EAQs Chapter 16 Fluid and Electrolytes

Question 1

The nurse is reviewing magnesium levels for a patient. What does the nurse recognize is the importance of assessing this level for a patient?

It may cause extracellular fluid overload.
Can affect neuromuscular excitability and contractility.
It is the most abundant intracellular cation present in the body.
The patient is at risk for hypotension when the levels decrease.

Answer 1

Can affect neuromuscular excitability and contractility.

Alterations in serum magnesium levels profoundly affect neuromuscular excitability and contractility because magnesium directly acts on the myoneural junction. A decrease in blood magnesium levels increases the blood pressure. Magnesium is the second most abundant intracellular cation. The majority of the body’s magnesium is present in the bones. Causing extracellular fluid overload, being the most abundant intracellular cation, and the patient being at risk for hypotension are not relevant to this situation.

Question 2

The nurse is caring for a patient with severe hyperphosphatemia. What type of treatment does the nurse anticipate administering to this patient?

Insulin infusion
Fluid restriction
Calcium supplements
Loop diuretic therapy

Answer 2

Insulin infusion

For severe hyperphosphatemia, hemodialysis or an insulin and glucose infusion can decrease levels rapidly. Fluid restriction, calcium supplements, and diuretic therapy are not treatment options for hyperphosphatemia.

Question 3

The nurse is monitoring a patient with hyperkalemia. Which conditions should the nurse conclude may cause this condition? Select all that apply.

Alkalosis
Renal failure
Low blood volume
Large urine volume
Adrenal insufficiency

Answer 3

Renal failure
Adrenal insufficiency

Hyperkalemia is a condition in which there is an abnormal increase of potassium in the blood. Renal failure may cause hyperkalemia, because the kidneys cannot remove potassium from the body. Adrenal insufficiency causes aldosterone deficiency, which leads to the retention of potassium ions and also may result in hyperkalemia. Alkalosis is seen in hypocalcemia. Low blood volume and a large urine volume can result in hypokalemia.

Question 4

The nurse is reviewing the serum potassium results for a patient. What level best supports the rationale for administering a stat dose of potassium chloride 20 mEq in 250 mL of normal saline over two hours?

3. 1 mEq/L
4. 9 mEq/L
5. 6 mEq/L
6. 3 mEq/L

Answer 4

3.1 mEq/L

The normal range for serum potassium is 3.5 to 5.0 mEq/L. This intravenous (IV) prescription 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; 3.9 mEq/L, 4.6 mEq/L, and 5.3 mEq/L are not low values.

Question 5

A patient’s ECG tracing has a short QT interval and a high peaked T wave. Which prescription should the nurse question?

D5W with 20 meq KCL to run at 125 mL/hr
Sodium polystyrene sulfonate 30 grams by mouth
10 units regular insulin IVP and one-half ampule D50W IVP
2 grams calcium gluconate intravenous (IV) administered over two minutes

Answer 5

D5W with 20 meq KCL to run at 125 mL/hr

A short QT interval and a high peaked T wave are indicative of hyperkalemia. The prudent nurse should question any prescription that could increase the potassium level in the patient. IV insulin with D50W and calcium gluconate are given to force the potassium back into the cells, temporarily correcting the hyperkalemia. Polystyrene sulfonate binds with potassium in the gastrointestinal (GI) tract and excretes it via feces.

Question 6

The nurse is providing care to a patient with hypocalcemia. Which clinical manifestation should the nurse anticipate for this patient?

Shortened ST segment
Prolonged QT segment
Ventricular dysrhythmia
Increased digitalis effect

Answer 6

Prolonged QT segment

A prolonged QT segment is a clinical manifestation the nurse would anticipate when providing care to a patient with hypocalcemia. A shortened ST segment, ventricular dysrhythmia, and increased digitalis effects are anticipated when providing care to a patient with hypercalcemia.

Question 7

The nurse finds that the patient with renal disease is irritable and has an irregular pulse. ECG changes suggest severe hyperkalemia. What is the first nursing action?

Stop all sources of dietary potassium
Administer intravenous calcium gluconate
Administer ion-exchange resins
Administer intravenous insulin with glucose

Answer 7

Administer intravenous calcium gluconate

In the case of severe hyperkalemia, manifested by irritation, irregular pulse, and changes in ECG findings, the nurse should act immediately to prevent cardiac arrest. The nurse should administer intravenous calcium gluconate to reverse the membrane potential effects of extracellular fluid (ECF) potassium. Administering ion-exchange resins (to increase elimination of potassium) and intravenous insulin with glucose (to force potassium from ECF to intracellular fluid [ICF]) can be done once the patient is stable. Stopping all sources of dietary potassium is an important measure when hyperkalemia is mild.

Question 8

The nurse is caring for a patient receiving calcium carbonate for the treatment of osteopenia. Which serum laboratory result would be identified as an adverse effect related to this therapy?

Sodium falling to 138 mEq/L
Potassium rising to 4.1 mEq/L
Magnesium rising to 2.9 mg/dL
Phosphorus falling to 2.1 mg/dL

Answer 8

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. Because 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. Sodium falling, potassium rising, and magnesium rising are not adverse reactions to the treatment.

Question 9

A patient with cancer is found to have a serum phosphate level of 5.4 mg/dL. What does the nurse determine is the probable reason for the increase in phosphate levels in this patient?

Chemotherapy
Insulin therapy
Total parenteral nutrition
Phosphate-binding antacids

Answer 9

Chemotherapy

Phosphate levels greater than 4.4 mg/dL indicate hyperphosphatemia. Chemotherapy drugs increase the patient’s phosphate levels. Insulin therapy decreases the phosphate levels to less than 2.4 mg/dL. Patients with total parenteral nutrition have decreased phosphate levels. Phosphate-binding antacids remove phosphates from the body, resulting in hypophosphatemia.

Question 10

An older adult patient is admitted with pneumonia. Why would it be important for the nurse to closely monitor fluid and electrolyte balance in this patient?

Older adults are at an increased risk of impaired renal function.

Older adults have an impaired level of consciousness and need to be reminded to drink fluids.

Older adults are more likely than younger adults to lose extracellular fluid during severe illnesses.

Small losses of fluid are more significant because body water accounts for only about 50% of body weight in older adults.

Answer 10

Small losses of fluid are more significant because body water accounts for only about 50% of body weight in older adults.

Older adults, with less muscle mass and more fat content, have less body water than younger adults. In the older adult, body water content averages 45% to 55% of body weight, leaving them at a higher risk for fluid-related problems than young adults. Renal function, level of consciousness, and severe illnesses are not relevant in this instance.

Question 11

The nurse is administering regular insulin intravenously to a patient with moderate hyperkalemia. Which additional intravenous medication will the nurse administer to the patient?

Glucose
Furosemide
Pamidronate
Calcium gluconate

Answer 11

Glucose

While administering regular insulin intravenously to a hyperkalemic patient to help force potassium from extracellular fluid to intracellular fluid, the nurse also administers glucose to prevent hypoglycemia. Furosemide is administered if the patient has hypermagnesemia. Pamidronate is administered if the patient has hypercalcemia. Calcium gluconate is administered to treat hypocalcemia.

Question 12

The nurse is caring for a patient with sickle cell anemia. What common electrolyte imbalance should the nurse carefully assess the patient for that is commonly associated with this disease?

Increased calcium levels
Increased potassium levels
Increased phosphate levels
Increased magnesium levels

Answer 12

Increased phosphate levels

Sickle cell anemia leads to increased concentration of phosphates in the body, thus causing hyperphosphatemia. Hypercalcemia, or increased calcium levels, is associated with hyperparathyroidism. Hyperkalemia, or increased potassium levels, is associated with tumor-lysis syndrome. Hypermagnesemia, or increased magnesium levels, is associated with diabetic ketoacidosis.

Question 13

A patient sustains multiple injuries in a motor vehicle accident and is hypovolemic due to hemorrhage. Blood transfusions are given to replace the lost blood. The nurse finds that the patient has now developed laryngeal stridor, dysphagia, and numbness and tingling around the mouth. What could be the reason for these new manifestations?

The patient has developed anemia.
The patient has developed hypocalcemia.
The patient has developed fluid overload.
The patient has developed a hemolytic reaction.

Answer 13

The patient has developed hypocalcemia.

Laryngeal stridor, dysphagia, and numbness and tingling around the mouth after multiple blood transfusions can be attributed to hypocalcemia. Blood and blood products have citrate in them, which can bind with calcium in the body and make it unavailable. Multiple blood transfusions have thus caused hypocalcemia. This usually manifests as laryngeal stridor, dysphagia, and numbness and tingling around the mouth. Such symptoms are not caused by fluid overload, which manifests as edema. Anemia can be the result of hemorrhage but does not present with laryngeal stridor and dysphagia. There are chances of hemolytic reactions, because the patient is receiving multiple transfusions. However, a hemolytic reaction manifests as severe anaphylaxis, so the patient is not having a hemolytic reaction.

Question 14

The nurse is caring for a patient and observes with a serum potassium of 2.8 mEq/L. What is the greatest risk for this patient that the nurse should monitor for?

Dysrhythmias
Acute renal failure
Metabolic alkalosis
Malignant hypertension

Answer 14

Dysrhythmias

Potassium exerts a direct effect on the excitability of cardiac muscle tissue. Therefore an increased or low serum level of potassium can alter cardiac function and heart rhythm, resulting in dysrhythmias. Acute renal failure is not a complication of hypokalemia, but it may be seen with hyperkalemia. Metabolic alkalosis and malignant hypertension are not associated with hypokalemia.

Question 15

The nurse is caring for a patient that has a nasogastric tube (NGT) on intermittent suction. The patient asks why they cannot have something to drink. What is the best response by the nurse?

“It will cause sodium retention.”
“It will disrupt the intermittent suction.”
“It will increase nausea and vomiting.”
“It will increase the loss of electrolytes.”

Answer 15

“It will increase the loss of electrolytes.”

Allowing a patient with an NGT to drink water increases the loss of electrolytes. It will not cause sodium retention, but sodium depletion. The free water will pull electrolytes into the stomach and the NGT will suck the fluids and electrolytes out of the stomach. Depending on the patient’s condition and amount of water being ingested, it may increase nausea and vomiting. However, this would most likely happen if the suction was not working properly; it is not the primary reason for withholding oral fluids. Oral intake of water would not disrupt the intermittent suction.

Question 16

The nurse receives a health care provider’s prescription to change a patient’s intravenous (IV) from D 5 ½ normal saline (NS) with 40 mEq KCl/L to D5 NS with 20 mEq KCl/L. Which serum laboratory value on this same patient best supports the rationale for this IV prescription change?

Sodium 136 mEq/L, potassium 4.5 mEq/L
Sodium 145 mEq/L, potassium 4.8 mEq/L
Sodium 135 mEq/L, potassium 3.6 mEq/L
Sodium 144 mEq/L, potassium 3.7 mEq/L

Answer 16

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 prescription decreases the amount of potassium and increases the amount of sodium. For this prescription to be appropriate, the potassium level must be near the high end and the sodium level near the low end of their respective ranges.

Question 17

The nurse is caring for a group of patients with a variety of diagnoses. Which conditions would cause the nurse to include interventions in the plan of care to address anticipated hypophosphatemia? Select all that apply.

Renal failure
Respiratory alkalosis
Diabetic ketoacidosis
Tumor lysis syndrome
Malabsorption syndrome

Answer 17

Respiratory alkalosis
Diabetic ketoacidosis
Malabsorption syndrome

The nurse would include interventions to address hypophosphatemia when providing care to patients with respiratory alkalosis, diabetic ketoacidosis, and malabsorption syndrome. The nurse should create a care plan for hyperphosphatemia when providing care to patients with renal failure and tumor lysis syndrome.

Question 18

The nurse suspects which possible conditions in a patient whose serum potassium level is 6.8 mEq/L on admission? Select all that apply.

The patient is on insulin therapy.
The patient is taking amiloride daily.
The patient suffers from renal disease.
The patient’s electrocardiogram reveals flattened T waves.
The patient’s orders will include intravenous fluids with added potassium.

Answer 18

The patient is taking amiloride daily.
The patient suffers from renal disease.

Potassium levels greater than 5.0 mEq/mL indicated hyperkalemia. Potassium-sparing diuretics, such as amiloride, increase the potassium levels. Insulin moves potassium into the cell and decreases serum potassium values. The kidneys excrete potassium, so renal disease can lead to increased potassium levels. Hyperkalemia is manifested on an electrocardiogram as tall, peaked T waves. Potassium should not be added to IV fluids if the patient suffers from hyperkalemia.

Question 19

The nurse is preparing to administer intravenous (IV) potassium chloride (KCl) to a patient. Which action should the nurse perform to ensure the patient’s safety?

Give KCl via IV push.
Add KCl to the hanging IV bag.
Give IV KCl in concentrated amounts.
Invert IV bags containing KCl several times.

Answer 19

Invert IV bags containing KCl several times.

Hypokalemia is characterized by a decreased concentration of potassium in the body. Therefore KCl should be administered to maintain normal potassium levels. Inverting the IV bags containing KCl several times ensures even distribution of KCl medication in the bag. The nurse should administer KCl through an infusion pump, not by IV push, to ensure that it is administered at an accurate rate. The nurse should not add KCl to the hanging IV bag because this would result in administering a bolus dose. The nurse will give IV KCl in diluted forms, rather than in concentrated amounts, to ensure the patient’s safety.

Question 20

The nurse is caring for a patient with a potassium level of 6.2 mEq/dl. What syndrome does the nurse suspect the patient may have?

Cushing syndrome
Milk-alkali syndrome
Tumor lysis syndrome
Malabsorption syndrome

Answer 20

Tumor lysis syndrome

Tumor lysis syndrome causes movement of potassium from the intracellular fluid (ICF) to the extracellular fluid (ECF), resulting in hyperkalemia. Cushing syndrome may cause hypernatremia. Milk-alkali syndrome may cause hypercalcemia. Malabsorption syndrome may cause hypophosphatemia.

Question 21

The patient has a one-time prescription for potassium chloride 20 mEq in 250 mL of normal saline intravenous (IV) to be given immediately. The nurse would seek clarification for this prescription if the patient’s more recent potassium level is at what level?

1. 7 mEq/L
2. 9 mEq/L
3. 6 mEq/L
4. 5 mEq/L

Answer 21

4.5 mEq/L
The normal range for serum potassium is 3.5 to 5 mEq/L. The IV prescription provides a substantial amount of potassium, so the patient’s potassium level must be low. A level of 4.5 mEq/L would not warrant this medication.

Question 22

The nurse is providing care to a patient whose serum potassium level is 5.1 mEq/L. Which change should the nurse make to the plan of care to address this finding?

Monitoring for digitalis toxicity
Adding bananas to the list of approved fruits
Implementing continuous monitoring of urine output
Ensuring that intravenous calcium gluconate is available at all times

Answer 22

Ensuring that intravenous calcium gluconate is available at all times

A patient with hyperkalemia, as indicated by the serum potassium level, is at risk for dysrhythmia. Therefore the nurse should ensure that intravenous calcium gluconate is available at all times. Monitoring for digitalis toxicity, adding bananas to the list of approved fruits, and implementing continuous monitoring of urine output are interventions the nurse should add to the plan of care for a patient who develops hypokalemia, not hyperkalemia.

Question 23

The nurse reviews laboratory findings for a patient with milk-alkali syndrome. What laboratory results are consistent with this diagnosis?

Calcium levels of 7 mg/dL
Calcium levels of 15 mg/dL
Phosphate levels of 2 mg/dL
Phosphate levels of 17 mg/dL

Answer 23

Calcium levels of 15 mg/dL

Milk-alkali syndrome is a condition in which large concentrations of calcium are found in the body. Calcium levels of more than 10.2 mg/dL indicate hypercalcemia. Calcium levels of 7 mg/dL indicate hypocalcemia. Phosphate levels of 2 mg/dL indicate hypophosphatemia. Phosphate levels of 17 mg/dL indicate hyperphosphatemia.

Question 24

The nurse is caring for a patient with a blood sodium level of 170 mEq/L and is experiencing intense thirst, agitation, and decreased alertness. What does the nurse anticipate administering?

Intravenous furosemide
Intravenous cation-exchange resin
Intravenous phosphate-binding agent
Intravenous 0.45% sodium chloride saline solution

Answer 24

Intravenous 0.45% sodium chloride saline solution

Hypernatremia is a condition in which water shifts out of the cells into the extracellular fluid, resulting in dehydration. Therefore the patient with hypernatremia would experience intense thirst, agitation, and decreased alertness. To reduce dehydration, fluid should be replaced by administering hypotonic intravenous fluids such as 5% dextrose in water or 0.45% sodium chloride saline solution. Administering intravenous furosemide may help treat hypercalcemia. A cation-exchange resin may be administered to treat hyperkalemia. A phosphate-binding agent may be administered to treat hyperphosphatemia.

Question 25

Upon assessment of laboratory data, the nurse notes a calcium level of 6.4 mg/dL. Which physical assessment finding is consistent with this data? Polyuria Bone pain Paresthesias Diminished deep tendon reflexes

Answer 25

Paresthesias Signs of hypocalcemia include paresthesias, tetany, and muscle weakness. Bone pain, diminished reflexes, and polyuria are signs of hypercalcemia.

Question 26

While reviewing a patient’s laboratory reports, the nurse finds the plasma concentration of calcium to be 11.2 mg/dL. Which clinical manifestations does the nurse anticipate observing? Select all that apply. ``` Polyuria Seizures Nephrolithiasis Chvostek’s sign Trousseau’s sign ```

Answer 26

Polyuria Nephrolithiasis Plasma concentration of calcium greater than 10.2 mg/dL indicates hypercalcemia, which results in increased concentration of calcium in the urine. This impairs sodium and water reabsorption and causes polyuria. Hypercalcemia can cause kidney stones, or nephrolithiasis, because an increased concentration of calcium in the urine deposits crystals in the kidney, which combine to form kidney stones. Seizures, Chvostek’s sign, and Trousseau’s sign are clinical manifestations of hypocalcemia.

Question 27

The nurse is caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. What classification of medications should be withheld until consulting with the health care provider? Antibiotics Loop diuretics Bronchodilators Antihypertensives

Answer 27

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 health care provider should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range. Antibiotics, bronchodilators, and antihypertensives are not an issue in this case.

Question 28

The nurse is preparing to administer a dose of potassium phosphate. What laboratory finding would indicate that the nurse should withhold the medication? Calcium 6.4 mg/dL Sodium 133 mEq/L Magnesium 1.8 mEq/L Potassium 5.2 mEq/L

Answer 28

Calcium 6.4 mg/dL Phosphorus and calcium have inverse or reciprocal relationships, meaning that when calcium levels are high, phosphorus levels tend to be low. Therefore administration of phosphorus will reduce a patient's already abnormally low calcium level, which can result in life-threatening complications. Potassium phosphate will not have any effect on sodium, magnesium, or potassium levels.

Question 29

A patient is admitted with alcohol abuse. Laboratory data reveals a phosphate level of 1.8 mg/dL. Which assessment finding is consistent with this data? Tetany Diarrhea Weakness Seizure activity

Answer 29

Weakness Signs of hypophosphatemia include weakness, confusion, coma, and diminished reflexes. Seizure activity, diarrhea, and tetany are not associated with this electrolyte imbalance.

Question 30

Which medical diagnosis would cause the nurse to include nursing interventions appropriate for hyponatremia in the plan of care? Diabetes insipidus Cushing syndrome Congestive heart failure Uncontrolled diabetes mellitus

Answer 30

Congestive heart failure Congestive heart failure increases the patient’s risk for developing hyponatremia; therefore this diagnosis would cause the nurse to include interventions specific to hyponatremia in the plan of care. Diabetes insipidus, Cushing syndrome, and uncontrolled diabetes mellitus increase the patient’s risk for hypernatremia, not hyponatremia.

Question 31

Which is a priority nursing action when providing care to a patient who is being treated for hypernatremia that developed slowly over several days? Initiating seizure precautions Administering prescribed diuretics Monitoring the patient’s weight each day Restricting the patient’s dietary sodium intake

Answer 31

Initiating seizure precautions A rapid reduction in the sodium level can cause a rapid shift of water back into the cells, resulting in cerebral edema and neurologic complications. This risk is greatest in a patient who developed hypernatremia over several days or longer. The priority nursing action in this case is to implement seizure precautions due to the risk of neurologic complications. Monitoring the patient’s weight each day, restricting dietary sodium intake, and administering prescribed diuretics are all appropriate nursing actions; however, these are not the priority given this patient’s risk for neurologic complications.

Question 32

A patient's potassium level is 2.9 meq/L. Which health care provider order should the nurse expect? Continuous ECG monitoring Increase digoxin (Lanoxin) to 0.25 mg every day Add 20 meq KCL to the present IV bag hanging and give over four hours 40 meq KCL in 100 cc D5W intravenous piggyback (IVPB) to infuse over 30 minutes

Answer 32

Continuous ECG monitoring Hypokalemia can cause lethal ventricular rhythms. Therefore continuous cardiac monitoring should be expected. Patients with hypokalemia are at risk for digoxin toxicity. The nurse should watch for signs of digoxin toxicity and question an increase in dosage. KCL infusion must be diluted and given at a rate not to exceed 10 meq/hour. 40 meq KCL in 100 cc of fluid is too concentrated and should be given over at least two hours. To prevent bolusing, KCL should never be added to an IV bag that already is hanging.

Question 33

Which patient statements indicate the need for further education from the nurse regarding the use of potassium supplementation for the treatment of hypokalemia? Select all that apply. ``` "I will chew my tablets." "I will eat a banana every day." "I will include licorice in my diet." "I will take my medication with water." "I will tell my doctor if I develop constipation." ```

Answer 33

"I will chew my tablets." "I will include licorice in my diet." The patient statements regarding chewing the tablets and including licorice in the diet require additional education. The tablets should be swallowed whole and the patient should avoid, not include, licorice in the diet. The patient statements regarding eating a banana each day (a source of potassium), taking the medication with water (a full glass is recommended), and notifying the healthcare provider if constipation occurs (a clinical manifestation associated with hypokalemia) indicate correct understanding.

Question 34

The nurse is planning care for a patient with a new diagnosis of hypercalcemia resulting from treatment for hypocalcemia. Which change to the plan of care should the nurse anticipate? Encouraging weight-bearing exercises Teaching the patient to breathe into a bag Administering intravenous calcium gluconate Administering a loop rather than a thiazide diuretic

Answer 34

Encouraging weight-bearing exercises A patient with hypercalcemia as a result of treatment for hypocalcemia would require the addition of weight-bearing exercises to the plan of care. These exercises will facilitate the movement of extra calcium ions in the blood to the bone. Teaching the patient to breathe into a bag, administering calcium gluconate, and administering a loop diuretic are all appropriate for hypocalcemia; therefore these actions should be removed from the plan of care, not added.

Question 35

A nurse is caring for a patient with malignant lung cancer who experiences weakness, lethargy, depressed reflexes, and bone pain. Which changes in the electrocardiogram evaluated by the nurse may indicate suspected hypercalcemia? Select all that apply. ``` Shortened QT interval Prolonged QT interval Shortened ST segment Elongation of ST segment Flattened or inverted T wave ```

Answer 35

Shortened QT interval Shortened ST segment Hypercalcemia may result from malignancies. Bone destruction due to tumor invasion may cause a release of calcium, leading to high levels of calcium in the blood. This causes altered transmembrane potentials affecting conduction time and is manifested as a shortened ST segment and QT interval. An elongated ST segment and a prolonged QT interval are manifestations of hypocalcemia. A flattened or inverted T wave is a manifestation of hypokalemia.

Question 36

The nurse is preparing to cleanse the skin around a central venous access device. Which solution would the nurse select as the most effective means of killing harmful bacteria? Sterile saline solution Isopropyl alcohol solution Povidone-alcohol solution Chlorhexidine-based solution

Answer 36

Chlorhexidine-based solution Chlorhexidine-based solutions such as chlorhexidine gluconate have been shown to be more effective at killing bacteria than povidone-alcohol or isopropyl alcohol solutions. Therefore chlorhexidine-based solutions should be used to cleanse around the central venous access device. A sterile saline solution does not have any antiseptic properties.

Question 37

The nurse is caring for a patient diagnosed with heat stroke and with a urine output of 4000 mL per day. What is the most appropriate nursing action? Transfusing blood Applying moisturizer regularly Administrating lactated Ringer's solution Administrating supplementary water in enteric formula

Answer 37

Administrating lactated Ringer's solution Heat stroke and an increased amount of urine output of about 4000 mL leads to a deficit in extracellular fluid volume, causing dehydration. Administering lactated Ringer’s solution to maintain fluid and electrolyte balance is beneficial. Blood transfusions are performed only when the fluid loss is due to blood loss. Moisturizers are applied to patients with dry skin to prevent the fluid loss.Tube feeding is preferred in the patient with severe extracellular fluid loss. The patient on tube feeding must be thereby supplemented with water added to the enteric formula.

Question 38

A patient has been treated for dehydration. What outcome does the nurse determine demonstrates effectiveness of the treatment regimen? Oral intake balances output. Oral intake is less than output. Oral intake is greater than output. No significant difference in fluid balance.

Answer 38

Oral intake balances output. Oral intake should equal output if fluid balance has been restored and dehydration has been corrected. Less intake than output would result in dehydration. Greater intake than output may indicate decreased renal function or impaired ability to excrete urine.

Question 39

The nurse is unable to flush a central venous access device and suspects occlusion. Which of these would be appropriate interventions to undertake? Select all that apply. Clamp the tubing immediately. Obtain cultures of the insertion site. Instruct the patient to change positions, raise arm, and Attempt to force flush 10 mL of normal saline into the device. Assess the tubing for clamping or kinking, and alleviate as needed.

Answer 39

Instruct the patient to change positions, raise arm, and cough. Assess the tubing for clamping or kinking, and alleviate as needed. Catheter occlusion interventions include instructing the patient to change position, raise an arm, and cough; assessing for and alleviating clamping or kinking; flushing with normal saline using a 10-mL syringe (do not force flush); using fluoroscopy to determine cause and site; and instilling anticoagulant or thrombolytic agents. Clamping the tubing and culturing the site would not assist in flushing the line or resolve the occlusion. The nurse should not force flush the line.

Question 40

A nurse is caring for a patient with a central venous access device. The patient is experiencing chest pain, dyspnea, hypotension, and tachycardia. What nursing actions are essential in the care of this patient? Select all that apply. Administer oxygen. Administer anticoagulants. Clamp the central venous access catheter. Place the patient on the left side with the head down. Flush the central venous access device with normal saline using a 10 mL syringe.

Answer 40

Administer oxygen. Clamp the central venous access catheter. Place the patient on the left side with the head down. Pulmonary embolism is a complication of central venous access devices. The nurse should start oxygen therapy to relieve dyspnea. The catheter should be clamped to prevent further formation of emboli. Because the signs suggest air embolism, the patient is placed on the left side with the head down. Administering anticoagulants and normal saline are required if the catheter is occluded, and they do not help in relieving a pulmonary embolus.

Question 41

A patient admitted with dehydration is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions? Select all that apply. ``` Lung sounds Bowel sounds Blood pressure (BP) Serum sodium level Serum potassium level ```

Answer 41

Lung sounds Blood pressure (BP) Serum sodium level BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions. Bowel sounds and serum potassium level do not need to be monitored frequently.

Question 42

``` The nurse must prepare the correct intravenous (IV) solution before administration. The prescription reads for the patient to receive D5 ½ NS with 40 mEq KCl/L at 125 mL/hr. The nurse must add KCl to the IV because no premixed solutions are available. The unit medication supply has a stock of KCl 3 mEq/mL in multidose vials. What amount of KCl should be added to a liter of D5 ½ NS to obtain the correct solution? Fill in the blank using one decimal place. ___ mL 40 mEq (dose desired) ÷ 3 mEq/ml (dose available) = 13.3 mL. ```

Answer 42

.

Question 43

The nurse is completing an assessment of a patient with heart failure who is being treated for accidental overuse of diuretics. For which potential respiratory issue should the nurse monitor the patient? Shortness of breath Pulmonary congestion Increased respiratory rate Moist crackles on inspiration

Answer 43

Increased respiratory rate Patients with deficient fluid volume experience decreased tissue perfusion and hypoxia resulting in an increased respiratory rate. Pulmonary congestion, shortness of breath, and moist crackles on inspiration are all characteristic of a fluid volume excess, not deficit.

Question 44

A patient with blood pressure of 160/90 mm Hg has pedal edema. Which process of transport of molecules would be in action? Osmosis Diffusion Active transport Facilitated diffusion

Answer 44

Osmosis A patient with blood pressure of 160/90 mm Hg has hypertension and develops pedal edema due to excess sodium in the blood. This leads to movement of water down the gradient. Therefore the water from the blood vessels moves from higher concentrations to lower concentration across the semipermeable membrane with the help of osmotic pressure and leads to accumulation of water in the extracellular spaces. This movement of water across a semi-permeable membrane to balance the solute is called Osmosis. Diffusion and facilitated diffusion involve molecules moving from a higher to lower concentrations, and active transport involves molecules moving from a lower to higher concentration.

Question 45

The patient has a prescription for lactated Ringer's intravenously (IV) at a rate of 200 mL/hr. An IV pump is not available. The IV tubing has a drop factor of 10 drops/mL. The nurse will administer the lactated Ringer's solution at drops per minute. Record your answer using a whole number. Use the following formula to calculate the rate of IV solutions: Volume multiplied by drop factor divided by time (in minutes). Multiply 200 by 10 to yield 2000 and divide this by 60 to yield 33.3 or 33 gtt/minute (because the nurse cannot count a fraction of a drop).

Answer 45

.

Question 46

A patient has been admitted for dehydration. What is a priority nursing intervention? Perform daily weights. Reorient the patient hourly. Restrict sodium intake to 2 grams per day. Provide continuous oxygen saturation monitoring.

Answer 46

Perform daily weights. Measuring weight is the most reliable means of detecting changes in fluid balance. Weight loss would indicate that the dehydration is worsening, whereas weight gain would indicate restoration of fluid volume. The nurse would recall that a 1-kg weight gain indicates a gain of approximately 1000 mL of body water. This patient is not disoriented, and that is not a common assessment finding in the patient with dehydration. Continuous oxygen saturation monitoring is not indicated. Sodium intake does not need to be restricted.

Question 47

A patient’s insensible water loss is estimated at 900 mL per day. The nurse understands that this fluid is lost via which mechanism? Excreted via urine Excreted in the feces Vaporized by the lungs and skin Secreted into the digestive tract

Answer 47

Vaporized by the lungs and skin Approximately 600-900 mL of water is lost each day via insensible water loss, which is vaporization by the lungs and skin. Approximately 1,500 mL is excreted in the urine and 100 mL in the feces. Approximately 8,000 mL of digestive fluids are secreted daily, but most is reabsorbed in the gastrointestinal tract.

Question 48

When the nurse is caring for a patient with a central venous access device, which nursing interventions are important to maintain a safe, functioning device? Select all that apply. Change the catheter dressing regularly. Monitor the heart rate and blood pressure. Cleanse around the catheter insertion site. Measure and record oral intake and output. Change the injection caps at regular intervals.

Answer 48

Change the catheter dressing regularly. Cleanse around the catheter insertion site. Change the injection caps at regular intervals. Nursing management of central venous access devices is important in keeping the devices safe and functioning and in reducing risk of infection. The catheter dressing and the injection caps should be regularly changed, and the catheter site should be regularly cleansed; these steps keep the site free from infection. Flushing is an important intervention to maintain the patency of the catheter and prevent occlusion. Monitoring vital parameters and assessing intake and output are general measures that are not specific to the care of central venous access devices.

Question 49

The nurse is reviewing the laboratory data of a patient admitted for evaluation of a fluid and electrolyte imbalance. The lab results show Na+ 132 mEq/L, BUN 5 mg/dL, and HCT 33%. What does the nurse infer from these findings? Hyperkalemia Hypernatremia Excess fluid volume Deficient fluid volume

Answer 49

Excess fluid volume A decreased sodium level (normal sodium ranges from 135 to 145 mEq/L), BUN (normal BUN ranges from 7-20 mg/dL), and HCT (normal level 35-47% for women and 39-50% for men) indicate fluid volume excess. The patient has hyponatremia, not hypernatremia, since the sodium level is below 135. There is no indication from the data that the patient is hyperkalemic. Because these values indicate excess, the patient is not at risk for a fluid volume deficit, nor does he or she have one.

Question 50

The nurse is preparing to document skin assessment findings for a patient being treated for renal failure. Assessment findings include cool, taut skin over the sternum with a 2-mm indentation when pressing with a thumb over the sternum. How does the nurse document the grade of the edema? 1+ 2+ 3+ 4+

Answer 50

1+ Cool, taut and hard skin indicates fluid accumulation. An indentation of 2-mm after pressing with the thumb to assess edema indicates a grade of 1+. A 4-mm indentation warrants a grade of 2+, a 6-mm indentation a grade of 3+, and an 8-mm indentation a grade of 4+.

Question 51

A patient with a tumor of the adrenal glands reports feeling unusually sleepy. After receiving the prescription from the health care provider, which nursing action is most appropriate considering the fact that the patient is at risk of hypernatremia due to primary aldosteronism? Administer furosemide Administer conivaptan Encourage sodium intake Give oral potassium supplements

Answer 51

Administer furosemide A tumor of the adrenal glands may cause hypersecretion of aldosterone, resulting in hypernatremia. Hypernatremia should be treated with a diuretic (to promote excretion of excess sodium) and with sodium-free intravenous fluids such as 5% dextrose in water (to dilute the sodium concentration). Sodium intake should also be restricted. Conivaptan is administered when treating hyponatremia. Potassium supplements are needed in cases of hypokalemia.

Question 52

A patient has a prescription to receive 0.9% sodium chloride (normal saline) intravenously (IV) at a rate of 100 mL per hour. The current bag of 1000 mL was hung at 1000. When making rounds at 1300, the nurse notes that the IV bag contains 900 mL of normal saline. How would the nurse document this incident report? Wrong rate Wrong route Wrong solution Wrong documentation

Answer 52

Wrong rate After three hours of infusion time, 300 mL of IV solution should have infused, but the patient has received 100 mL. Therefore the patient has received the wrong rate. The solution, route, and documentation are correct.

Question 53

A pregnant woman reports headaches and shortness of breath to the nurse. The nurse auscultates crackles and a bounding pulse. What is the appropriate nursing action? Applying hot and cold compresses Restricting the intake of dietary sodium Asking the patient to sit and then stand Providing ice chips to hydrate the patient

Answer 53

Restricting the intake of dietary sodium A pregnant woman with increased extracellular fluid may develop hypertension and pregnancy-related complications. Restriction of dietary sodium helps to control the fluid accumulation and may help to maintain fluid balance. Application of warm and cold compresses will not relieve the patient’s symptoms. Changing the position does not benefit the patient, and providing ice chips may increase the fluid volume and worsen the condition.

Question 54

The nurse is caring for an older patient who is receiving intravenous (IV) fluids postoperatively. During the 0800 assessment of this patient, the nurse notes that the IV solution, which was prescribed to infuse at 125 mL/hr, has infused 950 mL since it was hung at 0400. What is the priority nursing intervention? Notify the health care provider and complete an incident report. Obtain a new bag of IV solution to maintain patency of the site. Listen to the patient's lung sounds and assess respiratory status. Slow the rate to keep the vein open until the next bag is due at noon.

Answer 54

Listen to the patient's lung sounds and assess respiratory status. After four 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 the nurse should assess the patient's respiratory status and lung sounds as the priority action and then notify the health care provider for further prescriptions.

Question 55

The emergency room nurse is caring for a patient with a severe fluid volume deficit who presented after several days of diarrhea secondary to C. difficile infection. Which intravenous (IV) fluid does the nurse anticipate will be used to rapidly replace the fluid volume? 0.9% sodium chloride 0.45% sodium chloride 5% dextrose in 0.9% saline 5% dextrose in 0.25% saline

Answer 55

0.9% sodium chloride An isotonic fluid such as 0.9% sodium chloride is used to rapidly replace fluid volume. The solutions 0.45% sodium chloride, 5% dextrose in 0.25% saline, and 5% dextrose in 0.9% saline are all hypertonic solutions that are not used to rapidly increase fluid volume.

Question 56

The nurse is caring for a patient who is febrile with a body temperature of 103 oF. What clinical manifestation does the nurse anticipate when assessing this patient? Muscle spasm Bounding pulse Jugular vein distention Orthostatic hypotension

Answer 56

Orthostatic hypotension A patient with an elevated body temperature of 103oF may have a loss of body fluids leading to decreased blood volume and resulting in postural or orthostatic hypotension. Muscle spasm, a bounding pulse, and jugular vein distention are manifestations that occur due to an increase in the body fluid volume.

Question 57

The nurse is caring for a patient with heart failure. What assessment data indicates the patient is at risk for developing fluid volume excess? Full, bounding pulse Flattened neck veins Low blood pressure Easily obliterated pulse

Answer 57

Full, bounding pulse Any change in the fluid volume is reflected in changes in blood pressure, pulse rate force, and jugular venous distension. A fluid volume excess may cause a full bounding pulse, increased blood pressure, and distended neck veins. The pulse in this case is not easily obliterated. Flattened neck veins, low blood pressure, and a weak and thready pulse that can be easily obliterated indicate fluid volume deficit

Question 58

Which term is used to describe the fact that extracellular fluid and intracellular fluid have the same osmolality? Isotonic Hypotonic Hypertonic Oncotic pressure

Answer 58

Isotonic Extracellular fluid and intracellular fluid have the same osmolality; this characteristic is termed isotonic, meaning that there is no net movement of fluids. Hypotonic refers to fluids with a lower osmolality, which results in water moving into the cell when the cell is surrounded by a hypotonic fluid. Hypertonic refers to fluids with a higher osmolality, which results in water moving out of the cells when they are surrounded by a hypertonic solution. Oncotic pressure refers to the pressure of plasma colloids in a solution.

Question 59

A nurse is completing an assessment on a patient with suspected fluid volume excess. Which cardiovascular changes would support this diagnosis? Select all that apply. ``` Full, bounding pulse Distended neck veins Orthostatic hypotension Increase in the heart rate Presence of an S3 heart sound ```

Answer 59

Full, bounding pulse Distended neck veins Presence of an S3 heart sound Fluid volume excess results in a full, bounding pulse, presence of an S3 heart sound, and jugular venous distention (distended neck veins). Orthostatic hypotension and an increased heart rate are clinical manifestations of deficient, not excess, fluid volume.

Question 60

A nurse is assessing a patient's weight in order to evaluate fluid volume status. The patient's weight on the day of admission was 60 kg. On day 2, the weight is 62 kg. What is the quantity of fluid retention in the patient? Record your answer using a whole number and no punctuation. _______ mL An increase in 1 kg is equal to 1000 mL of fluid retention. The patient has gained 2 kg, which is equal to 2000 mL of fluid retention.

Answer 60

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Question 61

A patient is receiving intravenous albumin 5%. The nurse understands that albumin is commonly used to treat which metabolic alteration? Alkalosis Hypovolemia Hyperkalemia Mixed acid-base disorder

Answer 61

Hypovolemia Albumin is a colloid solution that pulls fluid into the blood vessels, which restores blood volume. This medication is used to treat hypovolemia. Albumin is not effective in the treatment of alkalosis, hyperkalemia, or a mixed acid-base disorder.

Question 62

A patient comes to the emergency department after three days of continuous vomiting. This patient is at risk for which acid-base imbalance? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 62

Metabolic alkalosis Metabolic alkalosis can occur with prolonged vomiting secondary to the loss of strong gastric acids. Respiratory acidosis is caused by hypercarbia of respiratory origin. Metabolic acidosis is an increase in acid levels related to a metabolic dysfunction such as lactic acidosis, starvation, or diarrhea. Respiratory alkalosis occurs with hypocarbia related to hyperventilation.

Question 63

An older adult patient with dementia arrives in the emergency department with a family member; the patient is found to be hypercarbic. The patient has an advanced directive and does not want any invasive procedure. The family member asks if this issue will resolve by itself. Which is the nurse’s most appropriate response? "The kidneys will compensate for increased levels of CO2 after about 24 hours." "The kidneys sense increased levels of CO2 in the blood and reabsorb additional bicarbonate." "Older adults have a harder time compensating because they have decreased respiratory and kidney functions." "The respiratory center senses increased levels of CO2 in the blood and stimulates hyperventilation to compensate."

Answer 63

"Older adults have a harder time compensating because they have decreased respiratory and kidney functions." Hypercarbia is an increased level of CO2 in the blood, which is a hallmark of respiratory acidosis. Older adults have difficulty compensating for acid-base imbalances because of decreased functional capacity in the respiratory and renal systems. Hyperventilation is a normal physiologic response to hypercarbia; hyperventilation may not be possible with decreased functional respiratory reserves. Normal kidneys can sense hypercarbia and begin to reabsorb buffer to normalize pH; however, older adults may lack the functional capacity or have some degree of kidney disease. Normal renal compensation is slow and will often begin in 24 hours, if kidney function is normal

Question 64

The nurse is evaluating a patient’s arterial blood gases. Which value of partial pressure of carbon dioxide (PaCO2) in arterial blood indicates a compensatory response in metabolic alkalosis? 38 mm Hg 40 mm Hg 44 mm Hg 47 mm Hg

Answer 64

47 mm Hg Metabolic alkalosis results in decreased carbonic acid. Therefore, to increase its concentration, the respiratory rate is reduced. This reduction leads to a rise in carbon dioxide concentration in the blood. Normal values of partial pressure of carbon dioxide (PaCO2) range from 35 to 45 mm Hg; 47 mm Hg of PaCO2 indicates a compensatory response in metabolic alkalosis.

Question 65

A patient with gastroenteritis has the following arterial blood gas results: pH 7.30, PaO2 80 mm Hg, PaCO2 46 mm Hg, HCO314. What does the nurse determine that these results indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 65

Metabolic acidosis A low pH (normal 7.35-7.45) indicates acidosis. In the patient with gastroenteritis and diarrhea, bicarbonate is lost from the excessive stool, which would result in a low bicarbonate level and resulting metabolic acidosis. There is not a respiratory component associated with gastroenteritis.

Question 66

The nurse is reviewing the mechanisms of acid-base buffers in the body. The kidneys act as an acid-base buffer by which of these mechanisms? Select all that apply. Eliminating excess H + Excreting excess water Eliminating excess CO2 Reabsorbing additional HCO 3 - Reabsorbing additional sodium ions

Answer 66

Eliminating excess H + Reabsorbing additional HCO 3 - As a compensatory mechanism, the pH of the urine can decrease to 4 or increase to 8. To compensate for acidosis, the kidneys can reabsorb additional HCO3-and eliminate excess H+. Thus the pH of the blood increases and the pH of the urine decreases. Eliminating excess water or CO2 or reabsorbing additional sodium ions are not mechanisms of acid-base buffers

Question 67

The patient has chronic kidney disease and ate a lot of nuts, bananas, peanut butter, and chocolate. The patient is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient? Renal dialysis IV furosemide (Lasix) Intravenous (IV) potassium chloride IV normal saline at 250 mL per hour

Answer 67

Renal dialysis Renal dialysis will need to be administered to remove the excess magnesium that is in the blood from the increased intake of foods high in magnesium. If renal function was adequate, IV potassium chloride would oppose the effects of magnesium on the cardiac muscle. IV furosemide and increased fluid would increase urinary output, which is the major route of excretion for magnesium.

Question 68

The nurse is caring for a group of patients. Which patient should the nurse closely monitor for the development of respiratory acidosis? The patient with severe vomiting The patient with a pulmonary embolism The patient being treated for severe pneumonia A patient that has recovered from diabetic ketoacidosis

Answer 68

The patient being treated for severe pneumonia A patient that has recovered from diabetic ketoacidosis Pneumonia is an inflammatory condition that causes hypoventilation, which results in increased concentration of carbon dioxide in blood and precipitates respiratory acidosis. Severe vomiting may cause loss of strong acids from the body, resulting in metabolic alkalosis. A pulmonary embolism causes hyperventilation, resulting in respiratory alkalosis. Diabetic ketoacidosis causes accumulation of ketone bodies in the body, resulting in metabolic acidosis

Question 69

What happens when the respiratory center in the medulla senses an increased concentration of carbon dioxide (CO2) or H+? The respiratory center stimulates hyperventilation to get rid of CO2. The respiratory center stimulates a decreased rate of breathing to retain CO2. The respiratory center stimulates an increased depth of breathing to retain H+. The respiratory center stimulates a decreased depth of breathing to get rid of H+.

Answer 69

The respiratory center stimulates hyperventilation to get rid of CO2. Increased CO2 or H+ signals acidosis, which triggers the respiratory center to hyperventilate and get rid of CO2 to balance the pH. CO2 retention occurs to correct alkalosis. A decreased depth of breathing occurs in respiratory dysfunction. An increased depth of breathing occurs in hyperventilation; in this case, the body will expel CO2 to decrease H+

Question 70

The arterial blood gas (ABG) analysis of a patient with diabetes shows a partial pressure of carbon dioxide (PaCO2) of 43 mm Hg and pH of 5.1. What would be the nurse’s interpretation of these ABG results? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 70

Metabolic acidosis Metabolic acidosisis characterized by increased levels of acid in the blood. As a result, pH of the blood decreases. The normal range of pH of blood is 7.35 to 7.45, and the normal value of partial pressure of carbon dioxide (PaCO2) lies between 35 and 45 mm Hg. The patient’s numbers indicate metabolic acidosis. Metabolic alkalosis is manifested by an increased pH. A decreased pH and elevated PaCO2 indicate respiratory acidosis. Respiratory alkalosis is manifested by increased plasma pH and decreased PaCO2.

Question 71

What is the normal range of partial pressure of carbon dioxide (PaCO2) in arterial blood? 25 to 35 mm Hg 35 to 45 mm Hg 45 to 55 mm Hg 55 to 65 mm Hg

Answer 71

35 to 45 mm Hg The normal value of partial pressure of carbon dioxide (PaCO2) in arterial blood lies between 35 and 45 mmHg.

Question 72

A patient in the emergency department presents with lethargy and confusion and is found to have metabolic acidosis. The patient’s family alerts the nurse that the patient has a history of "heart problems" and is concerned about whether the acidosis will affect his cardiac system. Based on the nurse’s knowledge of acid-base imbalances, what is the best response to the family? "Acidosis may affect the patient’s blood pressure but not his or her heart." "Acidosis is often temporary and never life-threatening; it is nothing to worry about." "Metabolic acidosis is a symptom of an underlying disorder for which we will evaluate and treat during this admission." "Uncompensated acidosis can cause hypotension and cardiac dysrhythmias; we will monitor for and work to prevent these complications."

Answer 72

"Uncompensated acidosis can cause hypotension and cardiac dysrhythmias; we will monitor for and work to prevent these complications." Uncompensated and untreated acidosis of any type can prove life-threatening because of its untoward downstream effects on the cardiac system in the form of hypotension and dysrhythmias. The nurse should assure the family that the medical team will monitor for and work to prevent these complications. Metabolic acidosis is a symptom of an underlying disease that must be treated; however, profound acidosis must be monitored and treated as well. Acidosis can in fact be life-threatening. Changes in blood pressure have a direct effect on the heart and the circulatory system as a whole, both of which are affected in untreated and uncompensated acidosis.

Question 73

A patient reports headache and dizziness. After reviewing the electrocardiogram (ECG) and blood reports of the patient, the nurse finds that the patient has ventricular fibrillation and hypotension. Which condition does the nurse suspect? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 73

Respiratory acidosis Signs of respiratory acidosis include hypotension, headache, dizziness, and ventricular fibrillation. Metabolic acidosis is manifested by headache, dizziness, and dysrhythmia. Metabolic alkalosis is manifested by tachycardia, anorexia, and tremors. Patients with respiratory alkalosis exhibit tachycardia, tetany, and epigastric pain.

Question 74

A patient has the following arterial blood gas results: pH 7.16, PaCO2 80 mm Hg, PaO2 46 mm Hg, HCO3- 24 mEq/L, and SaO2 81%. How does the nurse interpret this information? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 74

Respiratory acidosis The pH is less than 7.35, indicating acidosis. This eliminates metabolic and respiratory alkalosis as possibilities. Because the PaCO2 is high at 80 mm Hg (normal range is 35 to 45 mm Hg) and the metabolic measure of HCO3– is normal (range is 22 to 28 mEq/L), the patient is in respiratory acidosis, not alkalosis

Question 75

A diabetic patient fasting before surgery reports feeling dizzy with deep, rapid breathing. A nurse observes that the patient has developed Kussmaul respirations. What condition is the patient most likely experiencing? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 75

Metabolic acidosis The patient has been fasting and complains of dizziness. The patient has likely developed diabetic ketoacidosis, a type of metabolic acidosis. Kussmaul respiration is deep, rapid breathing that develops in response to metabolic acidosis. This type of breathing is a compensatory mechanism to excrete excess carbon dioxide from the lungs. Metabolic alkalosis occurs when there is a loss of acid or a gain in bicarbonate. It is not associated with Kussmaul respiration. Respiratory acidosis results when the person hypoventilates and carbonic acid accumulates in the blood. Respiratory alkalosis occurs when the person hyperventilates.

Question 76

The nurse is caring for a patient with acute kidney failure due to severe dehydration. When evaluation of the arterial blood gases is done, what condition does the nurse likely interpret the findings to indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 76

Metabolic acidosis Renal failure will make the blood more acidic because of the inability of the kidneys to excrete acid. Therefore the nurse suspects that the patient would develop metabolic acidosis. Metabolic alkalosis is caused by excess bicarbonate intake and a potassium deficit. Respiratory acidosis is caused by hypoventilation. Respiratory alkalosis is caused by hyperventilation.

Question 77

A nurse is caring for a patient three days after abdominal surgery who continues to have poorly controlled abdominal pain with green bilious nasogastric output. The patient’s respiratory rate is 32 and heart rate is 128. Which acid-base imbalance does the nurse suspect is occurring? Mixed acidosis Mixed alkalosis Metabolic alkalosis Respiratory acidosis

Answer 77

Mixed alkalosis Mixed alkalosis can occur in a patient who is losing CO2 via hyperventilation (possibly related to pain) while also losing acid by another method, such as prolonged suctioning with a nasogastric tube. Respiratory acidosis occurs when the primary loss of acid is via a respiratory "blow off" of CO2. Metabolic alkalosis occurs with a systemic loss of acid via a metabolic process such as vomiting or suctioning with a nasogastric tube. Mixed acidosis occurs when acid is retained by both respiratory and metabolic systems, such as in a critically ill patient in shock with hypoperfusion and hypoventilation, and will often cause a more profoundly acidotic pH than either condition could independently create.

Question 78

A patient is diagnosed with Guillain-Barré syndrome. Which complication does the nurse anticipate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 78

Respiratory acidosis Guillain-Barré syndrome is a disease of the respiratory system that causes hypoventilation. Hypoventilation increases the concentration of carbonic acid, which results in respiratory acidosis. Metabolic acidosis, metabolic alkalosis, and respiratory alkalosis are not caused by Guillain-Barré syndrome.

Question 79

The nurse is caring for a patient that is in respiratory acidosis. What cardiovascular condition should the nurse closely monitor the patient for? Diarrhea Confusion Abdominal pain Ventricular fibrillation

Answer 79

Ventricular fibrillation Respiratory acidosis causes compensatory hyperkalemia, which leads to ventricular fibrillation. Diarrhea, confusion, and abdominal pain are manifestations of metabolic acidosis.

Question 80

A patient is admitted with exacerbation of chronic obstructive pulmonary disease (COPD). The arterial blood gas (ABG) reveals the following information: pH 7.34, PaCO2 46, PaO2 87, and oxygen saturation 94%. How does the nurse interpret these results? Normal Metabolic acidosis Respiratory acidosis Respiratory alkalosis

Answer 80

Respiratory acidosis The normal pH is 7.35 to 7.45. The normal PaCO 2 is 35 to 45 mm Hg, and normal PaO 2 is greater than 80 mm Hg. Normal oxygen saturation is greater than 95%. With the low pH and high PaCO2, the nurse can conclude that the patient's blood gas reveals respiratory acidosis, even without the bicarbonate level that usually is measured. This is not a normal ABG; the pH level is low, indicating acidosis. Because the patient is presenting with COPD and a slightly elevated PaCO2, this indicates that this is respiratory related.

Question 81

A patient has the following arterial blood gas results: pH 7.32; PaCO2 56 mm Hg; HCO3- 24 mEq/L. What does the nurse determine these results will indicate for the patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 81

Respiratory acidosis The normal ranges are as follows: pH 7.35-7.45; PaCO2 35-45 mm Hg; HCO3- 22-26 mEq/L. Respiratory acidosis (carbonic acid excess) occurs whenever a person experiences hypoventilation. Hypoventilation leads to a buildup of CO2, resulting in an accumulation of carbonic acid in the blood. Carbonic acid dissociates, liberating H+, and there is a decrease in pH. The patient is not experiencing metabolic acidosis. These results are not indicative of metabolic alkalosis or respiratory alkalosis (because the pH is high)

Question 82

When assessing the patient with a multilumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priority action? Administer oxygen Notify the health care provider Reposition the patient to the right side Rapidly administer more intravenous (IV) fluid

Answer 82

Administer oxygen The cap off the central line could allow entry of air into the circulation. For an air embolus, the priority is to administer oxygen; next, the catheter is clamped and the patient is positioned on the left side with the head down. Then the health care provider is notified.

Question 83

The nurse reviews the results of a patient's arterial blood gas tests: pH 7.21, PaCO2 82 mm Hg, PaO 2 51 mm Hg; HCO3 –24 mEq/L, and SaO2, 84%. What does the nurse interpret this data to mean? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 83

Respiratory acidosis The pH of 7.21 is acidic (normal range 7.35 to 7.45). This eliminates any form of alkalosis. Because the respiratory measure of PaCO2 is high at 82 mm Hg (normal range 35 to 45 mm Hg) and the metabolic measure of HCO3– is normal (range 22 to 26 mEq/L), this indicates that the patient has respiratory acidosis. Metabolic acidosis is also incorrect in light of the ABG values.

Question 84

While documenting the arterial blood gas values of a group of patients, the nurse suspects a patient to have respiratory alkalosis. Which patient’s findings support the nurse’s suspicion? Patient A Patient B Patient C Patient D

Answer 84

Patient B Respiratory alkalosis is characterized by an increased pH and decreased carbon dioxide concentration (PaCO2) in blood. The normal values of blood pH, partial pressure of carbon dioxide (PaCO2), and bicarbonate ion (HCO3-) are between 7.35 and 7.45, 35 and 45 mm Hg, and 22 and 26 mEq/L, respectively. The increased pH and decreased PaCO2 in patient B are indicators of respiratory alkalosis.

Question 85

What is the function of a buffer? To excrete weak acids To secrete hydrogen ions To convert strong acids to weak acids To convert ammonia to ammonium ions

Answer 85

To convert strong acids to weak acids Buffers convert strong acids to weak acids. Excretion of weak acids, secretion of hydrogen ions into the renal tubule, and conversion of ammonia to ammonium ions takes place in the kidneys.

Question 86

An arterial blood gas sample is drawn from an intubated patient in the emergency department. The patient is found to have a pH of 7.28, a PaCO2 level of 50 mm Hg, a bicarbonate level of 25 mm Hg, and a PaO2 level of 95 mm Hg. What condition does the nurse report to the health care provider? Compensated metabolic acidosis Compensated respiratory alkalosis Uncompensated metabolic acidosis Uncompensated respiratory acidosis

Answer 86

Uncompensated respiratory acidosis A pH of 7.28 implies acidosis because the lower range of blood pH is 7.35. An elevated PaCO2 level indicates that the cause is respiratory, and a normal bicarbonate level indicates that compensation has not yet occurred. Thus this patient appears to be experiencing uncompensated respiratory acidosis. Uncompensated metabolic acidosis is associated with a low pH, a low bicarbonate level, and a low to normal PaCO2 level. Compensated respiratory alkalosis is associated with a mildly elevated pH, a decreased PaCO2 level, and a decreased bicarbonate level. Compensated metabolic acidosis is associated with a mildly decreased pH, a decreased bicarbonate level, and an increased PaCO2 level.

Question 87

A patient’s arterial blood gas results indicate the presence of metabolic alkalosis. Which clinical manifestations assessed by the nurse confirm this interpretation? Select all that apply. ``` Tremors Vomiting Tachycardia Epigastric pain Numbness of limbs ```

Answer 87

Tremors Vomiting Tachycardia Tremors, vomiting, and tachycardia are signs of metabolic alkalosis. Epigastric pain and numbness of limbs are signs of respiratory alkalosis.

Question 88

A patient is on a long-term mineralocorticoid therapy. Which condition does the nurse suspect in the patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 88

Metabolic alkalosis Mineralocorticoids are used to maintain salt and water balance. Excessive use of mineralocorticoids may cause loss of strong acids, resulting in metabolic alkalosis. Metabolic acidosis is caused by conditions that increase the acid concentration in the body, such as diabetic ketoacidosis. Respiratory acidosis occurs as a result of hypoventilation. Respiratory alkalosis occurs because of hyperventilation.

Question 89

The nurse reviews the arterial blood gases for a patient that has taken an overdose of barbiturates. The results are: pH 7.32; PaCO2 52; HCO3- 24. What does the nurse interpret these results to mean? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 89

Respiratory acidosis Normal pH is 7.35 to 7.45. Values less than 7.35 indicate acidosis. Normal value for PaCO2 is 35 to 45 mm Hg. Because the HCO3- is normal and the PaCO2 is elevated, the source of the acidosis is respiratory. The patient is in respiratory acidosis.

Question 90

The nurse is caring for a patient scheduled for surgery with a chest wall abnormality. Which condition should the nurse carefully monitor the client’s arterial blood gases for? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 90

Respiratory acidosis A chest wall abnormality may cause difficulty in breathing, leading to hypoventilation. Hypoventilation may result in respiratory acidosis. Metabolic acidosis is caused by factors that increase the concentration of acid other than carbonic acid. Metabolic alkalosis occurs as a result of factors contributing to the loss of bicarbonate or gain of acids. Respiratory alkalosis is caused by conditions which result in hyperventilation.

Question 91

The nurse is performing an assessment on a client that is experiencing hyperreflexia. What condition should the nurse review the arterial blood gas results for? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 91

Respiratory alkalosis Respiratory alkalosis is manifested by hyperreflexia. Metabolic acidosis is manifested by abdominal pain and Kussmaul respirations. Tachycardia, anorexia, and muscle cramps are the manifestations of metabolic alkalosis. Headache, seizures, and hypotension are the manifestations of respiratory acidosis

Question 92

While caring for a patient with chronic kidney disease who is on diuretic therapy, the nurse suspects that the patient has developed metabolic alkalosis. Which set of findings supports the nurse’s suspicion? Patient A Patient B Patient C Patient D

Answer 92

Patient D The normal range of pH of blood ranges from 7.35 to 7.45, the normal partial pressure of carbon dioxide (PaCO2) ranges from 35 to 45 mm Hg, and the normal concentration of bicarbonate ion (HCO3-) ranges from 22 to 26 mEq/L. The laboratory reports of patient D indicate increased pH of blood and concentration of bicarbonate ion (HCO3-). Because diuretic therapy causes loss of strong acids and retention of bases, there is a risk for metabolic alkalosis.

Question 93

A nurse reviews the laboratory results of a patient. The arterial blood gas (ABG) values are pH 7.30, PaCO2 35 mm Hg, and bicarbonate (HCO3-) 16 mEq/L. What is the correct interpretation of the values given? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 93

Metabolic acidosis Normal ABG values fall in the range of pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, and HCO3- 22 to 26 mEq/L. Bicarbonate and pH values are less than the normal values and indicate metabolic acidosis. A pH value less than 7.35 and low PaCO2 indicate respiratory acidosis. Metabolic acidosis is indicated by a low pH and low bicarbonate levels. Respiratory alkalosis is indicated by decreased PaCO2. In Metabolic conditions, the pH and the HCO3 go in the same direction. The PaCO2 may also go in the same direction.

Question 94

The nurse is reviewing a patient's arterial blood gases (ABGs) that reveal pH 7.48, PaCO2 38, HCO3- 30. What does the nurse interpret the results indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 94

Metabolic alkalosis Normal pH is 7.35–7.45. Values greater than 7.45 indicate alkalosis. Normal value for HCO3- is 22-26 mEq/L. Because the PaCO2 is normal and the HCO3- is elevated, the source of the alkalosis is metabolic. The patient is in metabolic alkalosis.

Question 95

After reviewing the laboratory reports of four patients, the primary health care provider orders the nurse to prepare one of the patients for mechanical ventilation. Which patient’s reports indicate the need for this intervention? Patient A Patient B Patient C Patient D

Answer 95

Patient C A need for mechanical ventilation arises when the patient is not able to breathe properly. This is manifested by decreased oxygen and increased carbon dioxide in blood. The normal partial pressure of carbon dioxide (PaCO2) value lies between 35 and 45 mm Hg, and the normal range of blood pH is 7.35 to 7.45. Patient C has an increased concentration of carbon dioxide in the blood and a low pH, which indicate that the patient has difficulty breathing and requires mechanical ventilation.

Question 96

While caring for a patient with encephalitis, the nurse suspects that the patient has developed respiratory alkalosis. Which finding in the patient supports the nurse’s suspicion? Bicarbonate ion concentration, 18 mEq/L, partial pressure of carbon dioxide, 30 mm Hg Bicarbonate ion concentration, 22 mEq/L, partial pressure of carbon dioxide, 35 mm Hg Bicarbonate ion concentration, 24 mEq/L, partial pressure of carbon dioxide, 43 mm Hg Bicarbonate ion concentration, 26 mEq/L, partial pressure of carbon dioxide, 45 mm Hg

Answer 96

Bicarbonate ion concentration, 18 mEq/L, partial pressure of carbon dioxide, 30 mm Hg The normal range of bicarbonate (HCO3-) ion concentration in blood is 22 to 26 mEq/L, and the normal range of partial pressure of carbon dioxide (PaCO2) is 35 to 45 mm Hg. When the respiratory center is stimulated, patients with encephalitis will hyperventilate. This condition causes a decrease in partial pressure of carbon dioxide, resulting in decreased carbonic acid concentration. Because the laboratory reports show a decreased partial pressure of carbon dioxide and bicarbonate ion concentration, the nurse suspects respiratory alkalosis.

Question 97

Shortly after having a central IV catheter inserted into the subclavian vein, the patient experiences shortness of breath, anxiety, and restlessness. What is the highest priority for the nurse? Administering a sedative Advising the patient to relax Auscultating the breath sounds Obtaining an arterial blood gas analysis

Answer 97

Auscultating the breath sounds Because this is an acute episode, the nurse should first listen to the patient's lungs to see whether anything has changed. In this situation the probability is high that the patient sustained a pneumothorax during the subclavian IV catheter insertion procedure. The patient will need oxygen, and the care provider should be notified of the findings. Administering a sedative is not appropriate. Advising the patient to relax does provide reassurance, but the anxiety and restlessness are probably due to hypoxia. Obtaining an arterial blood gas analysis would likely be the next nursing action.

Question 98

A nurse is caring for a patient with metabolic acidosis. The patient wants to know how the acid-base imbalance will be corrected. Based on the nurse’s knowledge of acid-base imbalance, what is the best response? Select all that apply. "Medications are the primary treatment for acute acid-base imbalances." "The renal system compensates slowly, usually reacting to pH changes within 24 hours." "The respiratory system can compensate quickly to changes in pH, reacting in a matter of minutes." "The heart is vital in managing the acid-base balance by regulating perfusion to increase or decrease pH." "The buffer system is the primary manner in which the body changes strong acids into weaker ones to maintain pH balance."

Answer 98

"The renal system compensates slowly, usually reacting to pH changes within 24 hours." "The respiratory system can compensate quickly to changes in pH, reacting in a matter of minutes." "The buffer system is the primary manner in which the body changes strong acids into weaker ones to maintain pH balance." The buffer system is the primary manner in which the body maintains acid-base balance. This system is also the quickest, often working within seconds of sensing an imbalance. The respiratory system can compensate by changing the rate and depth of breathing within minutes of sensing an acid-base derangement; the renal system is slower to react, often working within hours to days. The heart is vital in regulating perfusion, but it does not have a major role in managing acid-base balance. Medications can be used to regulate acid-base imbalances, but the primary treatment is to resolve the underlying cause of the imbalance.

Question 99

A patient is recovering from a surgical procedure with pain rating at a 10 on a scale of 0-10 and has a nasogastric (NG) tube draining copious amounts of contents. The patient’s respiratory rate is 32. What condition is this patient at greatest risk for? Hypoxia and respiratory alkalosis Mixed respiratory and metabolic alkalosis Sedative overdose and respiratory acidosis Diabetic ketoacidosis and metabolic acidosis

Answer 99

Mixed respiratory and metabolic alkalosis A mixed acid-base disorder is a condition in which two or more disorders that affect the acid-base balance are present at the same time. Septicemia causes respiratory alkalosis, which causes acid-base imbalance. Metabolic alkalosis also affects the acid-base balance. Thus septicemia and metabolic alkalosis are examples of a mixed acid-base disorder. Hypoxia causes respiratory alkalosis. Overdose of sedatives causes respiratory acidosis. Diabetic ketoacidosis results in metabolic acidosis. An example of a mixed acidosis is a patient in severe shock with poor perfusion and hypoventilation. Mixed alkalosis can occur in a patient hyperventilating because of postoperative pain and losing acid secondary to NG suctioning.

Question 100

A patient is considered to have acidosis if his or her blood pH drops below what number? 7. 25 7. 35 7. 45 7. 55

Answer 100

7.35 Blood pH normally ranges from 7.35 to 7.45, so acidosis occurs when the blood pH drops below 7.35. Though the patient will have acidosis if the blood pH is at 7.25 or lower, the patient will also have acidosis if the blood pH is between 7.25 and 7.35. A blood pH of 7.45 is normal. A blood pH of 7.55 indicates alkalosis, not acidosis.

Question 101

The nurse is caring for a patient with suspected respiratory alkalosis. What does the nurse determine that the cause of the disorder may be? Select all that apply. ``` Fever Hypoxia Pneumonia Pulmonary emboli Chronic obstructive pulmonary disease (COPD) ```

Answer 101

Fever Hypoxia Pulmonary emboli Respiratory alkalosis occurs when the plasma pH is increased and the PaCO2 is decreased. The most common causes of respiratory alkalosis are hypoxia, fever, and pulmonary emboli. These conditions are associated with hyperventilation. Pneumonia and COPD cause respiratory acidosis through hypoventilation.

Question 102

A nurse is caring for a patient in the intensive care unit with respiratory acidosis. The family is concerned about the treatment for this disease. Which statement is the nurse’s best response to the family? "This disease is treated with mechanical ventilation." "This disease is treated with medications such as bicarbonate." "Respiratory acidosis is not something to worry about in the overall treatment regimen." "Respiratory acidosis is not a disease but a symptom of a larger disease process that we will treat separately." complication

Answer 102

"Respiratory acidosis is not a disease but a symptom of a larger disease process that we will treat separately." An acid-base imbalance like respiratory acidosis is not a disease but a symptom of an underlying health problem that must be treated to correct the imbalance. Medications such as sodium bicarbonate may be used to treat acidosis in critically ill patients; however, acidosis is not a disease but a symptom. Mechanical ventilation may assist in correcting the respiratory components of acid-base imbalances, but acidosis is a symptom of respiratory dysfunction (in this case), not a disease. Respiratory acidosis is a potentially deadly imbalance that warrants monitoring and treatment to prevent further complication

Question 103

The nurse is 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 interpretation of these results does the nurse report to the primary care provider? Fully compensated respiratory alkalosis Partially compensated respiratory acidosis Normal acid-base balance with hypoxemia Normal acid-base balance with hypercapnia

Answer 103

Partially compensated respiratory acidosis A low pH (normal 7.35-7.45) indicates acidosis. In the patient with a 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.

Question 104

A patient with diabetes presents with profound hyperglycemia. What type of acid-base imbalance does the nurse anticipate may affect the patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 104

Metabolic acidosis Diabetic ketoacidosis can occur in cases of uncontrolled hyperglycemia. This condition lead to acid accumulation, which causes metabolic acidosis. Respiratory acidosis is typically associated with chronic pulmonary diseases such as chronic obstructive pulmonary disease. Respiratory alkalosis occurs in cases of hyperventilation; this condition leads to a decreased amount of acid in the blood and an elevated pH. Metabolic alkalosis occurs with the loss of acid and causes an elevated (alkalotic) pH.

Question 105

A nurse reviews a patient's blood gas results: pH 7.15, PaO2 40 mm Hg, PaCO2 70 mm Hg, and HCO3 25 mEq/L. The nurse suspects hypoxia and what other condition? Metabolic acidosis Respiratory acidosis Respiratory alkalosis Compensating respiratory acidosis

Answer 105

Respiratory acidosis This patient is not breathing effectively and therefore has a buildup of carbon dioxide in the form of carbonic acid. This places the patient in an acidotic state because the pH is less than 7.35. Metabolic and respiratory alkalosis are therefore eliminated as possibilities. Because the PaCO2 is high at 70 mm Hg (normal range is 35 to 45 mm Hg) and the metabolic measure of HCO3–is normal at 25 mEq/L (normal range is 22 to 28 mEq/L), the patient is in respiratory acidosis. The patient is not compensated, because the HCO3–is still within normal range. If the HCO3–were increased, this would be an indication of compensation.

Question 106

After performing gastric suctioning on a patient who has ingested pesticides, the nurse suspects that the patient has developed metabolic alkalosis. Which finding supports the nurse’s suspicion? pH, 7, partial pressure of carbon dioxide (PaCO2), 34 mm Hg pH, 10, partial pressure of carbon dioxide (PaCO2), 52 mm Hg pH, 8.3, partial pressure of carbon dioxide (PaCO2), 44 mm Hg pH, 7.2, partial pressure of carbon dioxide (PaCO2), 38 mm Hg

Answer 106

pH, 10, partial pressure of carbon dioxide (PaCO2), 52 mm Hg Metabolic alkalosis is manifested by increased plasma pH and partial pressure of carbon dioxide (PaCO2). Normal pH of the blood ranges from 7.35 to 7.45 and the normal range of PaCO2 in blood ranges from 35 to 45 mm Hg. The laboratory findings of pH 10 and PaCO2 of 52 mm Hg support the nurse’s suspicion. A pH of 7 and PaCO2 of 34 mm Hg do not indicate metabolic alkalosis. A pH of blood of 8.3 is higher than normal and indicates alkalinity, and a PaCO2 of 44 mm Hg is normal. A pH value of 7.2 and a PaCO2 value of 38 mm Hg are normal.

Question 107

The nurse is caring for a patient admitted with an exacerbation of asthma. After several treatments, the arterial blood gas (ABG) results are pH 7.40, PaCO2 40 mm Hg, HCO3 24 mEq/L, PaO2 92 mm Hg, and O2 saturation 99%. What does the nurse interpret these findings to indicate? Within normal limits Slight metabolic acidosis Slight respiratory acidosis Slight respiratory alkalosis

Answer 107

Within normal limits The normal pH is 7.35 to 7.45. Normal PaCO2 levels are 35 to 45 mm Hg, and normal HCO3 levels are 22 to 26 mEq/L. A normal PaO2 level is greater than 80 mm Hg. Normal oxygen saturation is greater than 95%. Because 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.

Question 108

The patient is presently in respiratory acidosis. What concentration of bicarbonate ion in blood is an indicator of a compensatory response in this patient? 24 mEq/L 25 mEq/L 26 mEq/L 27 mEq/L

Answer 108

27 mEq/L The bicarbonate ion concentration in blood increases as a compensatory response in patients with respiratory acidosis. The normal range of bicarbonate ion is 22 to 26 mEq/L. Therefore, 27 mEq/L indicates a compensatory response.

Question 109

A patient reports nausea, four episodes of vomiting, and headache. The nurse finds that the patient is taking deep and rapid breaths and blood pressure as 90/60 mm Hg. Which condition does the nurse suspect in the patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 109

Metabolic acidosis Deep and rapid respirations are characteristic of Kussmaul’s respirations. Normal blood pressure is 120/80 mm Hg. Kussmaul’s respirations, low blood pressure, nausea, vomiting, and headache are manifestations of metabolic acidosis. Therefore, the nurse suspects that the patient has metabolic acidosis. Signs of metabolic alkalosis include tetany, nausea, and vomiting. Although headache and hypotension are seen in respiratory acidosis, nausea, vomiting, and rapid respirations are not observed. Respiratory alkalosis is characterized by tetany, anorexia, nausea, and vomiting.

Question 110

When evaluating a patient arterial blood gases (ABGs) the nurse determines there is an increase in the anion gap. What condition does the nurse interpret this to mean for the patient? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Answer 110

Metabolic acidosis The anion gap increases in patients with metabolic acidosis due to increase in the concentration of acid. Metabolic alkalosis, respiratory acidosis, and respiratory alkalosis do not increase the anion gap.

Question 111

A patient is admitted with exacerbation of chronic obstructive pulmonary disease (COPD). The arterial blood gas (ABG) reveals the following information: pH 7.34, PaCO2 46, PaO2 87, and oxygen saturation 94%. How does the nurse interpret these results? Normal Metabolic acidosis Respiratory acidosis Respiratory alkalosis

Answer 111

Respiratory acidosis The normal pH is 7.35 to 7.45. The normal PaCO 2 is 35 to 45 mm Hg, and normal PaO 2 is greater than 80 mm Hg. Normal oxygen saturation is greater than 95%. With the low pH and high PaCO2, the nurse can conclude that the patient's blood gas reveals respiratory acidosis, even without the bicarbonate level that usually is measured. This is not a normal ABG; the pH level is low, indicating acidosis. Because the patient is presenting with COPD and a slightly elevated PaCO2, this indicates that this is respiratory related.

Question 112

The nurse provides care for a patient with respiratory alkalosis. What arterial blood gas results correspond to this condition? pH 7.46, pCO2 44 mm Hg, PO2 95 mm Hg, and HCO3 – 36 mEq/L pH 7.27, pCO2 70 mm Hg, PO2 80 mm Hg, and HCO3 – 26 mEq/L pH 7.30, pCO2 35 mm Hg, PO2 70 mm Hg, and HCO3 – 20 mEq/L pH 7.52, pCO2 24 mm Hg, PO2 85 mm Hg, and HCO3 – 24 mEq/L

Answer 112

pH 7.52, pCO2 24 mm Hg, PO2 85 mm Hg, and HCO3 – 24 mEq/L The patient is experiencing alkalosis because the pH is greater than 7.45. The alkalosis is of a respiratory origin because the carbon dioxide is below normal (reflecting that there is not enough acid) and the HCO3– is within normal range. Normal arterial blood gas values include pH 7.35 to 7.45, pCO2 35 to 45, HCO3– 22 to 26. A pH of 7.46, pCO2 of 44 mm Hg, pO2 of 95 mm Hg, and HCO3– of 36 mEq/L indicate metabolic alkalosis because pH is increased, the pCO2 is normal, and the HCO3– is increased. A pH of 7.27, pCO2 of 70 mm Hg, pO2 of 80 mm Hg, and HCO3– of 26 mEq/L indicate respiratory acidosis because pH is low, pCO2 is increased, and HCO3- is normal. A pH of 7.30, pCO2 of 35 mm Hg, pO2 of 70 mm Hg, and HCO3– of 20 mEq/L indicate metabolic acidosis because the pH is low, pCO2 is normal, and HCO3– is low.9

Question 113

The nurse is admitting a patient reporting abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. The patient is assessed for which anticipated primary acid-base imbalance if the obstruction is high in the intestine? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Metabolic respiration

Answer 113

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. Metabolic acidosis is more likely with diarrhea than vomiting. Respiratory acidosis is associated with the lungs, not the gastrointestinal system. Metabolic respiration is not a real thing.

Question 114

After reviewing the patient’s arterial blood gas analysis report, the primary health care provider concludes that the patient has respiratory acidosis. Which findings made the primary health care provider reach this conclusion? pH, 7.4, partial pressure of carbon dioxide (PaCO2), 44, bicarbonate ion (HCO3 -), 26 pH, 7.2, partial pressure of carbon dioxide (PaCO2), 47, bicarbonate ion (HCO3 -), 25 pH, 7.36, partial pressure of carbon dioxide (PaCO2), 41, bicarbonate ion (HCO3 -), 23 pH, 7.42, partial pressure of carbon dioxide (PaCO2), 42, bicarbonate ion (HCO3 -), 24

Answer 114

pH, 7.2, partial pressure of carbon dioxide (PaCO2), 47, bicarbonate ion (HCO3 -), 25 Patients with respiratory acidosis have increased concentration of carbon dioxide (PaCO2) in the blood and decreased blood pH, whereas the bicarbonate ion concentration (HCO3-) is normal. The normal value ranges of pH, PaCO2, and HCO3- are 7.37 to 7.45, 35 to 45 mm Hg, and 22 to 26 mEq/L, respectively. Thus a pH value of 7.2, PaCO2 of 47, and HCO3-concentration of 25 indicate respiratory acidosis in the patient

Question 115

When planning the care of a patient with dehydration, what would the nurse instruct the unlicensed assistive personnel (UAP) to report? 60 mL urine output in 90 minutes 1200 mL urine output in 24 hours 300 mL urine output per 8-hour shift 20 mL urine output for two consecutive hours

Answer 115

20 mL urine output for two consecutive hours The minimal urine output necessary to maintain kidney function is 30 mL/hr. If the output is less than this for two consecutive hours, the nurse should be notified so that additional fluid volume replacement therapy can be instituted.

Question 116

A patient is admitted for hypovolemia associated with multiple draining wounds. Which assessment would be the most accurate way for the nurse to evaluate fluid balance? a. Skin turgor b. Daily weight c. Presence of edema d. Hourly urine output

Answer 116

b. Daily weight Daily weight is the most easily obtained and accurate means of assessing volume status. Skin turgor varies considerably with age. Considerable excess fluid volume may be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take account of fluid intake or of fluid loss through insensible loss, sweating, or loss from the gastrointestinal tract or wounds

Question 117

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give to this patient related to fluid intake? a. "Increase fluids if your mouth feels dry. b. "More fluids are needed if you feel thirsty." c. "Drink more fluids in the late evening hours." d. "If you feel lethargic or confused, you need more to drink."

Answer 117

a. "Increase fluids if your mouth feels dry. An alert, older patient will be able to self-assess for signs of oral dryness such as thick oral secretions or dry-appearing mucosa. The thirst mechanism decreases with age and is not an accurate indicator of volume depletion. Many older patients prefer to restrict fluids slightly in the evening to improve sleep quality. The patient will not be likely to notice and act appropriately when changes in level of consciousness occur

Question 118

A patient who is taking a potassium-wasting diuretic for treatment of hypertension complains of generalized weakness. It is most appropriate for the nurse to take which action? a. Assess for facial muscle spasms. b. Ask the patient about loose stools. c. Suggest that the patient avoid orange juice with meals. d. Ask the health care provider to order a basic metabolic panel.

Answer 118

d. Ask the health care provider to order a basic metabolic panel. Generalized weakness is a manifestation of hypokalemia. After the health care provider orders the metabolic panel, the nurse should check the potassium level. Facial muscle spasms might occur with hypocalcemia. Orange juice is high in potassium and would be advisable to drink if the patient was hypokalemic. Loose stools are associated with hyperkalemia

Question 119

A newly admitted patient is diagnosed with hyponatremia. When making room assignments, the charge nurse should take which action? a. Assign the patient to a room near the nurse's station. b. Place the patient in a room nearest to the water fountain. c. Place the patient on telemetry to monitor for peaked T waves. d. Assign the patient to a semi-private room and place an order for a low-salt diet.

Answer 119

ANS: A The patient should be placed near the nurse's station if confused in order for the staff to closely monitor the patient. To help improve serum sodium levels, water intake is restricted. Therefore a confused patient should not be placed near a water fountain. Peaked T waves are a sign of hyperkalemia, not hyponatremia. A confused patient could be distracting and disruptive for another patient in a semiprivate room. This patient needs sodium replacement, not restriction

Question 120

IV potassium chloride (KCl) 60 mEq is prescribed for treatment of a patient with severe hypokalemia. Which action should the nurse take? a. Administer the KCl as a rapid IV bolus. b. Infuse the KCl at a rate of 10 mEq/hour. c. Only give the KCl through a central venous line. d. Discontinue cardiac monitoring during the infusion.

Answer 120

ANS: B IV KCl is administered at a maximal rate of 10 mEq/hr. Rapid IV infusion of KCl can cause cardiac arrest. Although the preferred concentration for KCl is no more than 40 mEq/L, concentrations up to 80 mEq/L may be used for some patients. KCl can cause inflammation of peripheral veins, but it can be administered by this route. Cardiac monitoring should be continued while patient is receiving potassium because of the risk for dysrhythmias

Question 121

A postoperative patient who had surgery for a perforated gastric ulcer has been receiving nasogastric suction for 3 days. The patient now has a serum sodium level of 127 mEq/L (127 mmol/L). Which prescribed therapy should the nurse question? a. Infuse 5% dextrose in water at 125 mL/hr. b. Administer IV morphine sulfate 4 mg every 2 hours PRN. c. Give IV metoclopramide (Reglan) 10 mg every 6 hours PRN for nausea. d. Administer 3% saline if serum sodium decreases to less than 128 mEq/L.

Answer 121

ANS: A Because the patient's gastric suction has been depleting electrolytes, the IV solution should include electrolyte replacement. Solutions such as lactated Ringer's solution would usually be ordered for this patient. The other orders are appropriate for a postoperative patient with gastric suction

Question 122

The nurse notes that a patient who was admitted with diabetic ketoacidosis has rapid, deep respirations. Which action should the nurse take? a. Give the prescribed PRN lorazepam (Ativan). b. Start the prescribed PRN oxygen at 2 to 4 L/min. c. Administer the prescribed normal saline bolus and insulin. d. Encourage the patient to take deep, slow breaths with guided imagery.

Answer 122

ANS: C The rapid, deep (Kussmaul) respirations indicate a metabolic acidosis and the need for correction of the acidosis with a saline bolus to prevent hypovolemia followed by insulin administration to allow glucose to reenter the cells. Oxygen therapy is not indicated because there is no indication that the increased respiratory rate is related to hypoxemia. The respiratory pattern is compensatory, and the patient will not be able to slow the respiratory rate. Lorazepam administration will slow the respiratory rate and increase the level of acidosis

Question 123

A patient receives 3% NaCl solution for correction of hyponatremia. Which assessment is most important for the nurse to monitor for while the patient is receiving this infusion? a. Lung sounds b. Urinary output c. Peripheral pulses d. Peripheral edema

Answer 123

ANS: A Hypertonic solutions cause water retention, so the patient should be monitored for symptoms of fluid excess. Crackles in the lungs may indicate the onset of pulmonary edema and are a serious manifestation of fluid excess. Bounding peripheral pulses, peripheral edema, or changes in urine output are also important to monitor when administering hypertonic solutions, but they do not indicate acute respiratory or cardiac decompensation

Question 124

A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the health care provider immediately that the patient is on which medication? a. Oral digoxin (Lanoxin) 0.25 mg daily b. Ibuprofen (Motrin) 400 mg every 6 hours c. Metoprolol (Lopressor) 12.5 mg orally daily d. Lantus insulin 24 U subcutaneously every evening

Answer 124

ANS: A Hypokalemia increases the risk for digoxin toxicity, which can cause serious dysrhythmias. The nurse will also need to do more assessment regarding the other medications, but they are not of as much concern with the potassium level

Question 125

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? a. Maintain the patient on bed rest. b. Auscultate lung sounds every 4 hours. c. Monitor for Trousseau's and Chvostek's signs. d. Encourage fluid intake up to 4000 mL every day

Answer 125

ANS: D To decrease the risk for renal calculi, the patient should have a fluid intake of 3000 to 4000 mL daily. Ambulation helps decrease the loss of calcium from bone and is encouraged in patients with hypercalcemia. Trousseau's and Chvostek's signs are monitored when there is a possibility of hypocalcemia. There is no indication that the patient needs frequent assessment of lung sounds, although these would be assessed every shift

Question 126

When caring for a patient with renal failure on a low phosphate diet, the nurse will inform unlicensed assistive personnel (UAP) to remove which food from the patient's food tray? a. Grape juice b. Milk carton c. Mixed green salad d. Fried chicken breast

Answer 126

ANS: B Foods high in phosphate include milk and other dairy products, so these are restricted on low-phosphate diets. Green, leafy vegetables; high-fat foods; and fruits/juices are not high in phosphate and are not restricted

Question 127

A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make? a. Daily alcohol intake b. Intake of dietary protein c. Multivitamin/mineral use d. Use of over-the-counter (OTC) laxatives

Answer 127

ANS: A Hypomagnesemia is associated with alcoholism. Protein intake would not have a significant effect on magnesium level. OTC laxatives (such as milk of magnesia) and use of multivitamin/mineral supplements would tend to increase magnesium levels

Question 128

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? a. K+ 3.4 mEq/L (3.4 mmol/L) b. Ca+2 7.8 mg/dL (1.95 mmol/L) c. Na+ 154 mEq/L (154 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

Answer 128

ANS: C The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal

Question 129

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? a. Oral temperature of 100.1° F b. Serum sodium level of 138 mEq/L (138 mmol/L) c. Gradually decreasing level of consciousness (LOC) d. Weight gain of 2 pounds (1 kg) above the admission weight

Answer 129

ANS: C The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications

Question 130

A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first? a. Skin turgor b. Heart sounds c. Mental status d. Capillary refill

Answer 130

ANS: C Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema

Question 131

A patient with renal failure has been taking aluminum hydroxide/magnesium hydroxide suspension (Maalox) at home for indigestion. The patient arrives for outpatient hemodialysis and is unresponsive to questions and has decreased deep tendon reflexes. Which action should the dialysis nurse take first? a. Notify the patient's health care provider. b. Obtain an order to draw a potassium level. c. Review the magnesium level on the patient's chart. d. Teach the patient about the risk of magnesium-containing antacids

Answer 131

ANS: A The health care provider should be notified immediately. The patient has a history and manifestations consistent with hypermagnesemia. The nurse should check the chart for a recent serum magnesium level and make sure that blood is sent to the laboratory for immediate electrolyte and chemistry determinations. Dialysis should correct the high magnesium levels. The patient needs teaching about the risks of taking magnesium-containing antacids. Monitoring of potassium levels also is important for patients with renal failure, but the patient's current symptoms are not consistent with hyperkalemia

Question 132

A patient who had a transverse colectomy for diverticulosis 18 hours ago has nasogastric suction and is complaining of anxiety and incisional pain. The patient's respiratory rate is 32 breaths/minute and the arterial blood gases (ABGs) indicate respiratory alkalosis. Which action should the nurse take first? a. Discontinue the nasogastric suction. b. Give the patient the PRN IV morphine sulfate 4 mg. c. Notify the health care provider about the ABG results. d. Teach the patient how to take slow, deep breaths when anxious.

Answer 132

ANS: B The patient's respiratory alkalosis is caused by the increased respiratory rate associated with pain and anxiety. The nurse's first action should be to medicate the patient for pain. Although the nasogastric suction may contribute to the alkalosis, it is not appropriate to discontinue the tube when the patient needs gastric suction. The health care provider may be notified about the ABGs but is likely to instruct the nurse to medicate for pain. The patient will not be able to take slow, deep breaths when experiencing pain.

Question 133

Which action can the registered nurse (RN) who is caring for a critically ill patient with multiple IV lines delegate to an experienced licensed practical/vocational nurse (LPN/LVN)? a. Administer IV antibiotics through the implantable port. b. Monitor the IV sites for redness, swelling, or tenderness. c. Remove the patient's nontunneled subclavian central venous catheter. d. Adjust the flow rate of the 0.9% normal saline in the peripheral IV line.

Answer 133

ANS: B An experienced LPN/LVN has the education, experience, and scope of practice to monitor IV sites for signs of infection. Administration of medications, adjustment of infusion rates, and removal of central catheters in critically ill patients require RN level education and scope of practice

Question 134

A patient has a serum calcium level of 7.0 mEq/L. Which assessment finding is most important for the nurse to report to the health care provider? a. The patient is experiencing laryngeal stridor. b. The patient complains of generalized fatigue. c. The patient's bowels have not moved for 4 days. d. The patient has numbness and tingling of the lips.

Answer 134

ANS: A Hypocalcemia can cause laryngeal stridor, which may lead to respiratory arrest. Rapid action is required to correct the patient's calcium level. The other data are also consistent with hypocalcemia, but do not indicate a need for as immediate action as laryngospasm

Question 135

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Decreased thyroid hormone level d. Bleeding on the patient's dressing

Answer 135

ANS: A The patient's symptoms indicate possible hypocalcemia, which can occur secondary to parathyroid injury/removal during thyroidectomy. There is no indication of a need to check the potassium level, the thyroid hormone level, or for bleeding

Question 136

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? a. Arterial blood pH is 7.32. b. Serum calcium is 18 mg/dL. c. Serum potassium is 5.1 mEq/L. d. Arterial oxygen saturation is 91%.

Answer 136

ANS: B The serum calcium is well above the normal level and puts the patient at risk for cardiac dysrhythmias. The nurse should initiate cardiac monitoring and notify the health care provider. The potassium, oxygen saturation, and pH are also abnormal, and the nurse should notify the health care provider about these values as well, but they are not immediately life threatening

Question 137

When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately? a. The bibasilar breath sounds are decreased. b. The patellar and triceps reflexes are absent. c. The patient has been sleeping most of the day. d. The patient reports feeling "sick to my stomach."

Answer 137

ANS: B The loss of the deep tendon reflexes indicates that the patient's magnesium level may be reaching toxic levels. Nausea and lethargy also are side effects associated with magnesium elevation and should be reported, but they are not as significant as the loss of deep tendon reflexes. The decreased breath sounds suggest that the patient needs to cough and deep breathe to prevent atelectasis

Question 138

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse? a. The patient's radial pulse is 105 beats/minute. b. There is sediment and blood in the patient's urine. c. The blood pressure increases from 120/80 to 142/94. d. There are crackles audible throughout both lung fields

Answer 138

ANS: D Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the appearance of the urine also should be reported, but they are not as dangerous as the presence of fluid in the alveoli

Question 139

The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse take next? a. Monitor ionized calcium level. b. Give oral calcium citrate tablets. c. Check parathyroid hormone level. d. Administer vitamin D supplements.

Answer 139

ANS: A This patient with chronic malnutrition is likely to have a low serum albumin level, which will affect the total serum calcium. A more accurate reflection of calcium balance is the ionized calcium level. Most of the calcium in the blood is bound to protein (primarily albumin). Alterations in serum albumin levels affect the interpretation of total calcium levels. Low albumin levels result in a drop in the total calcium level, although the level of ionized calcium is not affected. The other actions may be needed if the ionized calcium is also decreased

Question 140

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.

Answer 140

ANS: B Because the patient's history suggests that fluid volume deficit may be a problem, assessment for adequate circulation is the highest priority. The other actions are also appropriate, but are not as essential as determining the patient's perfusion status

Question 141

Which action should the nurse take first when a patient complains of acute chest pain and dyspnea soon after insertion of a centrally inserted IV catheter? a. Notify the health care provider. b. Offer reassurance to the patient. c. Auscultate the patient's breath sounds. d. Give the prescribed PRN morphine sulfate IV.

Answer 141

ANS: C The initial action should be to assess the patient further because the history and symptoms are consistent with several possible complications of central line insertion, including embolism and pneumothorax. The other actions may be appropriate, but further assessment of the patient is needed before notifying the health care provider, offering reassurance, or administration of morphine

Question 142

After receiving change-of-shift report, which patient should the nurse assess first? a. Patient with serum potassium level of 5.0 mEq/L who is complaining of abdominal cramping b. Patient with serum sodium level of 145 mEq/L who has a dry mouth and is asking for a glass of water c. Patient with serum magnesium level of 1.1 mEq/L who has tremors and hyperactive deep tendon reflexes d. Patient with serum phosphorus level of 4.5 mg/dL who has multiple soft tissue calcium-phosphate precipitates

Answer 142

ANS: C The low magnesium level and neuromuscular irritability suggest that the patient may be at risk for seizures. The other patients have mild electrolyte disturbances and/or symptoms that require action, but they are not at risk for life-threatening complications

Question 143

Which of the following are functions of sodium in the body? Select all that apply. a. Maintenance of serum osmolarity b. Formation of bones and teeth c. Control of bronchodilation d. Control of serum glucose e. Maintenance of cellular function

Answer 143

A,E Sodium is the major cation in the blood and helps maintain serum osmolarity. Sodium is also important for cell function, especially in the central nervous system.

Question 144

A 93-year-old patient with diarrhea and dehydration is admitted to the hospital from an extended care facility. For which of the following symptoms of dehydration should the nurse assess? a. Pale-colored urine, bradycardia b. Disorientation, poor skin turgor c. Decreased hematocrit, hypothermia d. Lung congestion, abdominal discomfort

Answer 144

b Dehydration is associated with poor skin turgor because of loss of water in the tissues, and with disorientation because of loss of blood volume in the brain.

Question 145

Which patient is most at risk for fluid excess? a. An infant with pneumonia b. A teen with multiple injuries following and automobile accident. c. A middle-aged man who has just had surgery d. An elderly patient receiving IV therapy

Answer 145

d. | The elderly have reduced kidney function and may not be able to handle excess fluids

Question 146

Which of the following is the most reliable way to monitor a patient's fluid status? a. I&O b. Skin turgor c. Daily weights d. Lung sounds

Answer 146

c. Daily weights are the best way to monitor fluid imbalances. They are easier to monitor accurately than intake and output.

Question 147

When caring for a patient with fluid excess, which of the following interventions will best help relieve respiratory distress? a. Elevate the head of the bed b. Encourage the patient to cough and deep breathe. c. Increase fluids to promote urine output. d. Perform percussion and postural drainage.

Answer 147

a. Elevating the head of the bed will provide more room for lung expansion and provide the quickest relief for shortness of breath.

Question 148

A patient is being discharged following hospitalization for fluid imbalance. Which instruction by the nurse should take priority? a. "Weigh yourself at the same time every day and report changes." b. "Call your doctor immediately if you feel weak or fatigued." c. "Drink eight glasses of water a day." d. "Measure everything you drink, and measure how much you urinate each day."

Answer 148

a. Daily or every-other-day weights are easy to keep track of at home.

Question 149

A patient is being treated for hypokalemia. When evaluating his response to potassium replacement therpy, which of the following changes in his assessment should the nurse observe for? a. Improving visual acuity b. Worsening constipation c. Decreasing serum glucose d. Increasing muscle strength

Answer 149

d. Hypokalemia is associated with muscle weakness

Question 150

A patient is being placed on a potassium-losing diuretic. Which foods are high in potassium and should be recommended to the patient by the nurse? Select all that apply. a. Bread b. Potato c. Tomato juice d. Banana e. Gelatin

Answer 150

b, c, d Potatoes, tomatoes and bananas are highest in potassium

Question 151

A patient is being placed on a potassium-losing diuretic. Which foods are high in potassium and should be recommended to the patient by the nurse? Select all that apply. a. Bread b. Potato c. Tomato juice d. Banana e. Gelatin b, c, d Potatoes, tomatoes and bananas are highest in potassium. Which patient is at risk for respiratory acidosis? a. The patient with uncontrolled diabetes mellitus b. The patient with chronic pulmonary disease c. The patient who is very anxious d. The patient who overuses antacids

Answer 151

b. The patient with chronic pulmonary disease

Question 152

A positive Chvostek's sign and a positive Trousseau's sign are classic signs of hypocalcemia and of what other electrolyte imbalance? 1. Hypermagnesemia 2. Hyponatremia 3. Hypomagnesemia 4. Hypokalemia

Answer 152

3. Hypomagnesemia

Question 153

The nurse is caring for an older adult patient who presents to the emergency room complaining of severe vomiting and diarrhea, sweating, and rapid heartbeat. The body temperature is normal. Which of the following assessments should the nurse complete next? 1. Evaluate the presence of leg edema 2. Check skin turgor 3. Listen for crackles 4. Assess capillary refill

Answer 153

2. Check skin turgor

Question 154

The nurse working on a medical unit recognizes that which of the following individuals are a risk for hyponatremia? Select all that apply. 1. A 19-year-old drowning victim rescued from a nearby lake. 2. A 52-year-old with congestive heart failure taking diuretics who is NPO for a cardiac catheterization. 3. A 68-year-old with bowel obstruction receiving nasogastric suction 4. A 92-year-old who is receiving total parenteral nutrition 5. A 55-year-old who takes calcium supplements for osteoporosis 6. A 42-year-old with chronic renal failure.

Answer 154

1. A 19-year-old drowning victim rescued from a nearby lake. 2. A 52-year-old with congestive heart failure taking diuretics who is NPO for a cardiac catheterization. 3. A 68-year-old with bowel obstruction receiving nasogastric suction 4. A 92-year-old who is receiving total parenteral nutrition

Question 155

Which of the floowing intravenous solutions is isotonic? (select all that apply) 1. 0.9% saline 2. 5% dextrose in water (D5W) 3. 0.45% NaCl 4. Dextrose in 0.255% NaCl

Answer 155

1. 0.9% saline

Question 156

Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.2 mEq/L? 1. Lungs 2. Kidneys 3. Liver 4. Heart

Answer 156

4. Heart

Question 157

The nurse is caring for a patient with suspected hypokalemia. Which of the following are signs and/or symptoms for which the nurse should be vigilant? Select all that apply. 1. Weak thready pulse 2. Shallow breathing 3. Increased gastrointestinal motility 4. Muscle weakness 5. Nausea 6. Pinpoint pupils

Answer 157

1, 2, 4, 5

Question 158

The nurse is caring for a patient who is very anxious and hyperventilating. Which of the following are signs and symptoms of respiratory alkalosis for which to observe? Select all that apply. 1. Increased heart rate 2. Increased PaCO2 level 3. Slow deeps respirations 4. Rapid shallow respirations 5. Decreased heart rate 6. Lightheadedness

Answer 158

1, 4, 6

Question 159

What is an adequate intake of sodium for an adult aged 71 or older? 1. 1.2g 2. 1.3g 3. 1.5g 4. 2.3g

Answer 159

1

Question 160

What percentage of an older adult's body weight is water? 1. 30% 2. 50% 3. 60% 4. 70%

Answer 160

2

Question 161

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

Answer 161

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.

Question 162

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. 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

Answer 162

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

Question 163

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

Answer 163

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.

Question 164

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

Answer 164

a. fluid restriction Rationale: In hyponatremia that is caused by water excess, fluid restriction often is all that is needed to treat the problem.

Question 165

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

Answer 165

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

Question 166

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

Answer 166

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

Question 167

``` 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 ```

Answer 167

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.

Question 168

``` 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. 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

Answer 168

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.

Question 169

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.

Answer 169

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.

Question 170

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

Answer 170

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.

Question 171

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

Answer 171

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.

Question 172

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

Answer 172

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.

Question 173

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

Answer 173

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.

Question 174

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.

Answer 174

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.

Question 175

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

Answer 175

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.

Question 176

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

Answer 176

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.

Question 177

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.

Answer 177

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.

Question 178

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.

Answer 178

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.

Question 179

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

Answer 179

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.

Question 180

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.

Answer 180

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.

Question 181

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

Answer 181

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.

Question 182

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

Answer 182

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.

Question 183

While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? a. Weakness b. Paresthesia c. Facial spasms d. Muscle tremors

Answer 183

a. Weakness Signs of hypercalcemia are lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.

Question 184

While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply)? a. Have patient restrict fluid intake to less than 2000 mL/day. b. Renal calculi may occur as a complication of hypercalcemia. c. Weight-bearing exercises can help keep calcium in the bones. d. The patient should increase daily fluid intake to 3000 to 4000 mL. e. Treatment of heartburn can best be managed with Tums as needed.

Answer 184

b, c, & d A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.

Question 185

The patient has chronic kidney disease and ate a lot of nuts, bananas, peanut butter, and chocolate. The patient is admitted with loss of deep tendon reflexes, somnolence, and altered respiratory status. What treatment should the nurse expect for this patient? a. Renal dialysis b. IV potassium chloride c. IV furosemide (Lasix) d. IV normal saline at 250 mL per hour

Answer 185

a. Renal dialysis Renal dialysis will need to be administered to remove the excess magnesium that is in the blood from the increased intake of foods high in magnesium. If renal function was adequate, IV potassium chloride would oppose the effects of magnesium on the cardiac muscle. IV furosemide and increased fluid would increase urinary output which is the major route of excretion for magnesium.

Question 186

The patient is admitted with metabolic acidosis. Which system is not functioning normally? a. Buffer system b. Kidney system c. Hormone system d. Respiratory system

Answer 186

b. Kidney system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes hydrochloric acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin.

Question 187

The patient is admitted with metabolic acidosis. Which system is not functioning normally? a. Buffer system b. Kidney system c. Hormone system d. Respiratory system b. Kidney system When the patient has metabolic acidosis, the kidneys are not combining H+ with ammonia to form ammonium or eliminating acid with secretion of free hydrogen into the renal tubule. The buffer system neutralizes hydrochloric acid by forming a weak acid. The hormone system is not directly related to acid-base balance. The respiratory system releases CO2 that combines with water to form hydrogen ions and bicarbonate. The hydrogen is then buffered by the hemoglobin. The dehydrated patient is receiving a hypertonic solution. What assessments must be done to avoid risk factors of these solutions (select all that apply)? a. Lung sounds b. Bowel sounds c. Blood pressure d. Serum sodium level e. Serum potassium level

Answer 187

a, c, & d BP, lung sounds, and serum sodium levels must be monitored frequently because of the risk for excess intravascular volume with hypertonic solutions.

Question 188

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse's priority action? a. Administer oxygen. b. Notify the physician. c. Rapidly administer more IV fluid. d. Reposition the patient to the right side.

Answer 188

a. Administer oxygen. The cap off the central line could allow entry of air into the circulation. For an air emboli, oxygen is administered; the catheter is clamped; the patient is positioned on the left side with the head down. Then the physician is notified.

Question 189

When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse's priority action? a. Administer oxygen. b. Notify the physician. c. Rapidly administer more IV fluid. d. Reposition the patient to the right side. a. Administer oxygen. The cap off the central line could allow entry of air into the circulation. For an air emboli, oxygen is administered; the catheter is clamped; the patient is positioned on the left side with the head down. Then the physician is notified. The patient was admitted for a paracentesis to remove ascites fluid. Five liters of fluid was removed. What IV solution may be used to pull fluid into the intravascular space after the paracentesis? a. 0.9% sodium chloride b. 25% albumin solution c. Lactated Ringer's solution d. 5% dextrose in 0.45% saline

Answer 189

b. 25% albumin solution After a paracentesis of 5 L or greater of ascites fluid, 25% albumin solution may be used as a volume expander. Normal saline, lactated Ringer's, and 5% dextrose in 0.45% saline will not be effective for this action.