoms include excretion of dilute urine, non-pitting edema, dysrhythmias, and hyponatremia.
Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury? A. "I do not have to see my doctor unless i have problems." B. "I can stop taking my antibiotics once I am feeling better." C. "If I have redness, drainage, or fever, I should call my healthcare provider." D. "I can return to my normal activities as soon as I go home."
Answer: C. "If I have redness, drainage, or fever, I should call my healthcare provider." Knowledge that redness, drainage, or fever — signs of infection associated with cellular injury — require reporting indicates that the client has understood the nurse's discharge teaching. Follow-up checkups should be encouraged with an emphasis of antibiotic compliance even if the client feels better. There are usually activity limitations after cellular injury.
Normal serum sodium concentration ranges from: A. 120 to 125 mEq/L B. 125 to 130 mEq/L C. 136 to 145 mEq/L D. 140 to 148 mEq/L
Answer: C. 136 to 145 mEq/L Normal serum sodium level ranges from 136 to 145 mEq/L.
Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client's intake. A. 2,230 B. 2,740 C. 2,470 D. 2,320
Answer: C. 2,470 The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the shift.
The interstitial space holds approximately how many liters? A. 3 L B. 6 L C. 9 L D. 12 L
Answer: C. 9 L The interstitial space hold 9 L.
Mr. Wenceslao is scheduled to receive an isotonic solution; which one of the following is an example of such solution? A. D10% W B. 0.45% saline C. 0.9% saline D. 3% normal saline W
Answer: C. A solution of 0.9% saline is isotonic. A solution of 0.9% saline is isotonic. Solutions of 0.33% and 0.45% saline and D5W are hypotonic.
Jonas is admitted with 1,000 ml of diarrhea per day for the last 3 days. An IV of 0.45% NaCl mixed with 5% dextrose is infusing. Which of the following nursing interventions is the most appropriate? A. Get an infusion controller from central supply. B. Mix all antibiotics in 0.45% NaCl with 5% dextrose. C. Check the patient's potassium level and contact the doctor for IV additive orders. D. Assess the patient for signs of hyperkalemia.
Answer: C. Check the patient's potassium level and contact the doctor for IV additive orders. Potassium is lost via the GI and renal systems. Prolonged or excessive diarrhea can lead to hypokalemia. In the event of hypokalemia, a potassium additive would likely be prescribed.
Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism? A. Maintenance of asepsis with indwelling catheter insertion B. Use of masks, gowns, and gloves when caring for clients with infection C. Correct handwashing technique D. Cleanup of blood spills with sodium hydrochloride
Answer: C. Correct handwashing technique Handwashing remains the most effective procedure for controlling microorganisms and the incidence of nosocomial infections. Aseptic technique is essential with invasive procedures, including indwelling catheters. Masks, gowns, and gloves are necessary only when the likelihood of exposure to blood or body fluids is high. Spills of blood from clients with acquired immunodeficiency syndrome should be cleaned with sodium hydrochloride.
Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement? A. Instructing the client to breathe slowly into a paper bag B. Administering low-flow oxygen C. Encouraging the client to cough and deep breathe D. Nothing, because these ABG values are within normal limits.
Answer: C. Encouraging the client to cough and deep breathe The ABG results indicate respiratory acidosis requiring improved ventilation and increased oxygen to the lungs. Coughing and deep breathing can accomplish this. The nurse would administer high oxygen levels because the client does not have chronic obstructive pulmonary disease. Breathing into a paper bag is appropriate for a client hyperventilating and experiencing respiratory alkalosis. Some action is necessary, because the ABG results are not within normal limits.
Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client's need to maintain skin integrity? A. Monitoring intake and output accurately B. Instructing the client to cough and deep-breathe every 2 hours C. Keeping the linens dry and wrinkle free D. Using a foot board to maintain correct anatomic position
Answer: C. Keeping the linens dry and wrinkle free Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from interfering with adequate blood supply to the tissues, helping to maintain skin integrity. Using a foot board is appropriate for maintaining normal body function position. Monitoring intake and output aids in assessing and maintaining bladder function.. Coughing and deep breathing help promote gas exchange.
Annaliza has a nursing diagnosis of fluid volume deficit. Which one of the following medications could potentially exacerbate the problem? A. Synthroid B. Digoxin C. Lasix D. insulin
Answer: C. Lasix Lasix will contribute to fluid loss through its action as a diuretic.
Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client? A. Sodium level B. Magnesium level C. Potassium level D. Calcium level
Answer: C. Potassium level Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When the client is also taking digoxin, the subsequent hypokalemia may potentiate the action of digoxin, placing the client at risk for digoxin toxicity. Diuretic therapy may lead to the loss of other electrolytes such as sodium, but the loss of potassium in association with digoxin therapy is most important. Hypocalcemia is usually associated with inadequate vitamin D intake or synthesis, renal failure, or use of drugs, such as aminoglycosides and corticosteroids. Hypomagnesemia generally is associated with poor nutrition, alcoholism, and excessive GI or renal losses, not diuretic therapy.
Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale? A. Nutritional needs remain unchanged for the well-nourished adult. B. Age is an insignificant factor in cellular repair. C. The presence of infection may slow the healing process. D. Tissue with inadequate blood supply may heal faster.
Answer: C. The presence of infection may slow the healing process. Infection impairs wound healing. Adequate blood supply is essential for healing. If inadequate, healing is slowed. Nutritional needs, including protein and caloric needs, increase for all clients undergoing cellular repair because adequate protein and caloric intake is essential to optimal cellular repair. Elderly clients may have decreased blood flow to the skin, organ atrophy and diminished function, and altered immunity. These conditions slow cellular repair and increase the risk of infection.
Redd is receiving a blood transfusion. When monitoring the patient, the nurse would analyze an elevated body temperature as indicating: A. a normal physiologic process B. evidence of sepsis C. a possible transfusion reaction D. an expected response to the transfusion
Answer: C. a possible transfusion reaction An increase in the body temperature indicates a possible transfusion reaction and requires immediate discontinuation of the infusion.
The type of fluid used to manipulate fluid shifts among compartments states is: A. whole blood B. TPN C. albumin D. Ensure
Answer: C. albumin Albumin is a colloid that is used to manipulate fluid shifts among compartments. Whole blood is used to replace blood volume. TPN is used for patients who are unable to take in food or fluid. Ensure is high caloric nutritional supplement; it is not used to manipulate fluid shifts.
In the extracellular fluid, chloride is a major: A. compound B. ion C. anion D. cation
Answer: C. anion Chloride is a major anion found in the extracellular fluid. A compound occurs when two ions are bound together. Chloride is an ion, but this choice is too general. HCO3 is a cation.
To determine if a patient's respiratory system is functioning, the nurse would assess which of the following parameters: A. respiratory rate B. pulse C. arterial blood gas D. pulse oximetry
Answer: C. arterial blood gas Arterial blood gases will indicate CO2 and O2 levels. This is an indication that the respiratory system is functioning. Respiratory rate can reveal data about other systems, such as the brain, making letter c a better choice. Pulse rate is not measure of respiratory status. Pulse oximetry yields oxygen saturation levels, which is not a measure of acid-base balance.
Which of the following conditions is associated with elevated serum chloride levels? A. cystitis B. diabetes C. eclampsia D. hypertension
Answer: C. eclampsia Eclampsia is associated with increased levels of serum chloride.
The presence of which of the following electrolytes contributes to acidosis? A. sodium B. potassium C. hydrogen D. chloride
Answer: C. hydrogen The presence of hydrogen ions determines a solution's acidity.
A patient with which of the following disorders is at high risk for developing hyperphosphatemia? A. hyperkalemia B. hyponatremia C. hypocalcemia D. hyperglycemia
Answer: C. hypocalcemia Because calcium and phosphorus ratios are inversely proportional, when phosphorus levels are high, calcium levels are low.
Isotonic FVD can result from: A. GI fluid loss through diarrhea B. insensible water loss during prolonged fever C. inadequate ingestion of fluids and electrolytes D. impaired thirst regulation
Answer: C. inadequate ingestion of fluids and electrolytes Isotonic FVD may result from inadequate intake of fluids and electrolytes that can occur secondary to an inability to ingest orally. GI fluid loss through diarrhea is an etiology of hypotonic FVD. Insensible water loss during prolonged fever is a cause of hypertonic FVD. Impaired thirst regulation is a cause of hypertonic FVD.
The danger of fluid sequestered in the third space is that the fluid: A. is hypertonic and can cause hypervolemia B. is hypotonic and can cause water intoxication C. is not available for circulation D. contains large amounts of acids
Answer: C. is not available for circulation In third-spacing, fluid is sequestered and is unavailable to the general circulation.
Etiologies associated with hypomagnesemia include: A. decreased vitamin D intake B. constipation C. malabsorption syndrome D. renal failure
Answer: C. malabsorption syndrome Malabsorption syndrome is associated with hypomagnesemia. Increased vitamin D intake and diarrhea are also associated with hypomagnesemia.
Etiologies associated with hypocalcemia may include all of the following except: A. renal failure B. inadequate intake calcium C. metastatic bone lesions D. vitamin D deficiency
Answer: C. metastatic bone lesions Metastatic bone lesions are associated with hypercalcemia due to accelerated bone metabolism and release of calcium into the serum. Renal failure, inadequate calcium intake, and vitamin D deficiency may cause hypocalcemia.
The net diffusion of water from one solution of water from one solution through a semipermeable membrane to another solution containing a lower concentration of water is termed: A. filtration B. diffusion C. osmosis D. brownian motion
Answer: C. osmosis Osmosis is defined as the diffusion of water through a semipermeable membrane to a solution with a lower concentration of water. Filtration is the process in which fluids are pushed through biologic membranes by unequal processes. Diffusion (Brownian motion) is the random kinetic motion causing atoms and molecules to spread out evenly.
Which of the following blood products should be infused rapidly? A. packed red blood cells (PRBC) B. fresh frozen plasma (FFP) C. platelets D. dextran
Answer: C. platelets Platelets and cryoprecipitate can be infused quickly. PRBC and FFP should be administered over 1 ½ to 4 hours. Dextran is not a blood product.
Normal calcium levels must be analyzed in relation to: A. sodium B. glucose C. protein D. fats
Answer: C. protein Some calcium is bound to protein, so abnormal calcium levels are analyzed in relation to proteins.
Nursing interventions for a patient with hyponatremia include: A. administering hypotonic IV fluids B. encouraging water intake C. restricting fluid intake D. restricting sodium intake
Answer: C. restricting fluid intake Hyponatremia involves a decreased concentration of sodium in relation to fluid volume, so restricting fluid intake is indicated.
The nurse would analyze an arterial pH of 7.46 as indicating: A. acidosis B. alkalosis C. homeostasis D. neutrality
Answer: C. restricting fluid intake Hyponatremia involves a decreased concentration of sodium in relation to fluid volume, so restricting fluid intake is indicated.
Orly Khan is suffering from fluid volume deficit (FVD), which of the following symptoms would the nurse expect to assess in the patient? A. rales B. bounding pulse C. tachycardia D. bulging neck veins
Answer: C. tachycardia Tachycardia, poor tissue turgor, and hypotension are symptoms of FVD. Other choices are symptoms of FVE.
The lungs participate in acid-base balance by: A. reabsorbing bicarbonate B. splitting carbonic acid in two C. using CO2 to regulate hydrogen ions D. sending hydrogen ions to the renal tubules
Answer: C. using CO2 to regulate hydrogen ions The lungs use carbon dioxide to regulate hydrogen ion concentration
Lee Angela's lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you would interpret this serum chloride level as: A. high B. low C. within normal range D. high normal
Answer: C. within normal range Normal serum concentrations of chloride range from 95 to 108 mEq/L.
Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium? A. 14-year-old Elena who is taking diuretics B. 16-year-old John Joseph with ileostomy C. 16-year-old Gabriel with metabolic acidosis D. 18-year-old Albert who has renal disease
Answer: D. Albert who has renal disease Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Clients receiving diuretics, with ileostomies, or with metabolic acidosis may be hypokalemic and should be encouraged to eat foods high in potassium.
Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do? A. Administering the client's ordered pain medication immediately B. Using guided imagery instead of administering pain medication C. Using therapeutic conversation to try to discourage pain medication D. Attempting to rule out complications before administering pain medication
Answer: D. Attempting to rule out complications before administering pain medication When intervening with a client complaining of pain, the nurse must always determine if the pain is expected pain or a complication that requires immediate nursing intervention. This must be done before administering the medication. Guided imagery should be used along with, not instead of, administration of pain medication. The nurse should medicate the client and not discourage medication.
A 36-year-old male client is about to be discharged from the the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse's instructions about measures to prevent constipation? A. Discouraging the client from eating large amounts of roughage-containing foods in the diet. B. Encouraging the client to use laxatives routinely to ensure adequate bowel elimination. C. Instructing the client to establish a bowel evacuation schedule that changes every day. D. Instructing the client to fill a 2-L bottle with water every night and drink it the next day.
Answer: D. Instructing the client to fill a 2-L bottle with water every night and drink it the next day. Adequate fluids and fiber in the diet are key to preventing constipation. Having the client fill a 2-L bottle with water every night and drink it the next day is one method for ensuring the client receives at least 2,000 ml of water daily. The client also should be instructed to drink any other fluids throughout the day. High fiber or roughage foods are encouraged. Laxatives should not be used routinely for bowel elimination. They should be used only as a last resort, because clients may become dependent on them. A regular bowel evacuation schedule should be established.
Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase? A. Whole grains and nuts B. Milk products and green, leafy vegetables C. Pork products and canned vegetables D. Orange juice and bananas
Answer: D. Orange juice and bananas The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and bananas are high in potassium, along with raisins, apricots, avocados, beans, and potatoes. Whole grains and nuts would be encouraged for the client with hypomagnesemia; milk products and green, leafy vegetables are good sources of calcium for the client with hypocalcemia. Pork products and canned vegetables are high in sodium and are encouraged for the client with hyponatremia.
Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid? A. Potassium B. Phosphate C. Chloride D. Sodium
Answer: D. Sodium Sodium is the electrolyte whose level is the primary determinant of the extracellular fluid concentration. Sodium a cation (e.g., positively charged ion), is the major electrolyte in extracellular fluid. Chloride, an anion (e.g., negatively charged ion), is also present in extracellular fluid, but to a lesser extent. Potassium (a cation) and phosphate (an anion) are the major electrolytes in the intracellular fluid.
Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first? A. Massage the reddened are for a few minutes B. Notify the physician immediately C. Arrange for a pressure-relieving device D. Turn the client to the right side for 2 hours
Answer: D. Turn the client to the right side for 2 hours Turning the client to the right side relieves the pressure and promotes adequate blood supply to the left hip. A reddened area is never massaged, because this may increase the damage to the already reddened, damaged area. The health care provider does not need to be notified immediately. However, the health care provider should be informed of this finding the next time he is on the unit. Arranging for a pressure-relieving device is appropriate, but this is done after the client has been turned.
Hypophosphatemia may result from which of the following diseases? A. liver cirrhosis B. renal failure C. Paget's disease D. alcoholism
Answer: D. alcoholism Hypophosphatemia may occur secondary to alcoholism. Renal failure is usually associated with hyperphosphatemia
Which of the following hormones helps regulate chloride reabsorption? A. antidiuretic hormone B. renin C. estrogen D. aldosterone
Answer: D. aldosterone Chloride reabsorption depends on sodium reabsorption, which is regulated by aldosterone in the distal tubule and collecting ducts.
When assessing a patient for electrolyte balance, the nurse is aware that etiologies for hyponatremia include: A. water gain B. diuretic therapy C. diaphoresis D. all of the following
Answer: D. all of the following Water gain, diuretic therapy, and diaphoresis are etiologies of hyponatremia.
When chloride concentration drops below 95 mEq/L, reabsorption of which of the following electrolytes increases proportionally? A. hydrogen B. potassium C. sodium D. bicarbonate
Answer: D. bicarbonate When chloride concentrations drop below 95 mEq/L, bicarbonate reabsorption increases proportionally, causing metabolic alkalosis. Other choices are cations, chloride is an anion; a cation must always exchange for a cation in order to maintain electrical neutrality.
When serum calcium levels rise, which of the following hormones is secreted? A. aldosterone B. renin C. parathyroid hormone D. calcitonin
Answer: D. calcitonin When calcium levels rise, calcitonin is secreted from the thyroid; this hormone moves calcium from plasma into bone. Parathyroid hormone is secreted in response to lowered calcium levels; this hormone moves calcium from bone into plasma.
Respiratory regulation of acids and bases involves: A. hydrogen B. hydroxide C. oxygen D. carbon dioxide
Answer: D. carbon dioxide Respiratory regulation of acid-base balance involves the elimination or retention of carbon dioxide.
Christoff is diagnosed with hypermagnesemia. Symptoms of her condition may include: A. hypertension B. tachycardia C. hyperactive deep-tendon reflex D. cardiac arrhythmias
Answer: D. cardiac arrhythmias Cardiac arrhythmias are associated with hypermagnesemia. Hypertension, tachycardia, and hyperactive reflexes are signs of hypomagnesemia.
Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance? A. skin turgor B. intake and output C. osmotic pressure D. cardiac rate and rhythm
Answer: D. cardiac rate and rhythm Cardiac rate and rhythm are the most important physical assessment parameter to measure. Skin turgor, intake and output are physical assessment parameters a nurse would consider when assessing fluid and electrolyte imbalance, but choice d is the most important.
Sodium balance is important for which of the following functions? A. transmitting impulses in nerve and muscle fibers via the calcium-potassium pump B. exchanging for magnesium and attracting chloride C. combining with hydrogen and chloride for acid-base balance D. exchanging for potassium and attracting chloride
Answer: D. exchanging for potassium and attracting chloride Sodium influences the levels of potassium and chloride by exchanging for potassium and attracting chloride.
When assessing a patient's total body water percentage, the nurse is aware that all of the following factors influence this except: A. age B. fat tissue C. muscle mass D. gender
Answer: D. gender A patient's gender does not influence the percentage of total body water.
Which of the following electrolytes are lost as a result of vomiting? A. bicarbonate and calcium B. sodium and hydrogen C. sodium and potassium D. hydrogen and potassium
Answer: D. hydrogen and potassium In upper gastrointestinal fluid loss, hydrogen and potassium are lost because these electrolytes are present in abundance in the stomach.
Which of the following findings would the nurse expect to assess in a patient with hypokalemia? A. hypertension B. pH below 7.35 C. hypoglycemia D. hyporeflexia
Answer: D. hyporeflexia Hyporeflexia is a symptom of hypokalemia
Daniel who is a marathon runner is at high risk for fluid volume deficit. Which one of the following is a related factor? A. decreased diuresis B. disease-related process C. decreased breathing and perspiration D. increased breathing and perspiration
Answer: D. increased breathing and perspiration Excessive fluid can be lost if breathing and perspiration are at an increased rate for a prolonged period.
A rise in arterial pressure causes the baroreceptors and stretch receptors to signal an inhibition of the sympathetic nervous system, resulting in: A. decreased sodium reabsorption B. increased sodium reabsorption C. decreased urine output D. increased urine output
Answer: D. increased urine output Arterial baroreceptors and stretch receptors help maintain fluid balance by increasing urine output in response to a rise in arterial pressure.
Insensible fluid losses include: A. urine B. gastric drainage C. bleeding D. perspiration
Answer: D. perspiration Perspiration and the fluid lost via the lungs are termed insensible losses; normally, insensible losses equal about 1000 cc/day.
A patient in which of the following disorders is at high risk to develop hypermagnesemia? A. insulin shock B. hyperadrenalism C. nausea and vomiting D. renal failure
Answer: D. renal failure Renal failure can reduce magnesium excretion, leading to hypermagnesemia. Diabetic ketoacidosis, not insulin shock is a cause of hypermagnesemia. Hypoadrenalism, not hyperadrenalism is a cause of hypermagnesemia. Nausea and vomiting lead to hypomagnesemia
In renal regulation of water balance, the functions of angiotensin II include: A. blood clotting within the nephron B. increasing progesterone secretion into the renal tubules C. catalyzing calcium-rich nutrients D. selectively constricting portions of the arteriole in the nephron
Answer: D. selectively constricting portions of the arteriole in the nephron As part of the renal regulation of water balance, angiotensin II selectively constricts portions of the arteriole in the nephron.
The process of endocrine regulation of electrolytes involves: A. sodium reabsorption and chloride excretion B. chloride reabsorption and sodium excretion C. potassium reabsorption and sodium excretion D. sodium reabsorption and potassium excretion
Answer: D. sodium reabsorption and potassium excretion ACTH stimulates release of aldosterone, which in turn acts on the tubules to reabsorb sodium. When this occurs, the cation potassium is excreted.
Which of the following findings would the nurse expect to asses in hypercalcemia? A. prolonged QRS complex B. tetany C. petechiae D. urinary calculi
Answer: D. urinary calculi Urinary calculi may occur with hypercalcemia. Shortened, not prolonged QRS complex would be seen in hypercalcemia. Tetany and petechiae are signs of hypocalcemia.
A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury? A. Administering anti-inflammatory agents as prescribed B. Elevating the injured area to decrease venous return to the heart C. Keeping the skin clean and dry D. Applying warm packs initially to reduce edema
Anti-inflammatory agents help reduce edema and relieve pressure on nerve endings, subsequently reducing pain. Elevating the injured area increases venous return to the heart. Maintaining clean, dry skin aids in preventing skin breakdown. Cool packs, not warm packs, should be used initially to cause vasoconstriction and reduce edema.
