Prep U's - Chapter 40 - Fluid, Electrolyte, and Acid-Base Balance

The health care provider writes an order for intravenous fluids to infuse at 150 mL per hour. If the drop factor of the tubing is 10, at how many drops per minute should the fluid infuse? Record your answer using a whole number.

Answer: 25 Rationale: Amount to infuse in milliliters x rate of infusion in minutes / drop factor of tubing = drops per minute 150 mL x 60 minutes / 10 drop factor = 25 drops per minute.

Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? A. isotonic B. colloid C. hypotonic D. hypertonic

Answer: A Rationale: Isotonic fluids have an osmolarity of 250-375 mOsm/L, which is the same osmotic pressure as that found within the cell.

A decrease in arterial blood pressure will result in the release of: A. thrombus. B. insulin. C. renin. D. protein.

Answer: C Rationale: Decreased arterial blood pressure, decreased renal blood flow, increased sympathetic nerve activity, and/or low-salt diet can stimulate renin release.

The nurse is preparing a packed red blood cell transfusion for a client. The nurse checks the client's blood type in the electronic medical record (EMR) and notes that it is blood type B. What does this mean? A. The client has anti-A antibodies. B. The client is a universal donor. C. The client has both anti-A and anti-B antibodies. D. The client has anti-B antibodies.

Answer: A Rationale: Clients with type B blood have anti-A antibodies. This means they would attack any type A blood they receive, prompting a transfusion reaction. Clients with type O blood are universal donors.

The nurse is teaching a healthy adult client about adequate hydration. How much average daily intake does the nurse recommend? A. 1,000 mL/day B. 2,500 mL/day C. 1,500 mL/day D. 3,500 mL/day

Answer: B Rationale: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss. 1,000 mL/day and 1,500 mL/day are too low, and 3,500 mL/day is too high.

The process of filtration begins at the: A. Bowman's capsule. B. glomerulus. C. collecting ducts. D. Loop of Henle.

Answer: B Rationale: The process of filtration begins at the glomerulus.

The nurse is administering 1,000 mL 0.9 normal saline over 10 hours (set delivers 60 gtt/1 mL). Using the formula below, the flow rate would be: gtt/min = milliliters per hour x drop factor (gtt/mL) ÷ 60 min/hr. A. 60 gtt/min B. 600 gtt/min C. 100 gtt/min D. 160 gtt/min

Answer: C Rationale: 100gtt/min is the correct rate. 1000 mL divided by 10 hours = 100 mL per hour x 60 gtt/minute, divided by 60 minutes/hour.

A health care provider has asked the nurse to use microdrip tubing to administer a prescribed dosage of IV solution to a client. What is the standard drop factor of microdrip tubing? A. 90 drops/mL B. 120 drops/mL C. 30 drops/mL D. 60 drops/mL

Answer: D Rationale: Microdrip tubing, regardless of manufacturer, delivers a standard volume of 60 drops/mL. Macrodrip tubing manufacturers, however, have not been consistent in designing the size of the opening. Therefore, the nurse must read the package label to determine the drop factor (number of drops/mL).

A health care provider orders a bolus infusion of 250 mL of normal saline to run over 1 hour. The set delivers 20 gtt/mL. What is the flow rate in gtt/min? A. 167 gtt/min B. 42 gtt/min C. 83 gtt/min D. 5,000 gtt/min

Answer: C Rationale: The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. 250 mL × 20 gtt/mL ÷ 60 min = 83 gtt/min

The nurse is caring for a client diagnosed with an acute myocardial infarction requiring strict monitoring of intake and output. Calculate the intake for the shift. Record your answer using a whole number rounded to the nearest 10 mL. 550 mL of urine ¼ cup of grapes 200 mL of liquid stool 4 oz of Jell-O 250 mL of IV normal saline 1 cup of apple juice.

Answer: 610mL Rationale: The nurse would include all items that are liquid or turn to liquid at room temperature in the calculation. Jello, IV normal saline, and apple juice are calculated as intake. Urine and stool are calculated as output. Grapes will not be included as intake. Convert all units to mL, rounded to the nearest 10 mL: 4 oz of Jello = 120 mL 1 cup of apple juice = 240 mL 120 mL + 250 mL IV fluid +240 mL = 610 mL

A client needs an intravenous fluid that will pull fluids into the vascular space. What type of fluid does the nurse prepare to administer as prescribed? A. Hypertonic B. Isotonic C. Hypotonic D. Osmolar

Answer: A Rationale: A hypertonic solution has a greater osmolarity than plasma, which causes water to move out of the cells and be drawn into the intravascular compartment. A hypotonic solution has a lower osmolarity than plasma; therefore, fluid would move out of the intravascular space rather than pulling fluids from the tissues into the vascular space. An isotonic fluid remains in the intravascular compartment without any net flow across the semipermeable membrane. The concentration of particles in a solution is referred to as the osmolarity of a solution.

A nurse is inspecting the IV access site of a client receiving intravenous therapy. The nurse suspects that the IV has infiltrated based on which finding at the site? Select all that apply. A. Coolness B. Redness C. Pallor D. Swelling E. Warmth

Answer: A, C, D Rationale: The nurse should inspect the tissue around the IV entry site for swelling, coolness, or pallor. These are signs of fluid infiltration into the tissue around the IV catheter. The nurse should also inspect the site for redness, swelling, and warmth. These signs might indicate the development of phlebitis or an inflammation of the blood vessel at the site.

A nurse is required to initiate IV therapy for a client. Which should the nurse consider before starting the IV? A. Use half-instilled IV solutions before infusing a new one. B. Ensure that the prescribed solution the expected color and consistency. C. Avoid replacing IV solutions every 24 hours. D. Select a primary tubing of about 37 inches (94 cm) long.

Answer: B Rationale: Before preparing the solution, the nurse should inspect the container and determine that the solution's color and consistency matches that expected based on the prescription, the expiration date has not elapsed, no leaks are apparent, and a separate label is attached. The primary tubing should be approximately 110 inches (2.8 m) long and the secondary tubing should be about 37 inches (94 cm) long. To reduce the potential for infection, IV solutions are replaced every 24 hours even if the total volume has not been completely instilled.

A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? A. Chloride B. Calcium C. Phosphorus D. Potassium

Answer: D Rationale: Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. Signs of potassium defecit, or hypokalemia, include muscle weakness and leg cramps, fatigue, paresthesias, and arrythmias.

A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? A. 3,750 B. 500 C. 1,000 D. 3,000

Answer: D Rationale: Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit.

When caring for a client who is on intravenous therapy, the nurse observes that the client has developed redness, warmth, and discomfort along the vein. Which intervention should the nurse perform for this complication? A. Elevate the client's head. B. Apply antiseptic and a dressing. C. Position the client on the left side. D. Restart infusion in another vein and apply a warm compress.

Answer: D Rationale: Prolonged use of the same vein can cause phlebitis; the nurse should apply a warm compress after restarting the IV. The nurse need not elevate the client's head, position the client on the left side, or apply antiseptic and a dressing. The client's head is elevated if the client exhibits symptoms of circulatory overload. The client is positioned on the left side if exhibiting signs of air embolism. The nurse applies antiseptic and a dressing to an IV site in the event of an infection.

A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? A. Decreased potassium levels. B. Decreased oxygen levels. C. Increased sodium levels. D. Increased potassium levels.

Answer: A Rationale: Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia.

The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching? A. optic function B. cardiac function C. skeletal function D. auditory function

Answer: B Rationale: Potassium is essential for normal cardiac function. Optic, auditory, and skeletal function are dependent to other electrolytes.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? A. fingerprinting over sternum B. muscle twitching C. distended neck veins D. nausea and vomiting

Answer: C Rationale: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

A nursing student is teaching a healthy adult client about adequate hydration. Which statement by the client indicates understanding of adequate hydration? A. "I need to drink no more than 1,000 mL/day." B. "I should drink 1,500 mL/day of fluid." C. "I should drink more than 3,500 mL/day of fluid." D. "I should drink 2,500 mL/day of fluid."

Answer: D Rationale: In healthy adults, fluid intake generally averages approximately 2,500 mL/day, but it can range from 1,800 to 3,000 mL/day with a similar volume of fluid loss.

The nurse is caring for a client whose blood type is A negative. Which donor blood type does the nurse confirm as compatible for this client? A. A positive B. B positive C. AB negative D. O negative

Answer: D Rationale: Type O blood is considered the universal donor because it lacks both A and B blood group markers on its cell membrane. Therefore, type O blood can be given to anyone because it will not trigger an incompatibility reaction when given to recipients with other blood types. Rh-negative persons should never receive Rh-positive blood.

During an assessment of an older adult client, the nurse notes an increase in pulse and respiration rates, and notes that the client has warm skin. The nurse also notes a decrease in the client's blood pressure. Which medical diagnosis may be responsible? A. hypovolemia B. hypervolemia C. edema D. circulatory overload

Answer: A Rationale: The nurse should recognize that hypovolemia, also known as dehydration, may be responsible. Additional indicators of dehydration in older adults include mental status changes; increases in pulse and respiration rates; decrease in blood pressure; dark, concentrated urine with a high specific gravity; dry mucous membranes; warm skin; furrowed tongue; low urine output; hardened stools; and elevated hematocrit, hemoglobin, serum sodium, and blood urea nitrogen (BUN). Hypervolemia means a higher-than-normal volume of water in the intravascular fluid compartment and is another example of a fluid imbalance that would manifest itself with different signs and symptoms. Edema develops when excess fluid is distributed to the interstitial space.

A nurse is reviewing the dietary intake of a client prescribed a potassium-sparing diuretic. The client tells the nurse that they had a banana, yogurt, and bran cereal for breakfast and a turkey sandwich with a glass of milk for lunch. The intake of which food would be a cause for concern? A. banana B. yogurt C. milk D. turkey

Answer: A Rationale: Bananas are high in potassium and would place the client receiving a potassium-sparing diuretic at risk for increased potassium levels. Milk and yogurt are good sources of calcium and phosphorus and would not be a concern. Turkey provides protein and would not be problematic.

A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? A. albumin B. cryoprecipitate C. platelets D. granulocytes

Answer: C Rationale: Platelets are administered to restore or improve the ability to control bleeding. Granulocytes are used to overcome or treat infection. Albumin is used to pull third-spaced fluid by increasing colloidal osmotic pressure. Cryoprecipitate is used to treat clotting disorders like hemophilia.

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse? A. Stop the transfusion and infuse normal saline using a new administration set. B. Check the client's vital signs. C. Stop the transfusion and infuse normal saline using the blood tubing. D. Notify the health care provider of the client's response.

Answer: A Rationale: A client who reports difficulty breathing during a blood transfusion may be having a transfusion reaction. The first action is to stop the transfusion and infuse normal saline using a new administration set. Changing the administration set prevents the client from receiving more of the blood that is causing the reaction. After stopping the transfusion and infusing normal saline using a new administration set, the nurse should check the client's vital signs and notify the health care provider of the reaction.

A client's most recent blood work indicates a K+ level of 7.2 mEq/L (7.2 mmol/L), a finding that constitutes hyperkalemia. For what signs and symptoms should the nurse vigilantly monitor? A. cardiac irregularities B. metabolic acidosis C. muscle weakness D. increased intracranial pressure (ICP)

Answer: A Rationale: Hyperkalemia compromises the normal functioning of the sodium-potassium pump and action potentials. The most serious consequence of this alteration in homeostasis is the risk for potentially fatal cardiac arrythmias. Muscle weakness is associated with low magnesium or high phosphorus. Increased intracranial pressure is a result of increase of blood or brain swelling. Metabolic acidosis is associated with a low pH, a normal carbon dioxide level and a low bicarbonate level.

Which statement accurately describes appropriate nursing interventions in unexpected situations when removing a peripherally inserted central catheter (PICC)? A. If a portion of the catheter breaks when removing it, apply a tourniquet to the upper arm and notify the health care provider. B. If resistance is encountered when removing a PICC line, stop removal, tape it down, and do not attempt to remove again. C. If a portion of the catheter breaks when removing it, tape the catheter down and notify the health care provider. D. If resistance is encountered when removing a PICC, apply sufficient force to the catheter to pull it out.

Answer: A Rationale: If resistance is felt when removing catheter, stop removal. Apply slight tension to the catheter by taping it down. Wait a few minutes, then attempt to remove it without using force. If a portion of the catheter breaks upon removal, immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of the piece of catheter into the right atrium. Check the client's radial pulse. If unable to detect a pulse, the tourniquet is too tight. Notify the primary care provider immediately.

The nurse is caring for a client receiving intravenous fluids through a peripheral intravenous catheter (IV). On rounds, the nurse notes that the client's IV site and arm are swollen and cool to the touch. Based on these assessment findings, what will the nurse do next? A. Remove the peripheral intravenous catheter. B. Place a warm compress over the swollen site. C. Elevate the swollen extremity on a pillow. D. Decrease the rate of the intravenous fluids.

Answer: A Rationale: The assessment findings of a swollen IV site with surrounding tissue swelling and cool to touch indicate infiltration. The correct action for an infiltrated IV is to remove the IV. Decreasing the rate of fluids requires the health care provider's prescription and is not indicated for infiltration. Placing a warm compress is not indicated for infiltration. Elevating the swollen extremity is for peripheral edema, not infiltration.

What is the lab test commonly used in the assessment and treatment of acid-base balance? A. Urinalysis B. Arterial blood gas C. Basic metabolic panel D. Complete blood count

Answer: B Rationale: ABGs are used to assess acid-base balance. The pH of plasma indicates balance or impending acidosis or alkalosis. The complete blood cell count measures the components of the blood, focusing on the red and white blood cells. The urinalysis assesses the components of the urine. Basic metabolic panel (BMP) assess kidney function (BUN and creatinine), sodium and potassium levels, and blood glucose level.

A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this client's needs? A. A peripheral venous catheter inserted to the cephalic vein. B. An implanted central venous access device (CVAD). C. A midline peripheral catheter. D. A peripheral venous catheter inserted to the antecubital fossa.

Answer: B Rationale: Implanted CVADs are ideal for long-term uses such as chemotherapy. The short-term nature of peripheral IVs, and the fact that they are sited in small-diameter vessels, makes them inappropriate for the administration of chemotherapy. Because of the caustic nature of most chemotherapy agents, peripheral IV's are not appropriate.

A client who is NPO prior to surgery reports feeling thirsty. What is the physiologic process that drives the thirst factor? A. increased blood volume and intracellular dehydration. B. decreased blood volume and intracellular dehydration. C. decreased blood volume and extracellular overhydration. D. increased blood volume and extracellular overhydration.

Answer: B Rationale: Located within the hypothalamus, the thirst control center is stimulated by intracellular dehydration and decreased blood volume. When a client does not drink, the body begins intracellular dehydration and the client becomes thirsty. There is no extracellular dehydration.

A client is admitted to the unit with a diagnosis of intractable vomiting for 3 days. What acid-base imbalance related to the loss of stomach acid does the nurse observe on the arterial blood gas (ABG)? A. Respiratory alkalosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory acidosis

Answer: B Rationale: Metabolic alkalosis is associated with an excess of HCO3, a decrease in H+ ions, or both, in the extracellular fluid (ECF). This may be the result of excessive acid losses or increased base ingestion or retention. Loss of stomach acid may result in this condition. Metabolic acidosis is a proportionate deficit of bicarbonate in ECF. The deficit can occur as the result of an increase in acid components or an excessive loss of bicarbonate such as in diarrhea. Respiratory acidosis is when the carbon dioxide level is high and the ph is low. Respiratory alkalosis is when the carbon dioxide level is low and the ph is high.

A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? A. "I was breathing so fast because I was so anxious and in so much pain." B. "I've been taking antacids almost every 2 hours over the past several days." C. "I've had a fever for the past 3 days that just doesn't seem to go away." D. "I've had a GI virus for the past 3 days with severe diarrhea."

Answer: B Rationale: Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit (known as contraction alkalosis). Vomiting or vigorous nasogastric suction frequently causes metabolic alkalosis. Endocrine disorders and ingestion of large amounts of antacids are other causes. Hyperventilation, commonly caused by anxiety or pain, would lead to respiratory alkalosis. Fever, which increases carbon dioxide excretion, would also be associated with respiratory alkalosis. Severe diarrhea is associated with metabolic acidosis.

Upon assessment of a client's peripheral intravenous site, the nurse notices the area is red and warm. The client complains of pain when the nurse gently palpates the area. These signs and symptoms are indicative of: A. rapid fluid administration. B. phlebitis. C. a systemic blood infection. D. an infiltration.

Answer: B Rationale: Phlebitis is a local infection at the site of an intravenous catheter. Signs and symptoms include redness, exudate, warmth, induration, and pain. A systemic infection includes manifestations such as chills, fever, tachycardia, and hypotension. An infiltration involves manifestations such as swelling, coolness, and pallor at the catheter insertion site. Rapid fluid administration can result in fluid overload, and manifestations may include an elevated blood pressure, edema in the tissues, and crackles in the lungs.

The nurse is administering intravenous (IV) therapy to a client. The nurse notices acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Which complication related to IV therapy should the nurse most suspect? A. Sepsis B. Phlebitis C. Infiltration D. Air embolism

Answer: B Rationale: Phlebitis is an inflammation of a vein caused by mechanical trauma from a needle or catheter. It is characterized by local acute tenderness, redness, warmth, and slight edema of the vein above the insertion site. Infiltration, the escape of fluid into the subcutaneous tissue, is caused by a dislodged needle or penetrated vessel wall. It is characterized by swelling, pallor, coldness, or pain around the infusion site and a significant decrease in the flow rate. Sepsis, or infection, is caused by invasion of microorganisms. It is characterized by erythema, edema, induration, drainage at the insertion site, fever, malaise, chills, and other vital sign changes. Air embolism is air in the circulatory system caused by a break in the IV system above the heart level. It is characterized by respiratory distress, increased heart rate, cyanosis, decreased blood pressure, and a change in level of consciousness.

As observed the nurse changing a peripheral venous access site dressing is demonstrating inappropriate technique by implementing which action? A. Not performing the intervention under sterile conditions. B. Not wearing gloves when performing the intervention. C. By applying stabilizing pressure to the catheter. D. By pulling the dressing toward the insertion site.

Answer: B Rationale: The changing of a peripheral venous access site dressing requires the use of clean gloves to minimize the transmission of microorganisms during the procedure and to prevent the nurse from coming into contact with blood. The intervention does not require sterile precautions. The manner in which the nurse is applying stabilizing pressure to the catheter and pulling the adhered dressing toward the insertion site demonstrates appropriate technique.

A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action? A. Elevate the arm. B. Remove the IV. C. Slow the rate of IV fluids. D. Apply a warm compress.

Answer: B Rationale: The client likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. Potassium is known to be irritating to the veins. The priority action is to remove the IV and restart another IV using a different vein. The other actions are appropriate but should occur after the IV is removed.

The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? A. potassium and chloride B. calcium and phosphorus C. chloride and magnesium D. potassium and sodium

Answer: B Rationale: The parathyroid gland secretes parathyroid hormone, which regulates the level of calcium and phosphorus. Removal of the parathyroid gland will cause calcium and phosphorus imbalances. Sodium, chloride, and potassium are regulated by the kidneys and affected by fluid balance.

A student nurse is selecting a venipuncture site for an adult client. Which action by the student would cause the nurse to intervene? A. asking the client to pump their fist several times. B. placing the tourniquet on the upper arm for 2 minutes. C. palpating the veins on the nondominant hand. D. asking if the client is right or left-handed.

Answer: B Rationale: The tourniquet should not be applied for longer than 1 minute, as this allows for stasis of blood that can lead to clotting and also creates prolonged discomfort for the client. Other options are correct techniques when preparing for venipuncture.

A client is admitted to the nursing unit from the emergency department with a diagnosis of hypokalemia. Laboratory results show a serum potassium of 3.2 mEq/l (3.2 mmol/l). For what set of manifestations should the nurse be alert? A. nausea, vomiting, and constipation. B. muscle weakness, fatigue, and arrythmias. C. diminished cognitive ability and hypertension. D. muscle weakness, fatigue, and constipation.

Answer: B Rationale: Typical signs of hypokalemia include muscle weakness and leg cramps, fatigue, paresthesias, and arrythmias. Manifestations of hypercalcemia include nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. Diminished cognitive ability and hypertension may result from hyperchloremia. Constipation is a sign of hypercalcemia.

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? A. a 20-year-old, 2 days postoperative open appendectomy who refuses to ambulate today. B. a newly admitted 88-year-old with a 2-day history of vomiting and loose stools. C. a 60-year-old who is 3 days post-myocardial infarction and has been stable. D. a 47-year-old who had a colon resection yesterday and is reporting pain.

Answer: B Rationale: Young children, older adults, and people who are ill are especially at risk for hypovolemia. Fluid volume deficit can rapidly result in a weight loss of 5% in adults and 10% in infants. A 5% weight loss is considered a pronounced fluid deficit; an 8% loss or more is considered severe. A 15% weight loss caused by fluid deficiency usually is life threatening. It is important to ambulate after surgery, but this can be addressed after assessment of the 88-year-old. The stable MI client presents no emergent needs at the present. The pain is important to address and should be addressed next or simultaneously (asking a colleague to give pain med).

A client is preparing for discharge to home following a diagnosis of hypoparathyroidism with associated low parathyroid hormone. Which food(s) will the nurse include when creating a diet-based teaching plan for the client? Select all that apply. A. peanuts B. broccoli C. tofu D. bananas E. peaches F. yogurt

Answer: B, C, F Rationale: The parathyroid produces the hormone parathormone (PTH), which regulates serum calcium levels. A low level of PTH results in hypocalcemia. The nurse's diet-based teaching plan should include foods that include high levels of calcium, such as dairy products like yogurt and cheese. Dark green vegetables like broccoli, spinach, or greens are important sources of calcium. Oysters, salmon, and sardines are also great sources of calcium. Peanuts will help raise the levels of sodium, but not calcium. Other sources of sodium are bouillon, canned soups, and snack foods. A client can increase their levels of potassium by eating fruits such as peaches and other fruits, vegetables, or juices like orange and tomato juices. Bananas are excellent sources of magnesium, as well as potassium. Other sources of magnesium include eggs, milk, and whole grains.

A nurse is reviewing the client's serum electrolyte levels which are as follows: Sodium: 138 mEq/L (138 mmol/L) Potassium: 3.2 mEq/L (3.2 mmol/L) Calcium: 10.0 mg/dL (2.5 mmol/L) Magnesium: 2.0 mEq/L (1.0 mmol/L) Chloride: 100 mEq/L (100 mmol/L) Phosphate: 4.5 mg/dL (2.6 mEq/L) Based on these levels, the nurse would identify which imbalance? A. hyponatremia B. hypercalcemia C. hypokalemia D. hypermagnesemia

Answer: C Rationale: All of the levels listed are within normal ranges except for potassium, which is decreased (normal range is 3.5 to 5.3 mEq/L; 3.5 to 5.3 mmol/L). Therefore, the client has hypokalemia.

The nurse is caring for a client with metabolic alkalosis whose breathing rate is 8 breaths/min. Which arterial blood gas data does the nurse anticipate finding? A. pH: 7.28; PaCO2: 52 mm Hg (6.92 kPa); HCO3: 32 mEq/l (32 mmol/l) B. pH: 7.32; PaCO2: 26 mm Hg (3.46 kPa); HCO3: 18 mEq/l (18 mmol/l) C. pH: 7.60; PaCO2: 64 mm Hg (8.51 kPa); HCO3: 42 mEq/l (42 mmol/l) D. pH: 7.32; PaCO2: 28 mm Hg (3.72kPa); HCO3: 24 mEq/l (24 mmol/l)

Answer: C Rationale: In metabolic alkalosis, arterial blood gas results are anticipated to reflect pH greater than 7.45; a high PaCO2 such as 64 mm Hg (8.51 kPa) and a high HCO3 such as 42 mEq/l (42 mmol/l). The numbers correlate with metabolic alkalosis, which is indicated by the hypoventilation and the retention of CO2. The other blood gas findings do not correlate with metabolic alkalosis.

The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? A. "This surgery has a very low chance of hemorrhage, so you will not need blood." B. "We now have artificial blood products, so giving your own blood is not necessary." C. "Let me refer you to the blood bank so they can provide you with information." D. "Unfortunately, your own blood cannot be reinfused during surgery."

Answer: C Rationale: Referring the client to a blood bank is the appropriate response. Most blood given to clients comes from public donors. In some cases, when a person anticipates the potential need for blood in the near future or when procedures are used to reclaim blood from wound drainage, the client's own blood may be reinfused.

A client aged 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: A. hypocalcemia. B. hypoglycemia. C. hypokalemia. D. hypothyroidism.

Answer: C Rationale: The frequent use of laxatives and diuretics promotes the excretion of potassium and magnesium from the body, increasing the risk for fluid and electrolyte deficits.

What is the priority goal for the activity in which the nurse is engaging, related to the administration of a prescribed IV solution? A. To demonstrate effective nursing care in the administration of the prescribed IV solution. B. To assure effective administration of the prescribed IV solution. C. To assure the IV solution is appropriate for this administration. D. To provide for effective time management in the administration of the prescribed IV solution.

Answer: C Rationale: The nurse is engaged in the scanning of the bar code associated with the selected IV solution. This activity will help assure the solution is the one prescribed and that the expiration date is not expired. This information helps assure the selected solution is appropriate for this IV prescription. Scanning the bar code does not contribute to the affective administration of the solution. While appropriate goals, neither effective time management nor effective nursing care is the priority goal in this particular situation.

The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? A. Bowel motility will be restored within 24 hours after eliminating salt substitutes, coffee, tea, and other K+-rich foods from the diet. B. ECG will show no cardiac arrythmias within 24 hours after beginning supplemental K+. C. Bowel motility will be restored within 24 hours after beginning supplemental K+. D. ECG will show no cardiac arrythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet.

Answer: D Rationale: If the client is taking a potassium-conserving diuretic, he must be mindful of the amount of potassium he is ingesting because the potassium level is more likely to elevate above normal. Cardiac arrythmias may result if hyperkalemia occurs. Supplemental potassium should not be added to the client's intake. Potassium does not have a direct impact on bowel motility.

The student nurse asks, "What is interstitial fluid?" What is the appropriate nursing response? A. "Watery plasma, or serum, portion of blood." B. "Fluid inside cells." C. "Fluid outside cells." D. "Fluid in the tissue space between and around cells."

Answer: D Rationale: Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood).

A nurse is caring for a client who has recently suffered burns on 30% of his body. Based on his condition, what type of IV solution might be ordered for this client? A. 5% dextrose in 0.45% NaCl. B. 5% dextrose in 0.9% NaCl. C. 0.9% NaCl (normal saline). D. Lactated Ringer's.

Answer: D Rationale: Lactated Ringer's solution is a roughly isotonic solution that contains multiple electrolytes in about the same concentrations as found in plasma (note that this solution is lacking in Mg2+ and PO43- ). It is used in the treatment of hypovolemia, burns, and fluid lost as bile or diarrhea and in treating mild metabolic acidosis.

An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? A. Have a loved one tell the client to drink more. B. Ask the client every hour to drink more fluid. C. Leave water on the bedside table. D. Offer small amounts of preferred beverage frequently.

Answer: D Rationale: Rather than asking older adults if they would like a drink, it is important to identify their preferences and offer small amounts of their preferred liquids at frequent intervals. This intervention will assist in keeping oral mucosa moist and providing hydration needs.

A nurse inspecting a client's IV site notices redness and swelling at the site. What would be the most appropriate nursing intervention for this situation? A. Call the primary care provider to see whether anti-inflammatory drugs should be administered. B. Stop the infusion, cleanse the site with alcohol, and apply transparent polyurethane dressing over the entry site. C. Cleanse the site with chlorhexidine solution using a circular motion and continue to monitor the site every 15 minutes for 6 hours before removing the IV. D. Discontinue the IV and relocate it to another site.

Answer: D Rationale: The nurse should inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration and discontinue and relocate the IV if any of these signs are noted. Cleansing will not resolve this common complication of therapy.