Adult Health Fluid and Electrolytes
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 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
Answer: A. Administering anti-inflammatory agents as prescribed 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.
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
Answer: 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 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.
To supplement a diet with foods rich in potassium, the nurse should recommend the addition of: A. Fruits such as bananas and apricots B. Green leafy vegetables C. Milk and yogurt D. Nuts and legumes
Answer: A. Fruits such as bananas and apricots A: Bananas and apricots are rich in potassium. B: Green leafy vegetables are rich in iron. C: Milk and yogurt are rich in calcium. D: Nuts and legumes are rich in protein.
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.
The primary organs involved in pH regulation are: A. Kidneys and lungs. B. Heart and intestines. C. Lung and endocrine glands. D. Skin and kidneys.
Answer: A. Kidneys and lungs. A: The kidneys and lungs are the primary organs involved in pH regulation. B: The heart and the intestines are not involved in pH regulation. C: The lung and endocrine glands are not involved in pH regulation. D: The skin and kidneys are not involved in pH regulation.
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.
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.
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.
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.
A chemical set up to resist changes, particularly in the level of pH, is: A. A base. B. A buffer. C. A salt. D. An acid.
Answer: B. A buffer. B: A buffer is a chemical system set up to resist changes, particularly in hydrogen ion levels. A: A base or alkali is a compound that contains the hydroxyl ion. C: A salt is a combination of a base and an acid and is created when the positive ions of a base replace the positive hydrogen ions of an acid. D: An acid is one type of compound that contains the hydrogen ion.
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.
Nursing intervention for a patient with a diagnosis of hyponatremia includes all of the following except: A. Assessing for symptoms of nausea and malaise. B. Encouraging the intake of low-sodium liquids such as coffee or tea. C. Monitoring neurologic status D. Restricting tap water intake.
Answer: B. Encouraging the intake of low-sodium liquids such as coffee or tea. B: The nurse should encourage intake of high-sodium liquids to correct hyponatremia. A: The nurse must assess for nausea and malaise because these are clinical manifestations of hyponatremia. C: Neurologic status should be monitored to avoid neurologic complications. D: Tap water intake should be restricted for patients with hyponatremia.
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 clinical manifestation not found in hypokalemia is: A. Muscle weakness B. Oliguria C. Postural hypotension D. Bradycardia
Answer: B. Oliguria B: Polyuria is present in hypokalemia instead of oliguria. A: Muscle weakness is a clinical manifestation of hypokalemia. C: Postural hypotension a clinical manifestation of hypokalemia. D: Bradycardia a clinical manifestation of hypokalemia
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. Bronchodilator
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.
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.
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.
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.
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.
To balance water output, an average adult must have daily fluid intake of approximately: A. 500-900 ml. B. 1,000-2,000 ml. C. 2,000-3,000 ml. D. 4,000-6,000 ml.
Answer: C. 2,000-3,000 ml. C: An adult human at rest takes appropriately 2, 500 ml of fluid daily. A: 500-900 ml is inadequate fluid intake. B: 1,000-2,000 ml is inadequate fluid intake. D: 4,000-6,000 ml is inadequate fluid intake.
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.
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.
ECF is primarily composed of: A. Aqueous fluid and lymphatic fluid. B. CSF and interstitial fluid. C. Interstitial and intravascular fluids. D. Vascular fluid and CSF.
Answer: C. Interstitial and intravascular fluids. C: The extracellular fluid is primarily composed of interstitial and intravascular fluids. A: Aqueous fluid and lymphatic fluid is not a part of the ECF. B: CSF is not a part of ECF while interstitial fluid is. D: Vascular fluid and CSF is not a part of the ECF.
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.
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 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.
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.
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.
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.
The nurse should expect that a patient with mild fluid volume excess would be prescribed a diuretic that blocks sodium reabsorption in the distal tubule, such as: A. Bumex B. Demadex C. HydroDIURIL D. Lasix
Answer: D. Lasix D: Lasix is a diuretic commonly prescribed for patients with mild fluid volume excess. A: Bumex is not recommended for patients with mild fluid volume excess. B: Demadex is not recommended for patients with mild fluid volume excess. C: HydroDIURIL is not the diuretic that blocks sodium reabsorption in the distal tubule.
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.
Water moves across a semipermeable membrane via which process? A. Active transport. B. Diffusion. C. Filtration. D. Osmosis.
Answer: D. Osmosis. D: Osmosis is the diffusion of a pure solvent, such as water, across a semipermeable membrane in response to a concentration gradient in situations where the molecules of a higher concentration are non diffusible. A: Active transport mechanisms require specific enzymes and energy expenditure in the form of adenosine triphosphate (ATP). B: Diffusion, or the process of "being widely spread", is the random movement of molecules from an area of higher concentration to an area of lower concentration. C: Filtration is the transport of water and dissolved materials concentration already exists in the cell.
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.
The most characteristic manifestation of hypocalcemia and hypomagnesemia is: A. Anorexia and nausea. B. Constipation C. Lack of coordination D. Tetany
Answer: D. Tetany D: Decreased levels of calcium and magnesium leads to tetany. A: Anorexia is a manifestation of hypomagnesemia while nausea is a sign of hypercalcemia. B: Constipation is not a manifestation of hypocalcemia or hypomagnesemia. C: Lack of coordination is not a manifestation of hypocalcemia or hypomagnesemia.
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 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.
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.
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.
Clinical signs and symptoms include acute weight loss, decreased skin turgor, oliguria, concentrated urine, orthostatic hypotension, a weak, rapid heart rate, flattened neck veins, increased temperature, thirst, decreased or delayed capillary refill, cool, clammy skin, muscle weakness, and cramps.
Fluid volume deficit
Clinical manifestations for FVE include edema, distended neck veins, and crackles.
Fluid volume excess
The signs and symptoms include muscle weakness, constipation, anorexia, nausea and vomiting, dehydration, hypoactive deep tendon reflexes lethargy, calcium stones, flank pain, pathologic fractures, and deep bone pain.
Hypercalcemia
is calcium level greater than 10.2 mg/dl.
Hypercalcemia
Signs and symptoms include muscle weakness, tachycardia, paresthesia, dysrhythmias, intestinal colic, cramps, abdominal distention, and anxiety.
Hyperkalemia
refers to a potassium level greater than 5.0 mEq/L.
Hyperkalemia
Signs and symptoms are flushing, hypotension, muscle weakness, drowsiness, hypoactive reflexes, depressed respirations, and diaphoresis.
Hypermagnesemia
are serum levels over 2.3 mg/dl
Hypermagnesemia
The signs and symptoms are thirst, elevated body temperature, hallucinations, lethargy, restlessness, pulmonary edema, twitching, increased BP and pulse.
Hypernatremia
is a serum sodium level higher than 145 mEq/L.
Hypernatremia
Clinical manifestations are tetany, tachycardia, anorexia, nausea and vomiting, muscle weakness, and hyperactive reflexes.
Hyperphosphatemia
is a serum phosphorus level that exceeds 4.5 mg/dl in adults.
Hyperphosphatemia
The signs and symptoms are numbness, tingling of fingers, toes, and circumoral region, positive Trousseau's sign and Chvostek's sign, seizures, hyperactive deep tendon reflexes, irritability, and bronchospasm.
Hypocalcemia
are serum levels below 8.6 mg/dl.
Hypocalcemia
Clinical manifestations are fatigue, anorexia, muscle weakness, polyuria, decreased bowel motility, paresthesia, ileus, abdominal distention, and hypoactive reflexes
Hypokalemia
usually indicates a deficit in total potassium stores.
Hypokalemia
Clinical manifestations include neuromuscular irritability, positive Trousseau's and Chvostek's sign, insomnia, mood changes, anorexia, vomiting, and increased deep tendon reflexes.
Hypomagnesemia
refers to a below-normal serum magnesium concentration.
Hypomagnesemia
Signs and symptoms include anorexia, nausea and vomiting, headache, lethargy, dizziness, confusion, muscle cramps and weakness, muscular twitching, seizures, dry skin, and edema.
Hyponatremia
refers to a serum sodium level that is less than 135 mEq/L
Hyponatremia
Signs and symptoms include paresthesias, muscle weakness, bone pain and tenderness, chest pain, confusion, seizures, tissue hypoxia, and nystagmus.
Hypophosphatemia
is indicated by a value below 2.5 mg/dl.
Hypophosphatemia
Which of the following is a gas component of the ABG measurement? A. carbon dioxide B. bicarbonate C. hydrogen D. pH
nswer: 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.
