acid ase

Question 1

Approximately two thirds of the body’s total water volume exists in the _____
fluid.

Answer 1

Intracellular

Question 2

The process of passively moving water from an area of lower particle
concentration to an area of higher particle concentration is known as

Answer 2

osmosis

Question 3

The nurse knows that edema in a patient who has venous congestion from
right heart failure is facilitated by an imbalance with regard to _____ pressure.

Answer 3

hydrostatic

Question 4

The nurse understands that administering a hypertonic solution to a patient
will shift water from the _____ to the _____ space.

Answer 4

Intracellular; extracellular

Question 5

Which patient is most at risk for sensible water loss?
A 7-year-old child with asthma
b. A 24-year-old adult with constipation
c. A 56-year-old patient with gastroenteritis
d. An 80-year-old patient with pneumonia

Answer 5

An 80-year-old patient with pneumonia

Question 6

The nurse knows that the most abundant cation in the blood is

Answer 6

sodium

Question 7

The nurse receives the patient’s most recent blood work results. Which
laboratory value is of greatest concern?

Answer 7

Calcium of 17.5 mg/dL

Question 8

The nurse would expect a patient with increased levels of serum calcium to
also have _____ levels.

Answer 8

Decreased phosphate

Question 9

The nurse knows that an imbalance of which ion causes acid-base
impairment?

Answer 9

hydrogen

Question 10

The nurse would expect a patient with respiratory acidosis to have an
excessive amount of

Answer 10

carbon dioxide

Question 11

A 2-year-old child was brought into the emergency department after
ingesting several morphine tablets from a bottle in his mother’s purse. The nurse knows
that the child is at greatest risk for which acid-base imbalance?

Answer 11

Respiratory acidosis

Question 12

A patient was admitted for a bowel obstruction and has had a nasogastric
tube set to low intermittent suction for the past 3 days. The patient’s respiratory rate has
decreased to 12 breaths per minute. The nurse would expect the patient to have which of
the following arterial blood gas values?

Answer 12

pH 7.52, PaCO2

48 mm Hg, HCO3
– 28

mEq/L

Question 13

The nurse would not expect full compensation to occur for which acid-base
imbalance?

Answer 13

Respiratory alkalosis

Question 14

A nurse is caring for a patient whose ECG presents with changes
characteristic of hypokalemia. Which assessment finding would the nurse expect?

Answer 14

abdominal distention

Question 15

In which patient would the nurse expect to see a positive Chvostek sign?

Answer 15

A 24-year-old adult admitted for chronic

alcohol abuse

Question 16

Which organ system is responsible for compensation of respiratory acidosis?

Answer 16

Renal

Question 17

Which laboratory value should the nurse examine when evaluating
uncompensated respiratory alkalosis?

Answer 17

PaCO2

Question 18

The nurse is caring for a diabetic patient in renal failure. Which laboratory
findings would the nurse expect?

Answer 18

pH 7.3, PaCO2

36 mm Hg, HCO3
– 19

mEq/L

Question 19

The nurse is assessing a patient and finds crackles in the lung bases and
neck vein distention. The nurse gives the patient a diuretic. What electrolyte imbalance is
the nurse most concerned about?

Answer 19

Potassium imbalance

Question 20

A chemotherapy patient has gained 5 pounds in 2 days. Which assessment
question by the nurse is most appropriate?

Answer 20

“How many times a day do you urinate?”

Question 21

Which fluid order should the nurse question for a patient with a traumatic
brain injury?

Answer 21

0.45% sodium chloride

Question 22

The physician asks the nurse to monitor the fluid volume status of a
congestive heart failure patient and a patient at risk for clinical dehydration. What is the
most effective nursing intervention for monitoring both of these patients?

Answer 22

Weigh the patients every morning

before breakfast.

Question 23

A nurse is caring for a cancer patient who presents with anorexia, blood
pressure 100/60, elevated white blood cell count, and oral candidiasis. The nurse knows
that the purpose of starting total parenteral nutrition (TPN) is to

Answer 23

Replace fluid, electrolytes, and nutrients

in the patient.

Question 24

A patient presents to the emergency department with the complaint of
vomiting and diarrhea for the past 48 hours. The nurse anticipates which fluid therapy
initially?

Answer 24

0.9% sodium chloride

Question 25

A patient with a lower respiratory infection has pH of 7.25, PaCO2

of 55 mm

Hg, and HCO3

– of 20 mEq/L. The physician has been notified. Which is the priority nursing

intervention for this patient?

Answer 25

Encourage the patient to increase

respirations.

Question 26

The nurse knows that intravenous fluid therapy has been effective for a
patient with hypernatremia when

Answer 26

Serum sodium concentration returns to

normal.

Question 27

The nurse would select the dorsal venous plexus of the foot as an IV site for
which patient?

Answer 27

A 2-year-old child

Question 28

Which assessment finding should cause a nurse to question administering a
sodium-containing isotonic intravenous fluid?

Answer 28

Pitting edema

Question 29

A patient is to receive 1500 mL of 0.9% sodium chloride intravenously at a
rate of 125 mL/hr. The nurse is using microdrip gravity drip tubing. What is the minute flow
rate (drops per minute)?

Answer 29

125 gtt/min

Question 30

A nurse begins infusing a 250-mL bag of IV fluid at 1845 on Monday and
programs the pump to infuse at 20 mL/hr. At what time should the infusion be completed?

Answer 30

0715 Tuesday

Question 31

A nurse is caring for a diabetic patient with a bowel obstruction and has
orders to ensure that the volume of intake matches the output. In the past 4 hours, the
patient received dextrose 5% with 0.9% sodium chloride through a 22-gauge catheter
infusing at 4 mL/hr and has eaten 200 mL of ice chips. The patient also has an NG suction
tube set to low continuous suction that had 300 mL output. The patient has voided 400 mL
of urine. After reporting these values to the physician, what orders does the nurse
anticipate?

Answer 31

Add a potassium supplement to replace

loss from output.

Question 32

A nurse is caring for a patient who is in hypertensive crisis. When the nurse
is flushing the patient’s peripheral IV, the patient complains of pain. Upon assessment, the
nurse notices a red streak that is warm to the touch. What is the nurse’s initial action?

Answer 32

Start a new IV line.

Question 33

A patient was admitted for hypovolemia and has intravenous fluid running at

250 mL/hr. The patient complains of burning at the IV insertion site. Upon assessment,
the nurse does not find redness, swelling, heat, or coolness. The nurse suspects that the

Answer 33

Fluid is infusing too quickly.

Question 34

The nurse is caring for a patient with sepsis. The plan of care for the patient
is to administer antibiotics 3 times a day for 4 weeks. What device will be used to
administer these antibiotics?

Answer 34

a PICC Line

Question 35

A nurse is preparing to administer a blood transfusion. Which assessment
finding would the nurse report immediately?

Answer 35

Temperature 101.3° F

Question 36

A nurse has just received a bag of packed red blood cells. The nurse knows
that the blood must not remain at room temperature for longer than

Answer 36

4 hours.

Question 37

A patient had an acute intravascular hemolytic reaction to a blood
transfusion. After discontinuing the blood transfusion, what is the nurse’s next action?

Answer 37

Start normal saline at TKO rate using

new tubing.

Question 38

A nurse is assessing a patient who is receiving a blood transfusion and finds
that the patient is anxiously fidgeting in bed. The patient is afebrile and dyspneic. The
nurse auscultates crackles in both lung bases and sees jugular vein distention. The nurse
recognizes that the patient is experiencing which transfusion complication?

Answer 38

Fluid volume overload

Question 39

The nurse selects appropriate tubing for a blood transfusion by ensuring that
the tubing has

Answer 39

A filter to ensure that clots do not enter

the patient.

Question 40

The nurse is caring for a patient with hyperkalemia. Which body system
would be most important for the nurse plan to monitor closely?

Answer 40

Cardiac

Question 41

Which assessment finding would the nurse expect for a patient with the
following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

Answer 41

Tingling of the extremities and tetany

Question 42

A patient informs the nurse that he has the type of diabetes that does not
require insulin. The nurse advises the patient to make which dietary change?

Answer 42

Drink plenty of fluids throughout the day

to stay hydrated.

Question 43

When selecting a site to insert an intravenous catheter on an adult, the nurse
should (Select all that apply.)
a. Start proximally and move distally on the

arm.

b. Choose a vein with minimal curvature.
c. Choose the patient’s dominant arm.
d. Check for contraindications to the

extremity.

e. Select a vein that is rigid.
f. Avoid areas of flexion.

Answer 43

b. Choose a vein with minimal curvature.
d. Check for contraindications to the

extremity.

f. Avoid areas of flexion.`

Question 44

Which of the following assessments would indicate that a patient’s IV has
infiltrated? (Select all that apply.)
a. Edema of the extremity near the

insertion site

b. Skin discolored or bruised in

appearance

c. Pain and warmth at the insertion site
d. Skin cool to the touch
e. Reddish streak proximal to the insertion

site

f. Numbness or loss of sensation
g. Palpable venous cord

Answer 44

a. Edema of the extremity near the

insertion site

b. Skin discolored or bruised in

appearance

d. Skin cool to the touch
f. Numbness or loss of sensation

Question 45

When discontinuing a peripheral IV access, the nurse should (Select all that

apply. )
a. Use scissors to remove the IV site

dressing and tape.

b. Keep the catheter parallel to the skin

while removing it.

c. Apply firm pressure with sterile gauze

during removal.

d. Stop the infusion before removing the IV

catheter.

e. Wear sterile gloves and a mask.
f. Apply pressure to the site for 2 to 3

minutes after removal.

Answer 45

b. Keep the catheter parallel to the skin

while removing it.

d. Stop the infusion before removing the IV

catheter.

f. Apply pressure to the site for 2 to 3

minutes after removal.