Fluid & Electrolyte Questions:

Maintaining fluid balance, especially in older adults, can be a challenge. While hypovolemia is to be avoided, there is also an accompanying danger for blood clots and urinary stones. What condition contributes to the possible development of these life-threatening events? 1. Hemoconcentration 2. Metabolic acidosis 3. Metabolic alkalosis 4. Hemodilution

1. Hemoconcentration

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults? 1.Third spacing 2. Dehydration 3. Hypervolemia 4. Fluid volume excess

2. Dehydration

A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond? 1. ADH-ANP buffer system 2. Sodium-potassium pump 3. Renin-angiotensin-aldosterone system 4. Bicarbonate-carbonic acid buffer system

4. Bicarbonate-carbonic acid buffer system

7. A client with chronic renal failure reports a 10 pound weight loss over 3 months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action? 1. Assess for depressed deep tendon reflexes 2. Call the physician to report calcium level 3. Place an intravenous catheter in anticipation of administering calcium gluconate 4. Check to see if a serum albumin level is available

4. Check to see if a serum albumin level is available Explanation: A client with chronic renal failure who reports a 10 pound weight loss over 3 months and has difficulty taking calcium supplements is poorly nourished and likely to have hypoalbuminemia. A drop in serum albumin will result in a false low total calcium level. Placing an IV is not a priority action. Depressed reflexes are a sign of hypercalcemia. Normal serum calcium is 9 to 11 mg/dl.

2. The nurse evaluates which of the following clients to be at risk for developing hypernatremia? 1. 50-year-old with pneumonia, diaphoresis, and high fevers 2. 62-year-old with congestive heart failure taking loop diuretics 3. 39-year-old with diarrhea and vomiting 4. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

1. 50-year-old with pneumonia, diaphoresis, and high fevers. Explanation: Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.

6. A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion? 1. Absent patellar reflex 2. Diarrhea 3. Premature ventricular contractions 4. Increase in blood pressure

1. Absent patellar reflex Explanation: An intravenous magnesium infusion may be used to treat a low serum magnesium level. Normal serum magnesium is 1.5 to 2.5 mEq/L. Clinical manifestations of hypermagnesemia are the result of depressed neuromuscular transmission. Absent reflexes indicate a magnesium level around 7 mEq/L. Diarrhea and PVCs are not clinical manifestations of high magnesium levels. Hypermagnesemia causes hypotension.

Which of the following solutions is administered to maintain fluid balance when a client is unable to eat or drink temporarily? 1. An isotonic solution 2. A hypotonic solution 3. A hypertonic solution 4. A colloid solution

1. An isotonic solution

24. Which of the following assessment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating? 1. Deep tendon reflexes decreasing from +2 to +1 2. Bicarbonate rising from 20 mEq/L to 22 mEq/L 3. Urine pH less than 6 4. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L

1. Deep tendon reflexes decreasing from +2 to +1 Explanation: A decrease in deep tendon reflexes is a sign that pH is dropping and that metabolic acidosis is worsening to diabetic ketoacidosis. An increase in bicarbonate would indicate that the acidosis is being corrected. A urine pH less than 6 indicates the kidneys are excreting acid. Serum potassium levels are expected to fall because acidosis is corrected and potassium moves back into the intracellular space.

Why should the nurse avoid maintaining clients on simple IV solutions such as dextrose in water longer than 1 to 2 days? 1. Dextrose in water is nutritionally and calorically inadequate. 2. Dextrose in water has high potential for severe adverse effects. 3. Dextrose in water is not as effective as complex solutions. 4. Dextrose in water carries a high risk of getting contaminated.

1. Dextrose in water is nutritionally and calorically inadequate.

9. The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action? 1. Provide passive ROM exercises and encourage fluid intake 2. Teach the client to increase intake of whole grains and nuts 3. Place a tracheostomy tray at the bedside 4. Administer calcium gluconate IM as ordered

1. Provide passive ROM exercises and encourage fluid intake Explanation: A client who has a serum calcium of 13 mg/dl has hypercalcemia. Normal serum calcium is 9 to 11 mg/dl. Fluid intake promotes renal excretion of excess calcium. ROM exercises promote reabsorption of calcium into bone. Placing a tracheostomy at the bedside is a nursing intervention for hypocalcemia. Although calcium gluconate may be administered in hypocalcemia, it is never administered IM.

A hospitalized client is at risk for respiratory alkalosis. How will this client's body attempt to restore the acid-base balance? 1. The client's kidneys will excrete more HCO3 to lower the pH. 2. The client's kidneys retain more HCO3 to raise pH. 3. The client's lungs "blow off" CO2 to raise pH. 4. The client's lungs retain CO2 to lower pH.

1. The client's kidneys will excrete more HCO3 to lower the pH.

50. A nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse understands that this type of fluid loss can occur through: 1. The skin 2. Urinary output 3. Wound drainage 4. The gastrointestinal tract

1. The skin

A 57 year old homeless female with a history of alcohol abuse has been admitted to your hospital unit. She was admitted with signs and symptoms of hypovolemia- minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition would she be presenting with? 1. Third-spacing 2. Pitting edema 3. Anasarca 4. Hypervolemia

1. Third-spacing

A 57-year-old homeless female with a history of alcohol abuse has been admitted to your hospital unit. She was admitted with signs and symptoms of hypovolemia - minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting? 1. Third-spacing 2. Pitting edema 3. Anasarca 4. Hypovolemia

1. Third-spacing

To confirm an acid-base imbalance, it is necessary to assess which of the following findings from the results of a client's arterial blood gas (ABG) results? Select all that apply. 1. pH 2. Glucose 3. PaCO2 4. Sodium 5. Potassium 6. HCO3

1. pH 3. PaCO2 6. HCO3

When evaluating arterial blood gases (ABGs), which value is consistent with alkalosis? 1. pH 7.48 2. PaCO 36 3. HCO 21 mEq/L 4. O2 saturation 95%

1. pH 7.48

27. A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client? 1. Deficient fluid volume related to decreased fluid intake 2. Excess fluid volume related to increased water retention 3. Deficient fluid volume related to excessive fluid loss 4. Risk for injury related to fluid volume loss

2. Explanation: The client exhibits signs of excess fluid volume. Syndrome of inappropriate antidiuretic hormone (SIADH) is the release of excess ADH by the pituitary gland, which results in hypervolemic hyponatremia and clinical manifestations of headache, weight gain, and nausea.

20. A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition? 1. D5.45 NS at 50 ml/hr 2. 0.9 NS at an open rate 3. D5W at 125 ml/hr 4. 0.45 NS at open rate

2. 0.9 NS at an open rate Explanation: A client who recently had surgery, is vomiting, becomes dizzy when standing up, has a blood pressure of 55/30, and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume. Hypotonic fluids such as 0.45 NS will leave the intravascular space. D5W will metabolize into free water and leave the intravascular space. D5.45 NS is a good maintenance fluid but a rate of 50 ml per hour is not sufficient to expand the vascular volume quickly.

14. The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients? 1. A client with osteoporosis taking vitamin D and calcium supplements 2. A client who is alcoholic receiving total parenteral nutrition 3. A client with chronic renal failure awaiting the first dialysis run 4. A client with hypoparathyroidism secondary to thyroid surgery

2. A client who is alcoholic receiving total parenteral nutrition Explanation: A client with osteoporosis taking vitamin and calcium supplements, a client with chronic renal failure awaiting dialysis, and a client with hypoparathyroidism secondary to thyroid surgery are at risk for hyperphosphatemia. Alcoholics and clients receiving TPN are at risk for low phosphorus levels, due to poor intestinal absorption and shifting of phosphorus into cells along with insulin and glucose.

Maintaining fluid balance, especially in older adults , can be a challenge. Hypovolemia is best avoided as it can lead to hemoconcentration. Identify some of the life-threatening conditions that can result from development of hemoconcentration and hypovolemia. CHOOSE ALL THAT APPLY: 1. Metabolic acidosis 2. Blood clots 3. Metabolic alkalosis 4. Urinary calculi

2. Blood clots 4. Urinary calculi

15. A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dl. The nurse should instruct the client to avoid which of the following foods upon discharge? Select all that apply. 1. Eggs 2. Broccoli 3. Organ meats 4. Nuts 5. Canned salmon

2. Broccoli 4. Nuts 5. Canned salmon Explanation: Fish, eggs, and organ meats are high in phosphorus. Broccoli, nuts, and canned salmon are high in calcium. Clients with lung or breast cancer often have elevated calcium levels due to tumor-induced hyperparathyroidism.

When a client's ventilation is impaired, the body retains which substance? 1. Sodium bicarbonate 2. Carbon dioxide (CO2) 3. Nitrous oxide 4. Oxygen

2. Carbon dioxide (CO2)

Which of the following electrolytes is a major anion in body fluid? 1. Calcium 2. Chloride 3. Potassium 4. Sodium

2. Chloride

3. A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention? 1. Request a physical therapy consult from the physician 2. Ensure the client is safe from falls and check the most recent potassium level 3. Allow uninterrupted rest periods throughout the day 4. Encourage the client to increase intake of dairy products and green leafy vegetables.

2. Ensure the client is safe from falls and check the most recent potassium level Explanation: In the treatment of diabetic ketoacidosis, the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium.

Your client has a diagnosis of hypervolemia. What would be an important intervention that you would initiate? 1. Give medications that promote fluid retention. 2. Limit sodium and water intake. 3. Assess for dehydration. 4. Teach client behaviors that decrease urination.

2. Limit sodium and water intake.

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanism associated with hypovolemia would cause what clinical manifestations? CHOOSE ALL THAT APPLY: 1. Hypertension 2. Oliguria 3. Tachycardia 4. Tachypnea 5. Bradycardia

2. Oliguria 3. Tachycardia 4. Tachypnea

A patient has been involved in a traumatic accident and is hemorrhaging from multiple sites. The nurse expects that the compensatory mechanisms associated with hypovolemia would cause what clinical manifestations? (Select all that apply.) 1. Hypertension 2. Oliguria 3. Tachycardia 4. Tachypnea 5. Bradycardia

2. Oliguria 3. Tachycardia 4. Tachypnea

5. The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client's serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action? 1. Call the physician and report results 2. Question the results and redraw the specimen 3. Encourage the client to increase the intake of bananas 4. Initiate seizure precautions

2. Question the results and redraw the specimen A client who has been in good health up to the present is admitted for cellulitis of the hands. When the serum potassium goes from 4.5 mEq/L to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen. The physician would likely question results as well. Bananas are a food high in potassium. Seizures are not a clinical manifestation of hyperkalemia.

17. The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure? 1. Increase intake of dairy products and nuts 2. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals 3. Reduce intake of chocolate, meats, and whole grains 4. Avoid calcium supplements

2. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals Explanation: Aluminum-based antacids are often prescribed in the treatment of renal failure to bind with phosphate and increase elimination through the GI tract. Dairy products and nuts are foods high in phosphorus. Chocolate, meats, and whole grains are foods high in magnesium. Clients with renal failure often require calcium supplements as a result of poor vitamin D metabolism and in order to prevent hyperphosphatemia.

28. The registered nurse is delegating nursing tasks for the day. Which of the following tasks may the nurse delegate to a licensed practical nurse? 1. Assess a client for metabolic acidosis 2. Evaluate the blood gases of a client with respiratory alkalosis 3. Obtain a glucose level on a client admitted with diabetes mellitus 4. Perform a neurological assessment on a client suspected of having hypocalcemia

3. Explanation: A licensed practical nurse may obtain a finger-sick glucose on a client with diabetes mellitus. A licensed practical nurse may not assess a client for metabolic acidosis, evaluate blood gases on a client with respiratory alkalosis, or perform a neurological assessment on a client suspected of hypocalcemia.

26. A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low? 1. Bone pain 2. Depressed deep tendon reflexes 3. Positive Chvostek's sign 4. Nausea

3. Explanation: Numbness and tingling around the mouth indicate hypocalcemia, which results in neuromuscular irritability. A positive Chvostek's sign is the contraction of facial muscles when the facial nerve in front of the ear is tapped. Bone pain, nausea, and depressed deep tendon reflexes are signs of hypercalcemia.

10. An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating 1. "The client may be suffering from dementia, and the hospitalization has worsened the confusion." 2. "Most older adults get confused in the hospital." 3. "The sodium level is low, and the confusion will resolve as the levels normalize." 4. "The sodium level is high and the behavior is a result of dehydration."

3. "The sodium level is low, and the confusion will resolve as the levels normalize." Explanation: Normal serum level is 135 to 145 mEq/L. Neurological symptoms occur when sodium levels fall below 120 mEq/L. The confusion is an acute condition that will go away as the sodium levels normalize. Dementia is an irreversible condition.

The normal serum value for potassium is? 1. 135 to 145 mEq/L. 2. 96 to 106 mEq/L. 3. 3.5 to 5.0 mEq/L. 4. 8.5 to 10.5 mg/dL

3. 3.5 to 5.0 mEq/L.

11. A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority? 1. Turn down the infusion 2. Check the latest sodium level 3. Assess for signs of fluid overload 4. Place a call to the physician

3. Assess for signs of fluid overload Explanation A complication of hypertonic sodium solution administration is fluid overload. While turning down the infusion, checking the latest sodium level, and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next.

8. A client with heart failure is complaining of nausea. The client has received IV furosemide (Lasix), and the urine output has been 2500 ml over the past 12 hours. The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins. Which of the following are the appropriate nursing actions before administering the digoxin? Select all that apply. 1. Administer an antiemetic prior to giving the digoxin 2. Encourage the client to increase fluid intake 3. Call the physician 4. Report the urine output 5. Report indications of nausea

3. Call the physician 4. Report the urine output 5. Report indications of nausea Explanation: Potassium is lost during diuresis with a loop diuretic such as furosemide (Lasix). Hypokalemia can cause digitalis toxicity, which often results in nausea. The physician should be notified, and digoxin should be held until potassium levels and digoxin levels are checked. Peaked T waves and widened QRS are manifestations of hyperkalemia.

A nurse is caring for a client who has a laboratory finding of serum potassium 5.4 mEq/L. The nurse should assess for which of the following clinical manifestations? 1. Polyuria 2. Constipation 3. ECG changes 4. Hypotension

3. ECG changes

25. A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse? 1. "The fluid is an adverse reaction to chemotherapy." 2. "A decrease in activity has allowed extra fluid to accumulate in the tissues." 3. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." 4. "Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues."

3. Explanation: Generalized edema, or anasarca, is often seen in clients with low albumin levels secondary to poor nutrition. Decreased oncotic pressure within the blood vessels allows fluid to move from the intravascular space to the interstitial space.

22. A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder? 1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Metabolic acidosis

3. Metabolic alkalosis Explanation: Clients with gastric suctioning can lose hydrogen ions resulting in a metabolic alkalosis.

The priority nursing intervention for a client with hypervolemia involves which of the following? 1. Establishing I.V. access with a large-bore catheter. 2. Drawing a blood sample for typing and cross-matching. 3. Monitoring respiratory status for signs and symptoms of pulmonary complications. 4. Encouragins the client to consume sodium-free fluids.

3. Monitoring respiratory status for signs and symptoms of pulmonary complications.

The priority nursing intervention for a client with hypervolemia involves which of the following? 1. Extstablishing I.V. access with a large-bore catheter. 2. Drawing a blood sample for typing and cross matching. 3. Monitoring respiratory status for signs and symptoms of pulmonary complications. 4. Encouraging the client to consume sodium-free fluids.

3. Monitoring respiratory status for signs and symptoms of pulmonary complications.

18. A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention? 1. Administer a sedative 2. Place client in left lateral position 3. Place client in high-Fowler's position 4. Assist the client to breathe into a paper bag

3. Place client in high-Fowler's position Explanation: The client with a pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis. Placing the client in high-Fowler's position will facilitate the expansion of the lungs and help the client blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher

A patient's lab results show a slight decrease in potassium. The physician has declined to treat with drug therapy but has suggested increasing potassium through diet. Which of the following would be a good source of potassium? 1. Apples 2. Asparagus 3. Potatoes 4. Carrots

3. Potatoes

You notify the physician that your client is third-spacing fluid. What orders would you expect the physician to give you? 1. Restrict fluids 2. Administer diuretics 3. Start IV fluids and blood products 4. Increase sodium in diet

3. Start IV fluids and blood products

In a pre-nursing pathophysiology class the instructor is teaching about the regulation of fluid volume. How is fluid volume primarily regulated? 1. Breathing 2. Perspiration 3. Urine excretion 4. Bowel elimination

3. Urine excretion

4. A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor 1. urine output. 2. blood pressure. 3. bowel movements. 4. ECG for tall, peaked T waves.

3. bowel movements. Explanation Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L

A patient who has a diagnosis 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 which of the following ? 1. complete blood count results, particularly the platelets 2. EEG results 3. electrolytes, particularly the serum sodium 4. urine analysis, particularly for the presence of white blood cells

3. electrolytes, particularly the serum sodium

21. A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis? 1. pH of 7.43, PCO2 of 36, HCO3 of 26 2. pH of 7.41, PCO2 of 49, HCO3 of 30 3. pH of 7.33, PCO2 of 35, HCO3 of 17 4. pH of 7.25, PCO2 of 56, HCO3 of 28

3. pH of 7.33, PCO2 of 35, HCO3 of 17

19. A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning's ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse's first intervention? 1. Call the physician and report the change in client's condition 2. Turn the client's O2 up to 4 liters nasal cannula 3. Encourage the client to sit down and to take deep breaths 4. Encourage the client to rest and to use pursed-lip breathing technique

4. Encourage the client to rest and to use pursed-lip breathing technique Explanation: Clients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations. Deep breaths are not helpful, because clients with COPD have difficulty with air trapping in alveoli. There is no need to call the physician, since this client is presently most likely at baseline.

16. A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment? 1. Sodium 2. Phosphorus 3. Calcium 4. Magnesium

4. Magnesium Explanation: Low serum magnesium levels can inhibit potassium ions from crossing cell membranes, resulting in potassium loss through the urine. Generally, low magnesium levels must be corrected before potassium replacement is effective.

12. A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home? 1. Bisacodyl (Dulcolax) suppository 2. Fiber supplements 3. Docusate sodium 4. Milk of magnesia

4. Milk of magnesia Explanation Milk of magnesia contains magnesium, an electrolyte that is excreted by kidneys. Clients with renal failure are at risk for hypermagnesemia, since their bodies cannot excrete the excess magnesium. The client should avoid magnesium-containing laxatives.

13. A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action? 1. Encourage the client to increase fluid intake 2. Administer the dose as ordered 3. Draw a potassium level and administer the dose if the level is low or normal 4. Notify the physician of the urine output and hold the dose

4. Notify the physician of the urine output and hold the dose Explanation: Urine output is an indication of renal function. Normal urine output is at least 30 ml/hour. Clients with impaired renal function are at risk for hyperkalemia. Initiating a lab draw requires a physician order.

The calcium level of the blood is regulated by which mechanism? 1. Androgens 2. Adrenal gland 3. Thyroid hormone (TH) 4. Parathyroid hormone (PTH)

4. Parathyroid hormone (PTH)

A client with pancreatic cancer has the following blood chemistry profile: Glucose, fasting: 204 mg/dl; blood urea nitrogen (BUN): 12 mg/dl; Creatinine: 0.9 mg/dl; Sodium: 136 mEq/L; Potassium: 2.2 mEq/L; Chloride: 99 mEq/L; CO2: 33 mEq/L. Which result should the nurse identify as critical and report immediately? 1. CO2 2. Sodium 3. Chloride 4. Potassium

4. Potassium

23. A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers. ABG values are pH of 7.48, PaCO2 of 29, HCO3 of 24, and O2 is at 93% on room air. The nurse performs which of the following as a priority nursing intervention? 1. Monitor intake and output 2. Encourage client to increase activity 3. Institute deep breathing exercises every hour 4. Provide reassurance to the client and administer sedatives

4. Provide reassurance to the client and administer sedatives Explanation: A client who is anxious and upset, gets lightheaded, and has tingling in the fingers is in respiratory alkalosis. The arterial blood gases include a pH of 7.48, PaCO2 of 29, and HCO3 of 24. Administering sedatives will assist the client to slow breathe and retain more CO2, thus bringing the pH back into normal range. Deep breathing exercises may worsen the client's condition. Encouraging the client to increase activity is contraindicated because clients are often exhausted and require rest after expending so much energy breathing. Monitoring intake and output is not a priority.

A client has a serum calcium level of 7.2 mg/dl. During the physical examination, the nurse should assess: 1. Goodell's sign. 2.Hegar's sign. 3. Homans' sign. 4. Trousseau's sign.

4. Trousseau's Sign

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? 1. pH, 7.5; PaCO2 30 mm Hg 2. pH, 7.40; PaCO2 35 mm Hg 3. pH, 7.35; PaCO2 40 mm Hg 4. pH, 7.25; PaCO2 50 mm Hg

4. pH, 7.25; PaCO2 50 mm Hg

1. A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance? A. Hyponatremia B. Hypocalcemia C. Hyperkalemia D. Hypermagnesemia

B. Hypocalcemia Explanation: Hypoparathyroidism can cause low serum calcium levels. Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia. Normal calcium level is 9 to 11 mg/dl.