Pharm EOC, Chapter 33: Pharmacotherapy of Fluid Imbalance, Electrolyte, and Acid -- Base Disorders, Review FE, Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances, Chapter 16: Fluid, Electrolyte, and Acid-Base Imbalances
12. Which patient is at risk for hypernatremia? a. Has an aldosterone deficiency b. Has prolonged vomiting and diarrhea c. Receives excessive IV 5% dextrose solution d. Has impaired consciousness and decreased thirst sensitivity
12. d. A major cause of hypernatremia is a water deficit, which can occur in those with a decreased sensitivity to thirst, the major protection against hyperosmolality. All other conditions lead to hyponatremia.
13. In a patient with sodium imbalances, the primary clinical manifestations are related to alterations in what body system? a. Kidneys b. Cardiovascular system c. Musculoskeletal system d. Central nervous system
13. d. As water shifts into and out of cells in response to the osmolality of the blood, the cells that are most sensitive to shrinking or swelling are those of the brain, resulting in neurologic symptoms.
14. Match the electrolyte imbalances with their associated causes (answers may be used more than once and imbalances may have more than 1 associated cause).
14. a. 4; b. 6; c. 1; d. 1, 4, 6, 7; e. 2; f. 4, 8, 9; g. 2, 3; h. 4, 6, 8, 10; i. 6, 8; j. 1, 4; k. 5; l. 1, 4; m. 3, 6, 7, 9; n. 1, 2, 4, 5, 6
A nurse is caring for a client who has a blood potassium 5.4 meq/L. The nurse should assess for which of the following manifestations? A. eCG changes B. Constipation C. Polyuria d. Paresthesia
A. CORRECT: Assess for eCG changes. Potassium levels can affect the heart and result in arrhythmias. B. Constipation is a manifestation of hypokalemia. C. Polyuria is a manifestation of hypokalemia.d. Paresthesia is a manifestation of hypokalemia.
19) A client has a serum sodium level of 157 mEq/L. Which area of assessment is the priority? 1. Muscle pain 2. Daily weight 3. Thirst level 4. Level of consciousness
Answer: 4 Explanation: Hypernatremia can cause increased intracranial pressure. This should be reported to the healthcare provider immediately. Page Ref: 570
13) A client with long-standing hepatic cirrhosis might receive which intravenous solution to correct hypoproteinemia? 1. Dextrose 5% 2. Packed red cells 3. Whole blood 4. Albumin
Answer: 4 Explanation: Normal serum albumin is the preferred treatment for hypoproteinemia in a client with hepatic cirrhosis. Page Ref: 565
27) A client being treated long term with oral sodium bicarbonate should be monitored for which acid—base imbalance? 1. Metabolic acidosis 2. Respiratory acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis
Answer: 4 Explanation: Overdose or long-term use of sodium bicarbonate results in metabolic alkalosis. Page Ref: 576
5) A nurse is evaluating a client's serum osmolality. Which solute is not factored into this value? 1. Sodium 2. Glucose 3. Urea 4. Water
Answer: 4 Explanation: Water is not a solute. Page Ref: 563
15. A patient is taking diuretic drugs. Which fluid or electrolyte imbalance can occur in this patient (select all that apply)? a. Hyperkalemia b. Hyponatremia c. Hypocalcemia d. Hypotonic fluid loss e. Hypertonic fluid loss
15. b, c. Because of the osmotic pressure of sodium, water will be excreted with the sodium lost with the diuretic. A change in the relative concentration of sodium will not be seen, but an isotonic fluid loss will occur. Diuretics can also cause a loss of calcium in the urine.
10. While caring for an 84-year-old patient, the nurse monitors the patient's fluid and electrolyte balance, recognizing what as a normal change of aging? a. Hyperkalemia b. Hyponatremia c. Decreased insensible fluid loss d. Increased plasma oncotic pressures
10. b. A decrease in renin and aldosterone and an increase in ADH and atrial natriuretic peptide (ANP) lead to decreased sodium reabsorption and increased water retention by the kidney, both of which lead to hyponatremia. Loss of subcutaneous tissue and thinning dermis of aging lead to increased moisture lost through the skin. Plasma oncotic pressure is often decreased because of lack of protein intake.
1. A patient with consistent dietary intake who loses 1 kg of weight in 1 day has lost _________________ mL of fluid.
1000
11. The nurse is admitting a patient to the clinical unit from surgery. Being alert to potential fluid volume alterations, what assessment data will be important for the nurse to monitor to identify early changes in the patient's postoperative fluid volume (select all that apply)? a. Intake and output b. Skin turgor c. Lung sounds d. Respiratory rate e. Level of consciousness
11. a, b, c, d, e. All of these are important in assessing fluid balance in a postoperative patient. Daily weight along with these assessments will provide data about potential fluid volume abnormalities.
16. A common collaborative problem related to both hyperkalemia and hypokalemia is which potential complication? a. Seizures b. Paralysis c. Dysrhythmias d. Acute kidney injury
16. c. Potassium maintains normal cardiac rhythm, transmission and conduction of nerve impulses, and contraction of muscles. Cardiac cells have the most clinically significant changes with potassium imbalances because of changes in cardiac conduction. Although paralysis may occur with severe potassium imbalances, cardiac changes are seen earlier and much more commonly.
With which disorder is hyperkalemia often associated? a. Hypoglycemia b. Metabolic acidosis c. Respiratory alkalosis d. Decreased urine potassium levels
17. b. In metabolic acidosis, hydrogen ions in the blood are taken into the cell in exchange for potassium ions as a means of buffering excess acids. This results in an increase in serum potassium until the kidneys have time to excrete the excess potassium.
In a patient with a positive Chvostek's sign, the nurse would expect the IV administration of which medication? a. Calcitonin b. Vitamin D c. Loop diuretics d. Calcium gluconate
18. d. Chvostek's sign is a contraction of facial muscles in response to a tap over the facial nerve. This indicates the neuromuscular irritability of low calcium levels. IV calcium is the treatment used to prevent laryngeal spasms and respiratory arrest. Calcitonin and loop diuretics are treatments for hypercalcemia. Oral vitamin D supplements are part of the treatment for hypocalcemia but not for impending tetany.
19. A patient with chronic kidney disease has hyperphosphatemia. What is a commonly associated electrolyte imbalance? a. Hypokalemia b. Hyponatremia c. Hypocalcemia d. Hypomagnesemia
19. c. Kidneys are the major route of phosphate excretion, a function that is impaired in renal failure. A reciprocal relationship exists between phosphorus and calcium, and high serum phosphate levels of kidney failure cause low calcium concentration in the serum.
2 The nurse is teaching the patient about a liquid potassium chloride supplement. Which statement, if made by the patient, indicates that further teaching is necessary? "I should avoid salt substitutes unless approved by my health care provider." "Liquid preparations should not be diluted with other fluids." "I should report signs of potassium deficit such as weakness and fatigue." "Persistent vomiting will result in significant losses of potassium."
2 Answer: 2 Rationale: Liquid preparations are very irritating to the gastric mucosa and should always be diluted with juice or water. Options 1, 3, and 4 are incorrect. Salt substitutes are high in potassium and should be avoided by patients on potassium supplementation. Symptoms such as weakness or fatigue may be the first indicators of potassium imbalances. The GI secretions are rich in potassium. Episodes of persistent vomiting may lead to hypokalemia and should be reported to the health care provider. Cognitive Level: Applying; Client Need: Physiological Integrity; Nursing Process: Evaluation
29. To provide free water and intracellular fluid hydration for a patient with acute gastroenteritis who is NPO, the nurse would expect administration of which infusion? a. Dextrose 5% in water b. Dextrose 10% in water c. Lactated Ringer's solution d. Dextrose 5% in normal saline (0.9%)
29. a. Fluids such as 5% dextrose in water (D5W) allow water to move from the ECF to the ICF. Although D5W is physiologically isotonic, the dextrose is rapidly metabolized, leaving free water to shift into cells.
3 The nurse is administering dextran 40 (Gentran 40) to a patient with multiple traumatic injuries following a motor vehicle crash. The nurse knows that which adverse effect of this medication is toxic? A. DehydrationB. Increased urinary output C. Hypovolemic shockD. Bleeding
3 Answer: 4 Rationale: Dextran 40 interferes with coagulation and reduces blood viscosity. Bleeding, potentially severe, is associated with these effects. Options 1, 2, and 3 are incorrect. Dextran solutions are used to correct low circulating blood volume states. This solution does not cause dehydration. Dextran increases the circulating volume and thereby increases urine output, which is a therapeutic effect of the solution. Dextran is used for shock (hypovolemia); it does not cause shock. Cognitive Level: Analyzing; Client Need: Physiological Integrity; Nursing Process: Evaluation
3. Which statement(s) about fluid in the human body is (are) true (select all that apply)? a. The primary hypothalamic mechanism of water intake is thirst.b. Third spacing refers to the abnormal movement of fluid into interstitial spaces.c. A cell surrounded by hypoosmolar fluid will shrink and die as water moves out of the cell. d. A cell surrounded by hyperosmolar fluid will shrink and die as water moves out of the cell.e. Concentrations of Na+ and K+ in interstitial and intracellular fluids are maintained by the sodium-potassium pump.
3. a, d, e. With fluid volume deficit, the osmoreceptors stimulate thirst. Hyperosmolar extracellular fluid (ECF) draws fluid out of the cells. The sodium-potassium pump maintains the fluid balance between the intracellular fluid (ICF) and ECF. Third spacing is when fluid moves into spaces that normally have little or no fluid. A cell surrounded by hypoosmolar fluid will swell and burst as water moves into the cell.
30. What is an example of an appropriate IV solution to treat an extracellular fluid volume deficit? a. D5W b. 3% saline c. Lactated Ringer's solution d. D5W in 1⁄2 normal saline (0.45%)
30. c. An isotonic solution does not change the osmolality of the blood and does not cause fluid shifts between the ECF and ICF. In the case of ECF loss, an isotonic solution, such as lactated Ringer's solution, is ideal because it stays in the extracellular compartment. A hypertonic solution would pull fluid from the cells into the ECF, resulting in cellular fluid loss and possible vascular overload.
31. Priority Decision: On assessment of a central venous access device (CVAD) site, the nurse notes that the transparent dressing is loose along 2 sides. What should the nurse do immediately? a. Wait and change the dressing when it is due. b. Tape the 2 loose sides down and document. c. Apply a gauze dressing over the transparent dressing and tape securely. d. Remove the dressing and apply a new transparent dressing using sterile technique.
31. d. The greatest risk with central venous access device (CVAD) is systemic infection. Dressings that are loose should be changed at once to reduce this risk.
33. A patient is scheduled to have a tunneled catheter placed for administration of chemotherapy for breast cancer. When preparing the patient for the catheter insertion, what does the nurse explain about this method of chemotherapy administration? a. Decreases the risk for extravasation at the infusion site b. Reduces the incidence of systemic side effects of the drug c. Does not become occluded as peripherally inserted catheters can d. Allows continuous infusion of the drug directly to the area of the tumor
33. a. Catheters tunneled to the distal end of the superior vena cava or the right atrium are vascular access devices inserted into central veins, which decrease the incidence of extravasation, provide for rapid dilution of chemotherapy, and reduce the need for venipunctures. Most right atrial catheters, except for a Groshong catheter, must be flushed with heparin to prevent clotting in the tubing. Regional chemotherapy administration delivers the drug directly to the tumor and is the only administration route that can decrease the systemic effects of the drugs.
34. The nurse is reviewing a patient's morning laboratory results. Which result is of greatest concern? a. Serum Na+ of 150 mEq/L b. Serum Mg2 + of 1.1 mEq/L c. Serum PO43 − of 4.5 mg/dL d. Serum Ca2 + (total) of 8.6 mg/dL
34. b. With a low magnesium level there is an increased risk for hypokalemia and hypocalcemia as well as altered sodium-potassium pump and altered carbohydrate and protein metabolism. Hypokalemia could lead to dysrhythmias and severe muscle weakness. The sodium and phosphate levels are also not within normal limits. However, the implications are not as life-threatening. The calcium level is normal.
4 The patient will be receiving 5% dextrose in water (D5W) intravenous infusion. Which statement is correct about this therapy? D5W can cause hypoglycemia in the patient who has diabetes. D5W may be used to dilute mixed intravenous drugs. D5W is considered a colloid solution. D5W has a sufficient number of calories to supply metabolic needs.
4 Answer: 2 Rationale: This solution is often used to dilute (reconstitute) powdered forms of drugs that are intended to be given parenterally. Options 1, 3, and 4 are incorrect. This solution can cause hyperglycemia in the patient with diabetes due to the dextrose content. D5W is considered a crystalloid solution. One liter of this solution supplies only 170 calories, which is not enough to supply the metabolic nutritional needs of adult patients. Cognitive Level: Applying; Client Need: Physiological Integrity; Nursing Process: Implementation
5 The health care provider orders intravenous magnesium sulfate for a pregnant patient with preeclampsia. The nurse should consult with the prescriber about which patient assessment finding that may affect the drug therapy? A. Pupil constriction to direct light B. Chest congestion and coughing C. Elevated blood pressure D. Decreased patellar deep tendon reflexes
5 Answer: 4 Rationale: Magnesium sulfate toxicity may cause significant neuromuscular depression as noted by changes in level of consciousness and diminished deep tendon reflexes. Options 1, 2, and 3 are incorrect. Pupillary constriction to bright light is a normal physiological response. The nurse should notify the prescriber when the patient develops chest congestion and coughing, but they are not directly associated with magnesium sulfate toxicity. Elevated blood pressure is common in preeclampsia but it is not associated with magnesium toxicity. Cognitive Level: Applying; Client Need: Physiological Integrity; Nursing Process: Implementation
2. A man who weighs 90 kg has a total body water content of approximately _________________ L.
54 to 45 L: 90 kg × 60% = 54, 90 kg × 50% = 45
6 Which of the following nursing actions should be included in the care plan for a patient receiving normal serum albumin (Albuminar)? Select all that apply. A. Document past history of blood transfusion reactions. B. Restrict dietary intake of food high in potassium. C. Monitor blood pressure and pulse rate. D. Measure urinary output hourly. E. Observe for signs related to potassium deficit
6 Answer: 1, 3, 4 Rationale: Normal serum albumin is a product derived from blood. Although rare, transfusion reactions can still occur with normal serum albumin. Albumin causes intercellular and interstitial fluid to move into the intravascular compartment. This movement of fluid will cause increases in the patient's blood pressure and heart rate. The nurse should monitor the patient for fluid overload with this solution. As the circulating fluid volume is corrected, the patient's urinary output will increase. Options 2 and 5 are incorrect. Patients receiving normal serum albumin typically do not have any dietary restrictions while receiving this solution. Serum albumin is not administered for potassium imbalances.
6. As fluid circulates through the capillaries, there is movement of fluid between the capillaries and interstitium. What describes the fluid movement that would cause edema (select all that apply)? a. Plasma hydrostatic pressure is less than plasma oncotic pressure.b. Plasma oncotic pressure is higher than interstitial oncotic pressure. c. Plasma hydrostatic pressure is higher than plasma oncotic pressure. d. Plasma hydrostatic pressure is less than interstitial hydrostatic pressure.e. Interstitial hydrostatic pressure is lower than plasma hydrostatic pressure.
6. c, e. At the arterial end of the capillary, capillary hydrostatic pressure exceeds plasma oncotic pressure and fluid moves into the interstitial space. At the capillary level, hydrostatic pressure is the major force causing fluid to shift from vascular to the interstitial space. The other options would not cause edema.
8. A woman has ham with gravy and green beans cooked with salt pork for dinner. a. What could happen to the woman's serum osmolality because of this meal? b. What fluid regulation mechanisms are stimulated by the intake of these foods?
8. a. Serum osmolality increases as a large amount of sodium is absorbed. b. Intake of these foods stimulates antidiuretic hormone (ADH) release from the posterior pituitary, which increases water reabsorption from the kidney, lowering the sodium concentration but increasing vascular volume and hydrostatic pressure, perhaps causing fluid shift into interstitial spaces.
9. What stimulates aldosterone secretion from the adrenal cortex? a. Excessive water intake b. Increased serum osmolality c. Decreased serum potassium d. Decreased sodium and water
9. d. Aldosterone is secreted by the adrenal cortex in response to a decrease in plasma volume (loss of water) and resulting decreased renal perfusion; decreased serum sodium, increased serum potassium, or adrenocorticotropic hormone (ACTH).
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances? A. Hypercalcemia B. Hyponatremia C. Hyperphosphatemia d. Hyperkalemia
A. An increase in calcium is not indicated with nasogastric losses due to suctioning. B. CORRECT: Monitor the client for hyponatremia. Nasogastric losses are isotonic and contain sodium. C. Hyperphosphatemia is not indicated with nasogastric losses due to suctioning. d. A decrease in potassium can occur from nasogastric losses due to suctioning.
A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? a. Apply a blood pressure cuff to the client's arm. b. Place the stethoscope bell over the client's carotid artery. c. Tap lightly on the client's cheek. d. Ask the client to lower their chin to their chest.
A. Applying a blood pressure cuff to the client's arm is performed to assess for Trousseau's sign. B. Placing the stethoscope bell over the client's carotid artery is performed to auscultate a carotid bruit. C. CORRECT: Tap the client's cheek over the facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response is indicated when the client exhibits facial twitching on this side of the face. d. Asking the client to lower their chin to their chest is performed to assess for range of motion of the neck.
A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the following conditions as being associated with this electrolyte imbalance? A. diabetic ketoacidosis B. Heart failure C. Cushing's syndrome d. Thyroidectomy
A. CORRECT: Hyperkalemia, an increase in blood potassium, is a laboratory finding associated with diabetic ketoacidosis. B. Hyponatremia, a decrease in blood sodium, is a laboratory finding associated with heart failure. C. Hypernatremia, an increase in blood sodium, is a laboratory finding associated with Cushing's syndrome. d. Hypocalcemia, a decrease in blood calcium, is a laboratory finding that is found in clients following a thyroidectomy.
1. A nurse is caring for a client who has a blood sodium level 133 meq/L and blood potassium level 3.4 meq/L. The nurse should recognize that which of the following treatments can result in these laboratory findings? a. Three tap water enemas b. 0.9% sodium chloride solution iV at 50 mL/hr c. 5% dextrose with 0.45% sodium chloride solution with 20 meq of K+ iV at 80 mL/hr d. Antibiotic therapy
A. CORRECT: Three tap water enemas can result in a decrease in blood sodium and potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic. This creates an imbalance and solute dilution. B. 0.9% sodium chloride is an isotonic solution and will not produce these results. C. 5% dextrose with 0.45% sodium chloride is an isotonic solution with 20 meq of K+ at 80 mL/hr and would not produce these results. d. Antibiotic therapy would not produce these results.
6) When planning care, the nurse anticipates that which client will most likely require intravenous fluid replacement? 1. A client with a minor burn to the left arm 2. A client diagnosed with heart failure 3. A client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) 4. A client diagnosed with shock
Answer: 4 Explanation: A client in shock will require intravenous fluid replacement secondary to hypotension and fluid shifting. Page Ref: 563-564
26) A nurse is providing care to several postsurgical clients. Which prescription would the nurse question? 1. Infuse potassium chloride 40 mEq, IV push over 1 minute, once. 2. Infuse potassium chloride 40 mEq in 250 mL NaCl, over 4 hours, once. 3. Administer potassium chloride 20 mEq, by mouth, once. 4. Administer potassium chloride, 20 mEq diluted in 90 mL juice, by mouth, once.
Answer: 1 Explanation: Never give potassium as an IV push or in concentrated amounts by any route. Page Ref: 573
31) A nurse is scheduled to administer a potassium supplement to a client. Which action should the nurse take prior to administering the drug? 1. Check the client's potassium level from the morning labs. 2. Tell the client that the infusion will burn. 3. Place the client in a low Fowler's position. 4. Ask the client why the medication is ordered.
Answer: 1 Explanation: Serial serum potassium levels should be monitored before and during therapy. Page Ref: 573
23) A nursing instructor asks a student at what point it is appropriate to treat hyponatremia. Which response by the student is accurate? 1. "When serum levels fall below 130 mEq/L." 2. "When serum levels fall below 140 mEq/L." 3. "When serum levels fall below 145 mEq/L." 4. "When serum levels fall below 155 mEq/L."
Answer: 1 Explanation: Sodium chloride is administered for hyponatremia when serum levels fall below 130 mEq/L. Page Ref: 570
24) When infusing 3% NaCl solutions, which clinical manifestation will the nurse continuously check for? 1. Signs of pulmonary edema 2. Hyponatremia 3. Signs of thirst 4. Signs of depression
Answer: 1 Explanation: Solutions of 3% NaCl can cause increased intravascular fluid volume, which can lead to pulmonary edema. Page Ref: 570
30) A client is prescribed ammonium chloride. Which statement indicates an appropriate understanding after medication teaching? 1. "I will report sleepiness right away." 2. "It's okay if this medication makes me a little shaky." 3. "Confusion will be normal for a day or so." 4. "The IV infusion is going to be painful."
Answer: 1 Explanation: Symptoms of excessive drowsiness or confusion should be reported immediately because they are signs of overdose. Page Ref: 577
Cognitive Level: Remembering2) A client is prescribed a transfusion of fresh frozen plasma (FFP). The nurse plans care based on the knowledge that the transfusion will complete which process? 1. Replace multifactor deficiency states. 2. Rehydrate cells. 3. Dehydrate cells. 4. Cause fluid to shift out of the intravascular space.
Answer: 1 Explanation: Transfusing FFP will replace multifactor deficiency states when specific factors are not available. Page Ref: 564-565
10) When a nurse administers a hypotonic intravenous solution to a client, how will the water move? 1. By osmosis from the plasma compartment to the interstitial compartment 2. By diffusion from the plasma compartment to the interstitial compartment 3. By diffusion from the interstitial compartment to the plasma compartment 4. By osmosis from the interstitial compartment to the plasma compartment
Answer: 1 Explanation: Water will move from the plasma compartment to the interstitial compartment, by osmosis, in response to administration of hypotonic intravenous solutions. Page Ref: 563
7) When treating fluid imbalances, which is the ultimate goal of care? 1. To diagnose and correct the underlying cause of the disorder 2. To maintain normal vital signs 3. To keep clients normothermic 4. To administer intravenous fluids
Answer: 1 Explanation: When treating fluid imbalances, the ultimate goal of the healthcare team is to diagnose and correct the underlying cause of the disorder. Page Ref: 563
37) The nurse is preparing to administer normal serum albumin (Plasbumin) to a client with an albumin level of 3.2 g/dL. Which are appropriate classifications of Plasbumin? Select all that apply. 1. Blood product 2. Colloid 3. Crystalloid 4. Vitamin 5. Electrolyte
Answer: 1, 2 Explanation: Plasbumin is an albumin product. Albumin is considered a blood product. Plasbumin is an albumin product. Albumin is considered a colloid. Page Ref: 565
21) The nurse is caring for a client with severe electrolyte imbalances that have occurred as a result of kidney failure. The nurse knows that this client is at risk for which disorders as a result of this electrolyte imbalance? Select all that apply. 1. Fluid retention 2. Muscle spasms 3. Fractures 4. High cholesterol 5. Depression
Answer: 1, 2, 3 Explanation: Electrolytes are responsible for membrane permeability and water balance. An electrolyte imbalance, especially too much sodium, can result in fluid retention. Electrolytes are essential for muscle contractions. An imbalance in electrolytes can result in muscle spasms. Electrolytes are essential for bone growth and remodeling and may place a client at risk for fractures, especially when there is an imbalance of calcium. Page Ref: 569
32) A client is receiving an infusion of magnesium sulfate. The healthcare provider should be notified immediately if which response is observed? 1. A pulse rate of 99 beats/min 2. A blood pressure of 90/60 mmHg 3. Pain at the IV site 4. A respiratory rate of 9 breaths/min
Answer: 4 Explanation: A respiratory rate below 12 breaths/min should be reported to the healthcare provider immediately. This can indicate magnesium toxicity. Page Ref: 574
33) The nurse is preparing to administer magnesium sulfate to a pregnant client with preeclampsia. Which conditions must the nurse assess this client for while administering this medication? Select all that apply. 1. Level of consciousness 2. Deep tendon reflexes 3. Urine output 4. Neuromuscular depression 5. Magnesium level
Answer: 1, 2, 3, 5 Explanation: The nurse must monitor the client's level of consciousness while administering magnesium to determine the presence of adverse effects. The nurse must monitor the client's deep tendon reflexes while administering magnesium to determine the presence of adverse effects. The nurse must monitor the client's urine output while administering magnesium to determine the presence of adverse effects. The nurse would monitor the client's magnesium level in order to assess for toxicity. Page Ref: 57435) The nurse would be most concerned about administering which blood product to a client? 1. Fresh frozen plasma 2. Albumin 3. Whole blood 4. Packed red cellsANSAnswer: 3 Explanation: The administration of whole blood is uncommon due to potential adverse reactions and the small possibility of transmitting infectious disease. Page Ref: 564
38) The nurse is reviewing the client's medical record in preparation to administer 5% dextrose solution. Which findings would indicate a contraindication for this intravenous fluid? Select all that apply. 1. Heart failure 2. Hypoglycemia 3. Increased intracranial pressure 4. Hypernatremia 5. Hypercalcemia
Answer: 1, 3 Explanation: Heart failure is a contraindication for the administration of 5% dextrose solution. Increased intracranial pressure is a contraindication for the administration of 5% dextrose solution. Page Ref: 567
29) The nurse is caring for a client with a pH of 7.32. Which medications would be appropriate to administer to a client with this condition? Select all that apply. 1. Oral bicarbonate 2. Sodium chloride 3. Citrate salts 4. Potassium chloride 5. Ammonium chloride
Answer: 1, 3 Explanation: Oral bicarbonate is an agent used to treat acidosis. Citrate salts are an agent used to treat acidosis. Page Ref: 576
12) A seasoned nurse is caring for a client receiving intravenous fluid therapy for dehydration. The nurse knows that the osmolarity or tonicity of a fluid causes water to move to a different compartment. The nurse is caring for a client who weighs 40 kg. The osmolality of the body fluids for this client is between 11,000 and ________ milliosmoles. Record your answer rounding to the nearest whole number.
Answer: 11,800 Explanation: The normal osmolality of body fluids ranges from 275 to 295 milliosmoles per kilogram (mOsm/kg). Page Ref: 565
39) The nurse is preparing to administer a 5% dextrose in water (D5W) infusion to a client. Which explanation as to why the infusion is ordered is the most accurate? 1. "This is a colloid, and will increase the client's blood pressure." 2. "This medication is isotonic in its container, but when infused, the solution becomes hypotonic." 3. "This medication is hypotonic and will cause fluid to shift from the intravascular space into the interstitial and intracellular spaces." 4. "This medication is hypertonic and will cause fluid to shift from the extravascular space into the vascular space."
Answer: 2 Explanation: D5W is isotonic in the container. When infused, the dextrose is quickly metabolized in the body, leaving only water, and the solution becomes hypotonic. Page Ref: 567
14) A client diagnosed with diabetes insipidus is suffering from severe hypernatremia. The nurse anticipates the use of which type of intravenous solution? 1. A hypertonic crystalloid 2. A hypotonic crystalloid 3. An isotonic crystalloid 4. Albumin
Answer: 2 Explanation: Hypotonic crystalloids are indicated for clients with hypernatremia and cellular dehydration. Page Ref: 566
15) A client has vomited several times and continues to be nauseated. To correct mild hypovolemia, the nurse plans to complete which intervention? 1. Ask the client to drink 8 ounces of water every hour. 2. Administer an isotonic crystalloid. 3. Administer a hypotonic crystalloid. 4. Ask the client to drink 8 ounces of an electrolyte solution every 30 minutes for 4 hours.
Answer: 2 Explanation: Isotonic solutions are often used to tread fluid loss due to vomiting. Page Ref: 566
11) The nurse is reviewing a client's lab values, which indicate normal serum osmolality. Which intravenous solutions will not cause a fluid shift in this client? 1. Colloids 2. Isotonic solutions 3. Hypertonic solutions 4. Hypotonic solutions
Answer: 2 Explanation: Isotonic solutions will likely cause no fluid shift in this client. Page Ref: 563
18) A client prescribed 100 mL of 3% normal saline solution received 1,000 mL of 3% normal saline. Which is the priority assessment for this client? 1. Skin integrity 2. Blood pressure 3. Capillary refill 4. Coagulation profile
Answer: 2 Explanation: Overtreatment with hypertonic crystalloids such as 3% normal saline can lead to excessive expansion of the intravascular compartment, fluid overload, and hypertension. Page Ref: 566
22) A client has a serum potassium of 2.5 mEq/L. While reviewing the client's medical administration record, the nurse suspects that which medication might have contributed to this imbalance? 1. Metoprolol 2. Hydrochlorothiazide 3. Aspirin 4. Acetaminophen
Answer: 2 Explanation: The most frequent cause of hypokalemia is pharmacotherapy with loop and thiazide diuretics. Page Ref: 572
20) A nurse is caring for a client with a serum potassium level of 6.9 mEq/L. When planning care, which body system will be most profoundly affected by this value? 1. The respiratory system 2. The cardiovascular system 3. The hematologic system 4. The genitourinary system
Answer: 2 Explanation: This value represents hyperkalemia. Both hyperkalemia and hypokalemia are associated with fatal dysrhythmias and serious neuromuscular disorders. Page Ref: 572
8) The nurse is caring for a group of clients on a medical—surgical unit. For which clients would the nurse anticipate the need for intravenous fluid therapy to correct fluid depletion? Select all that apply. 1. A client suffering from constipation 2. A client exhibiting nausea and vomiting following a surgical procedure 3. A client with a severe burn 4. A client with heart failure with edema to the lower extremities and rales 5. A client with uncontrolled diabetic ketoacidosis
Answer: 2, 3, 5 Explanation: A client exhibiting nausea and vomiting may require intravenous fluid to avoid dehydration. A client with a severe burn will often require intravenous fluid due to fluid depletion that occurs from fluid shifts. A client with uncontrolled diabetic ketoacidosis often requires intravenous fluid administration for fluid depletion. Page Ref: 563
17) The nurse is reviewing the tonicity of the different intravenous fluids on the medical—surgical unit in preparation for an in-service presentation. Which fluids are considered to be isotonic and appropriate in the treatment of fluid loss due to a surgical procedure? Select all that apply. 1. 5% dextrose in lactated Ringer's 2. 0.9% sodium chloride (NS) 3. 0.45% sodium chloride 4. Lactated Ringer's 5. 5% dextrose in water
Answer: 2, 4, 5 Explanation: This is an isotonic solution and is appropriate for the treatment of fluid loss due to a surgical procedure. This is an isotonic solution and is appropriate to treat fluid loss caused by a surgical procedure. This is an isotonic solution and is appropriate to treat fluid loss caused by a surgical procedure. Page Ref: 564
4) The nurse is caring for a client who was admitted to the hospital for the treatment of dehydration. The nurse is discussing the difference between intracellular fluid and extracellular fluid and states that intracellular fluid accounts for ________ of the total amount of water in the body. Record your answer as a fraction.
Answer: 2/3 Explanation: The intracellular fluid (ICF) compartment, which contains water that is inside cells, accounts for about two thirds of the total body water. The remaining one third of body fluid resides outside cells in the extracellular fluid (ECF) compartment. Page Ref: 562
34) The nurse would question administering sodium bicarbonate to which client? 1. A client taking methotrexate 2. A client in chronic renal failure 3. A client on continuous nasogastric suctioning 4. A client diagnosed with metabolic acidosis
Answer: 3 Explanation: A client on continuous nasogastric suctioning might experience base excess secondary to loss of stomach acid, which predisposes the client to metabolic alkalosis. Page Ref: 576
28) Nurses must administer sodium bicarbonate with caution to clients with hypertension to avoid which adverse effect? 1. Respiratory acidosis 2. Metabolic acidosis 3. Retention of fluid 4. Unexpected diuresis
Answer: 3 Explanation: Administer sodium bicarbonate with caution to clients with hypertension, because this drug will promote retention of fluids. Page Ref: 576
40) The nurse is assessing a client being treated with 3% normal saline solution. Which assessment finding should be reported to the healthcare provider immediately? 1. Temperature of 100.1°F 2. Blood pressure of 146/92 mmHg 3. Presence of auscultated crackles 4. Presence of auscultated rhonchi
Answer: 3 Explanation: Crackles are a sign of pulmonary edema, which can occur with the use of 3% normal saline solution. This assessment finding should be reported to the healthcare provider immediately. Page Ref: 566
42) A client is scheduled receive a parenteral dose of magnesium sulfate. The nurse tests patellar reflexes and determines them to be absent. Which action by the nurse is the most appropriate? 1. Administer the drug as ordered, because this is a normal finding. 2. Hold the medication for 1 hour, then reassess. 3. Hold the medication and notify the healthcare provider. 4. Administer the drug after placing the client on a cardiac monitor.
Answer: 3 Explanation: Depression or absence of reflexes can indicate early magnesium intoxication. Page Ref: 573
9) A client is prescribed a hypertonic intravenous solution. Administration of this solution will most likely cause which manifestation to occur? 1. A shift of fluid from the vascular space to the interstitial space 2. No fluid shift 3. The plasma to have more solutes than the interstitial fluid 4. The plasma to have fewer solutes than the interstitial fluid
Answer: 3 Explanation: If a hypertonic solution is administered, the plasma gains more solutes than does the interstitial fluid. Page Ref: 563
25) The nurse is caring for a client with a serum sodium level of 110 mEq/L. The nurse anticipates that the client will require an infusion of ________% sodium chloride solution. Record your answer rounding to the nearest whole number.
Answer: 3 Explanation: Normal saline consists of 0.9% NaCl and is used to treat mild hyponatremia. When serum sodium falls below 115 mEq/L, a highly concentrated 3% NaCl solution may be infused. Page Ref: 571
36) Which is not an indication for the use of potassium chloride? 1. Prevention of hypokalemia 2. Treatment of hypokalemia 3. Treatment of peptic ulcer disease 4. Treatment of mild alkalosis
Answer: 3 Explanation: Potassium chloride supplements can cause peptic ulcers. Page Ref: 564
41) A nurse is providing medication teaching to a client who is prescribed potassium tablets. Which information should be included? 1. Allow potassium tablets to dissolve completely in the mouth. 2. Licorice helps alleviate the bad taste of the potassium tablets. 3. Avoid salt substitutes. 4. Add lots of potassium-rich foods to your diet.
Answer: 3 Explanation: Salt substitutes contain potassium and electrolytes other than sodium, and they could cause hyperkalemia. Page Ref: 572
3) A client has a severe fluid and electrolyte imbalance. The nurse is aware that in order for the body to move large molecules and molecules with electrical charges, which two processes are required? 1. Active transport and tonicity 2. Osmosis and active transport 3. Diffusion and active transport 4. Osmosis and diffusion
Answer: 3 Explanation: The processes of diffusion and active transport govern the movement of large molecules and those with electrical charges. Page Ref: 563
43) The nurse is caring for a client diagnosed with hyperkalemia. Which interventions are appropriate to include in the client's plan of care? Select all that apply. 1. A calcium supplement 2. A potassium supplement 3. Hypotonic fluids 4. Buffering agents 5. Citrus fruits in the diet
Answer: 3, 4 Explanation: Hypotonic fluids are often used in the treatment of hyperkalemia. Buffering agents are often used in the treatment of hyperkalemia. Page Ref: 572
16) The nurse is caring for a client in the emergency department who has experienced a below-the-knee traumatic amputation. The nurse anticipates the use of a whole blood transfusion because the client has lost ________% of the total blood volume in the accident. Record your answer rounding to the nearest whole number.
Answer: 30 Explanation: Blood loss can be treated with a number of different intravenous fluids. The nurse knows that whole blood will be used when the client loses 30% or more of the total blood volume. Page Ref: 565
1) The nurse is aware that body fluids are exchanged between which compartments? 1. Intravascular and interstitial 2. Intravascular and extracellular 3. Interstitial and extracellular 4. Intracellular and extracellular
Answer: 4 Explanation: Body fluids are exchanged between intracellular and extracellular compartments. Page Ref: 562
An older woman was admitted to the medical unit with dehydration. Clinical indications of this problem are (select all that apply): a. weight loss b. dry oral mucosa c. full bounding pulse d. engorged neck veins e. decreased central venous pressure
a, b, & e Rationale: Body weight loss, especially sudden change, is an excellent indicator of overall fluid volume loss. Other clinical manifestations of dehydration include dry mucous membranes and a decreased central venous pressure, which reflect fluid volume loss.
You are caring for a patient admitted with diabetes mellitus, malnutrition, and massive GI bleed. In analyzing the morning lab results, the nurse understands that a potassium level of 5.5 mEq/L could be caused by which factors in this patient (select all that apply)? a. The potassium level may be increased if the patient has renal nephropathy. b. The patient may be excreting extra sodium and retaining potassium because of malnutrition. c. The potassium level may be increased as a result of dehydration that accompanies high blood glucose levels. d. There may be excess potassium being released into the blood as a result of massive transfusion of stored hemolyzed blood. e. The patient has been overeating raisins, baked beans, and salt substitute that increase the potassium level.
a, c, & d Hyperkalemia may result from hyperglycemia, renal insufficiency, and/or cell death. Diabetes mellitus, along with the stress of hospitalization and illness, can lead to hyperglycemia. Renal insufficiency is a complication of diabetes. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus it is not a contributing factor to this patient's potassium level. Stored hemolyzed blood can cause hyperkalemia when large amounts are transfused rapidly. The patient with a massive GI bleed would have an NG tube and not be eating.
It is especially important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)? a. Confusion b, Weight gain c. Depressed reflexes d. Circumoral numbness e. Positive Chxostek's sign
a, d, & e Rationale: Inadvertent removal of a portion of or injury to the parathyroid glands during thyroid or neck surgery can result in a lack of parathyroid hormone, leading to hypocalcemia. A positive Chvostek sign, confusion, and circumoral numbness are manifestations of low serum calcium levels.
Which serum potassium result best supports the rationale for administering a stat dose of potassium chloride 20 mEq in 250 mL of normal saline over 2 hours? a. 3.1 mEq/L b. 3.9 mEq/L c. 4.6 mEq/L d. 5.3 mEq/L
a. 3.1 mEq/L The normal range for serum potassium is 3.5 to 5.0 mEq/L. This IV order provides a substantial amount of potassium. Thus the patient's potassium level must be low. The only low value shown is 3.1 mEq/L.
You receive a physician's order to change a patient's IV from D5½ NS with 40 mEq KCl/L to D5NS with 20 mEq KCl/L. Which serum laboratory values on this same patient best support the rationale for this IV order change? a. Sodium 136 mEq/L, potassium 4.5 mEq/L b. Sodium 145 mEq/L, potassium 4.8 mEq/L c. Sodium 135 mEq/L, potassium 3.6 mEq/L d. Sodium 144 mEq/L, potassium 3.7 mEq/L
a. Sodium 136 mEq/L, potassium 4.5 mEq/L The normal range for serum sodium is 135 to 145 mEq/L, and the normal range for potassium is 3.5 to 5.0 mEq/L. The change in the IV order decreases the amount of potassium and increases the amount of sodium. Therefore for this order to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.
The nursing care for a patient with hyponatremia includes: a. fluid restriction b. administration of hypotonic IV fluids c. administration of a cation-exchance resin d. increased water intake for patients on nasogastric suction
a. fluid restriction Rationale: In hyponatremia that is caused by water excess, fluid restriction often is all that is needed to treat the problem.
The lungs act as an acid-base buffer by: a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. b. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load c. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. d. decreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load.
a. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load. Rationale: As a compensatory mechanism, the respiratory system acts on the CO2 + H2O side of the reaction by altering the rate and depth of breathing to "blow off" (through hyperventilation) or "retain" (through hypoventilation) CO2.
During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is: a. osmosis b. diffusion c. active transport d. facilitated diffusion
a. osmosis Rationale: Osmosis is the movement of water between two compartments separated by a semipermeable membrane. Water moves through the membrane from an area of low solute concentration to an area of high solute concentration.
You are caring for a patient admitted with an exacerbation of asthma. After several treatments, the ABG results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation of 99%. You interpret these results as a. within normal limits. b. slight metabolic acidosis. c. slight respiratory acidosis. d. slight respiratory alkalosis.
a. within normal limits. The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 35 to 45 mm Hg, and HCO3 is 22 to 26 mEq/L. Normal PaO2 is >80 mm Hg. Normal oxygen saturation is >95%. Since the patient's results all fall within these normal ranges, the nurse can conclude that the patient's blood gas results are within normal limits.
When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report? a. 60 mL urine output in 90 minutes b. 1200 mL urine output in 24 hours c. 300 mL urine output per 8-hour shift d. 20 mL urine output for 2 consecutive hours
d. 20 mL urine output for 2 consecutive hours The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for 2 consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.
You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician? a. Antibiotics b. Loop diuretics c. Bronchodilators d. Antihypertensives
b. Loop diuretics Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.
You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which anticipated primary acid-base imbalance if the obstruction is high in the intestine? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
b. Metabolic alkalosis Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.
Which nursing intervention is most appropriate when caring for a patient with dehydration? a. Auscultate lung sounds every 2 hours. b. Monitor daily weight and intake and output. c. Monitor diastolic blood pressure for increases. d. Encourage the patient to reduce sodium intake.
b. Monitor daily weight and intake and output. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. Recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water.
You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? a. Fully compensated respiratory alkalosis b. Partially compensated respiratory acidosis c. Normal acid-base balance with hypoxemia d. Normal acid-base balance with hypercapnia
b. Partially compensated respiratory acidosis A low pH (normal 7.35-7.45) indicates acidosis. In the patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.
The nurse anticipates treatment of the patient with hyperphosphatemia secondary to renal failure will include: a. fluid restriction b. calcium supplements c. loop diuretic therapy d. magnesium supplements
b. calcium supplements Rationale: The major conditions that can lead to hyperphosphatemia are acute kidney injury and chronic kidney disease that alter the ability of the kidneys to excrete phosphate. For the patient with renal failure, measures to reduce serum phosphate levels include calcium supplements, phosphate-binding agents or gels, fluid replacement therapy, and dietary phosphate restrictions.
When planning care for adult patients, which oral intake is adequate to meet daily fluid needs of a stable patient? a. 500 to 1500 mL b. 1200 to 2200 mL c. 2000 to 3000 mL d. 3000 to 4000 mL
c. 2000 to 3000 mL Daily fluid intake and output is usually 2000 to 3000 mL. This is sufficient to meet the needs of the body and replace both sensible and insensible fluid losses. These would include urine output and fluids lost through the respiratory system, skin, and GI tract.
Which patient would be at greatest risk for the potential development of hypermagnesemia? a. 83-year-old man with lung cancer and hypertension b. 65-year-old woman with hypertension taking Beta-adrenergic blockers c. 42-year-old woman with systemic lupus erythematosus and renal failure d. 50-year-old man with benign prostatic hyperplasia and a urinary tract infection
c. 42-year-old woman with systemic lupus erythematosus and renal failure Rationale: Causes of hypermagnesemia include renal failure (especially if the patient is given magnesium products), excessive administration of magnesium for treatment of eclampsia, and adrenal insufficiency.
The nurse should be alert for which manifestations n a patient receiving a loop diuretic? a. Restlessness and agitation b. Paresthesias and irritability c. Weak, irregular pulse and poor muscle tone d. Increased blood pressure and muscle spasms
c. Weak, irregular pulse and poor muscle tone Rationale: Loop diuretics may result in renal loss of potassium (i.e., hypokalemia). Clinical manifestations of hypokalemia include fatigue, muscle weakness, leg cramps, nausea, vomiting, paralytic ileus, soft, muscle flab, paresthesias, decreased reflexes, weak, irregular pulse, polyuria, hyperglycemia, and electrocardiographic changes.
The typical fluid replacement for the patient with a fluid volume deficit is: a. dextran b. 0.45% saline c. lactated Ringer's d. 5% dextrose in 0.45% saline
c. lactated Ringer's Rationale: Administration of an isotonic solution expands only the extracellular fluid (ECF). There is no net loss or gain from the intracellular fluid (ICF). An isotonic solution is the ideal fluid replacement for a patient with an ECF volume deficit. Examples of isotonic solutions include lactated Ringer's solution and 0.9% NaCl.
When planning care for a patient with dehydration related to nausea and vomiting, the nurse would anticipate which fluid shift to occur because of the fluid volume deficit? a. Fluid movement from the blood vessels into the cells b. Fluid movement from the interstitial spaces into the cells c. Fluid movement from the blood vessels into interstitial spaces d. Fluid movement from the interstitial space into the blood vessels
d. Fluid movement from the interstitial space into the blood vessels In dehydration, fluid is lost first from the blood vessels. To compensate, fluid moves out of the interstitial spaces into the blood vessels to restore circulating volume in that compartment. As the interstitial spaces then become volume depleted, fluid moves out of the cells into the interstitial spaces.
When assessing a patient admitted with nausea and vomiting, which finding supports the nursing diagnosis of deficient fluid volume? a. Polyuria b. Decreased pulse c. Difficulty breathing d. General restlessness
d. General restlessness Restlessness is an early cerebral sign that dehydration has progressed to the point where an intracellular fluid shift is occurring. If the dehydration is left untreated, cerebral signs could progress to confusion and later coma.
You are caring for an older patient who is receiving IV fluids postoperatively. During the 8:00 AM assessment of this patient, you note that the IV solution, which was ordered to infuse at 125 mL/hr, has infused 950 mL since it was hung at 4:00 AM. What is the priority nursing intervention? a. Notify the physician and complete an incident report. b. Slow the rate to keep vein open until next bag is due at noon. c. Obtain a new bag of IV solution to maintain patency of the site. d. Listen to the patient's lung sounds and assess respiratory status.
d. Listen to the patient's lung sounds and assess respiratory status. After 4 hours of infusion time, 500 mL of IV solution should have infused, not 950 mL. This patient is at risk for fluid volume excess, and you should assess the patient's respiratory status and lung sounds as the priority action and then notify the physician for further orders.
You are caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would you identify as an adverse effect related to this therapy? a. Sodium falling to 138 mEq/L b. Potassium rising to 4.1 mEq/L c. Magnesium rising to 2.9 mg/dL d. Phosphorus falling to 2.1 mg/dL
d. Phosphorus falling to 2.1 mg/dL Calcium has an inverse relationship with phosphorus in the body. When phosphorus levels fall, calcium rises, and vice versa. Since hypercalcemia rarely occurs as a result of calcium intake, the patient's phosphorus falling to 2.1 mg/dL (normal 2.4-4.4 mg/dL) may be a result of the phosphate-binding effect of calcium carbonate.
The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to: a. apply warm moist compresses to the insertion site b. attempt to force 10mL of normal saline into the device c. place the patient on the left side with head-down position d. instruct the patient to change positions, raise arm, and cough.
d. instruct the patient to change positions, raise arm, and cough. Rationale: Interventions for catheter occlusion include instructing the patient to change position, raise an arm, and cough; assessing for and alleviating clamping or kinking of the tube; flushing the catheter with normal saline through a 10-mL syringe (do not force flush); using fluoroscopy to determine cause and site of occlusion; and instilling anticoagulant or thrombolytic agents.
A patient has the following arterial blood gas results: pH 7.52; PaCO2 30 mmHg; HCO3- 24 mEq/L. The nurse determines that these results indicate: a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis
d. respiratory alkalosis Rationale: Respiratory alkalosis (carbonic acid deficit) occurs with hyperventilation. The primary cause of respiratory alkalosis is hypoxemia from acute pulmonary disorders. Anxiety, central nervous system (CNS) disorders, and mechanical overventilation also increase ventilation rate and decrease the partial pressure of arterial carbon dioxide (PaCO2). This leads to a decrease in carbonic acid level and to alkalosis.
During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because: a. older adults have an impaired thirst mechanism and need reminding to drink fluids b. water accounts for a greater percentage of body weight in the older adult than in younger adults c. older adults are more likely than younger adults to lose extracellular fluid during surgical procedures d. small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults
d. small losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults Rationale: In the older adult, body water content averages 45% to 55% of body weight.