Ch.24-26 - Fluid and electrolyte balance and Acute Kidney Injury

Question 1

The nurse is reviewing laboratory results for a patient just admitted to the intensive care unit. The nurse would anticipate interventions to be necessary for which values? Select all that apply

1. Calcium 8.0 mg/dL
2. Potassium 3.0 mEq/L
3. Sodium 142 mEq/L
4. Phosphate 1.8 mEq/L
5. Magnesium 2.1 mEq/L

Answer 1

Correct Answer: 1,2

Rationale 1: The normal range for serum calcium is 8.5 to 10 mg/dL. A low value may indicate need for intervention.

Rationale 2: The normal range for potassium is 3.5 to 5.0 mEq/L. A low value would indicate need for supplementation.

Rationale 3: The normal range for serum sodium is between 135 to 145 mEq/L.

Rationale 4: The normal range for serum phosphate is 1.7 to 2.6 mEq/L.

Rationale 5: The normal range for serum magnesium is 1.5 to 2.5 mEq/L

Question 1

While assessing a high-acuity patient, the nurse learns the patient has a history of arthritis. Which question would provide the most information regarding potential impact on the patient’s fluid and electrolyte balance?

1. “How well are you able to take care of your daily needs?”
2. “How well do you sleep?”
3. “How often do you take nonsteroidal anti-inflammatory medications?”
4. “Does your arthritis affect mostly your hands or your feet and legs?”

Answer 1

Correct Answer: 3

Rationale 1: Ability to take care of ADLs would not have much impact on fluid and electrolyte balance.

Rationale 2: Sleep has little relationship to fluid and electrolyte balance.

Rationale 3: One question asked during the nursing history that relates to fluid and electrolyte assessment is if the patient is taking or receiving any medications that can alter the fluid and electrolyte balance. One such medication is NSAIDs. The patient has arthritis and could be taking NSAIDs on a regular basis. Therefore, the nurse should assess the patient’s frequency of taking this category of medication which could impact the fluid and electrolyte status.

Rationale 4: The body part affected by arthritis would not have an impact on fluid and electrolyte status.

Question 1

The nurse is preparing intravenous fluids for a patient whose serum sodium is 156 mmol/L. Which types of fluid would the nurse select?

1. 10% dextrose in water
2. Lactated Ringer’s
3. 0.45% normal saline
4. 5% dextrose and 0.45% normal saline

Answer 1

Correct Answer: 3

Rationale 1: Hypertonic solutions such as 10% dextrose in water are not used to treat hypernatremia.

Rationale 2: Lactated Ringer’s is an isotonic solution and would not be effective when treating hypernatremia.

Rationale 3: To effectively treat hypernatremia, the patient will need to be provided with hypotonic intravenous fluids. The fluid 0.45% normal saline is a hypotonic fluid.

Rationale 4: Hypertonic fluids such as 5% dextrose and 0.45% normal saline would not be used to treat hypernatremia.

Question 1

A patient is scheduled for arteriovenous access continuous renal replacement therapy (CRRT). Which nursing intervention should the nurse add to the patient’s plan of care? Select all that apply

1. Monitor the access site for leaking or hemorrhage.
2. Check settings on the external pump every 2 hours.
3. Monitor pulses in distal extremities.
4. Monitor for hemodynamic instability from rapid removal of water and wastes from the blood.
5. Monitor the tube for clotting.

Answer 1

Correct Answer: 1,3

Rationale 1: Arteriovenous CRRT requires cannulation of an artery, so hemorrhage is a risk for which the nurse should monitor.

Rationale 2: Arteriovenous CRRT does not require use of an external pump.

Rationale 3: Arteriovenous CRRT increases risk of limb ischemia, so the nurse must monitor for distal pulses regularly.

Rationale 4: Hemodynamic instability from rapid removal of water and wastes is an adverse effect of intermittent dialysis. Continuous dialysis does not have this same adverse effect. Hemodynamic instability in continuous dialysis is more likely related to hemorrhage.

Rationale 5: Tube clotting is more associated with venovenous CRRT.

Question 1

A patient with chronic renal failure and a blood pressure of 158/98 mm Hg refuses to take medication for the blood pressure. What information should the nurse provide for this patient?

1. “One of the problems associated with high blood pressure in people with renal failure is the development of heart failure.”
2. “Some people with chronic renal failure and high blood pressure end up with an infection around their heart.”
3. “You must realize that untreated hypertension may cause you to develop pneumonia.”
4. “There is a significant increase in risk for anemia if hypertension is not treated.”

Answer 1

Correct Answer: 1

Rationale 1: Hypertension, commonly seen in chronic renal failure, can progress to heart failure if left untreated.

Rationale 2: Pericarditis is a complication of end-stage renal disease, but it is inflammatory and not infectious.

Rationale 3: Pneumonia is not a potential problem because of untreated hypertension.

Rationale 4: The patient with chronic renal failure is at high risk for anemia, but this complication is not due to the presence of untreated hypertension.

Question 2

A patient with acute kidney injury has a hemoglobin level of 9.0 mg/dL. How would the nurse explain this change to the patient?

1. “Your kidneys may not be making enough of a hormone that is required to build red blood cells.”
2. “Since you are retaining so much fluid, your blood is more dilute.”
3. “I am afraid you may have some bleeding we have not found as of yet.”
4. “Your lungs are not exchanging oxygen as well as they should, so your body is not producing hemoglobin.”

Answer 2

Correct Answer: 1

Rationale 1: The kidneys produce erythropoietin in response to decreased oxygen delivery to the kidneys. Erythropoietin is necessary for red blood cell production and also plays a role in maintaining healthy endothelium, which promotes angiogenesis and anti-apoptosis. When kidney function deteriorates, red blood cell production is compromised and the life span of the existing red blood cells may decrease.

Rationale 2: When the nurse is explaining pathophysiological events to the patient, every effort should be made to provide accurate information that helps the patient understand changes. The statement about “more dilute” blood does explain a change in hemoglobin, but it might explain a change in hematocrit.

Rationale 3: It is unlikely that this low hemoglobin is related to undiagnosed bleeding. It is premature to worry a patient about that occurrence.

Rationale 4: There is no indication that this patient’s lungs are not exchanging oxygen well. Problems with oxygenation would increase hemoglobin levels.

Question 3

A patient’s temperature has been elevated for the past 24 hours. The nurse should monitor which electrolyte?

1. Phosphorous
2. Sodium
3. Potassium
4. Magnesium

Answer 3

Correct Answer: 2

Rationale 1: It is unlikely that temperature elevation will affect phosphorus levels.

Rationale 2: With an elevated temperature, there can be a loss of water and sodium through diaphoresis. The nurse should assess the patient’s sodium level.

Rationale 3: It is unlikely that temperature elevation will affect potassium level.

Rationale 4: It is unlikely that temperature level will affect magnesium level.

Question 4

A patient is receiving several units of packed red blood cells over several days to replace the blood lost during an active gastrointestinal bleed. The nurse would assess this patient for findings associated with which electrolyte imbalance?

1. Hyponatremia
2. Hypercalcemia
3. Hypokalemia
4. Hypomagnesaemia

Answer 4

Correct Answer: 4

Rationale 1: Blood is administered with normal saline so hypernatremia would be a more likely condition.

Rationale 2: Blood administration is not a primary cause of hypercalcemia.

Rationale 3: Blood transfusion is not a likely cause of hypokalemia.

Rationale 4: Hypomagnesaemia can be induced by the administration of large amounts of stored blood because stored blood is preserved with citrate. Citrate is added to stored blood as a preservative.

Question 4

A patient who was admitted to the intensive care unit has a magnesium level of 8.4 mg/dL. The nurse would prepare for which interventions? Select all that apply

1. Maintenance of strict bedrest
2. Administration of calcium gluconate
3. Observation for tetany
4. Intravenous administration of magnesium
5. Initiation of dialysis

Answer 4

Correct Answer: 2,5

Rationale 1: While ambulation may not be indicated for this patient due to changes in neuromuscular function, strict bedrest is not required. The patient may be able to sit on the side of the bed, use a bedside commode, or sit in a bedside chair.

Rationale 2: The neuromuscular and cardiac toxicity of hypermagnesemia can be antagonized by the administration of 10–20 mL of calcium gluconate over 10 minutes.

Rationale 3: Tetany is seen in hypomagnesaemia and not hypermagnesemia.

Rationale 4: This magnesium level is elevated, so additional magnesium is not indicated.

Rationale 5: Dialysis may be required to remove magnesium in severe cases.

Question 4

The nurse is assessing the integumentary system of a patient with chronic renal failure. Which findings would the nurse associate with this disease history? Select all that apply

1. Flushed, ruddy color
2. Yellow-brown hue
3. Areas of excoriation
4. Moist, clammy skin
5. Rubbery consistency

Answer 4

Correct Answer: 2,3

Rationale 1: Pale skin is associated with chronic renal failure due to anemia.

Rationale 2: The yellow-brown coloring associated with chronic renal failure is related to uremia.

Rationale 3: The patient with chronic kidney failure often experiences pruritus associated with the presence of urea in the skin. This causes itching and the resultant scratching causes skin breaks and excoriation.

Rationale 4: Skin is typically dry and maybe flaky.

Rationale 5: There is no effect that changes the skin to a rubbery consistency.

Question 5

A patient is demonstrating tremors and a positive Chvostek’s sign even though the serum calcium level is low normal. The nurse would review the medical record for which electrolyte imbalance?

1. Low phosphate
2. Low potassium
3. Low magnesium
4. Elevated sodium

Answer 5

Correct Answer: 3

Rationale 1: A positive Chvostek’s sign is associated with hyperphosphatemia.

Rationale 2: Potassium levels are not associated with a positive Chvostek’s sign.

Rationale 3: The symptoms associated with a low magnesium level are similar to those seen in a low calcium level. Therefore, the nurse should suspect that the patient is experiencing a low magnesium level since tremors and a positive Chvostek’s sign is also seen with a low calcium level.

Rationale 4: Sodium level is not associated with a positive Chvostek’s sign.

Question 6

The nurse notes that a patient’s serum albumin level is elevated. Which other lab result should the nurse review?

1. Potassium
2. Calcium
3. Sodium
4. Chloride

Answer 6

Correct Answer: 2

Rationale 1: Changes in albumin level should not change potassium level.

Rationale 2: Ionized calcium is the calcium used in physiological activities such as neuromuscular activity. The concentration of ionized calcium is inversely proportional to the albumin concentration, so the higher the serum albumin, the lower the plasma ionized calcium.

Rationale 3: Albumin level does not affect sodium level.

Rationale 4: Chloride level is not affected by albumin level.

Question 7

A patient’s potassium and calcium levels are below the normal range. The nurse should check for a decreased level of which other electrolyte?

1. Phosphorous
2. Sodium
3. Magnesium
4. Chloride

Answer 7

Correct Answer: 3

Rationale 1: The phosphorous level might be elevated since phosphorous has an inverse relationship to calcium.

Rationale 2: Sodium level will not be affected.

Rationale 3: Because magnesium is mainly excreted in the feces and a small amount is excreted through the urine, these mechanisms of excretion and conservation are similar to those of potassium and calcium. If the patient’s potassium and calcium levels are low, the patient might also demonstrate a low magnesium level since magnesium balance is closely related to potassium and calcium balance.

Rationale 4: Chloride level will not be affected.

Question 8

When assessing the patient’s edema of the lower extremities, the nurse notes that it takes 3 minutes before the indentation created by applying pressure above the ankles disappears. This information should be documented as being which type of pitting edema?

1. +2
2. +1
3. +4
4. +3

Answer 8

Correct Answer: 3

Rationale 1: Indentations that disappear within 10 to 15 seconds would be considered +2 pitting edema.

Rationale 2: Indentations that disappear rapidly would be considered +1 pitting edema.

Rationale 3: Indentations that disappear after 2 to 5 minutes would be considered +4 pitting edema.

Rationale 4: Indentations that disappear within 1 to 2 minutes would be considered +3 pitting edema.

Question 8

The nurse is concerned that a patient’s arterial blood carbon dioxide level is increasing because this can contribute to the development of which electrolyte imbalance?

1. Hyperkalemia
2. Hypokalemia
3. Hypercalcemia
4. Hypocalcemia

Answer 8

Correct Answer: 1

Rationale 1: A rise in arterial blood carbon dioxide is a diagnostic indicator of acidosis. Acidosis contributes to hyperkalemia because excess hydrogen ions shift into the cells, forcing potassium out into the serum. The nurse should be concerned about the patient developing hyperkalemia.

Rationale 2: Acidosis does not contribute to the development of hypokalemia.

Rationale 3: Acidosis does not contribute to the development of hypercalcemia.

Rationale 4: Acidosis does not contribute to the development of hypocalcemia.

Question 8

A patient’s acute kidney injury is suspected of being of postrenal etiology. Which medical history would support this diagnosis? Select all that apply.

1. The patient has been taking NSAIDs for arthritis pain.
2. The patient was diagnosed with heart failure last week.
3. The patient reports having the “flu” with vomiting and diarrhea for the last 6 days.
4. The patient has large renal calculi in the kidney and ureter.
5. The patient was just diagnosed with prostate cancer.

Answer 8

Correct Answer: 4,5

Rationale 1: The intake of NSAIDs for arthritis would contribute to an intrinsic cause for an acute kidney injury.

Rationale 2: The diagnosis of heart failure would be considered a prerenal cause for an acute kidney injury.

Rationale 3: Vomiting and diarrhea for the last 6 days is considered a prerenal cause for an acute kidney injury.

Rationale 4: Large renal calculi in the kidney and ureter are considered a mechanical cause for a postrenal acute kidney injury since they affect urine drainage from the kidney.

Rationale 5: Prostate cancer can cause obstruction of the urethra, which can result in postrenal acute renal failure.

Question 9

A patient’s BUN/creatinine ratio is 13:1. How would the nurse interpret this finding?

1. The patient is hypervolemic.
2. Renal tubule dysfunction may be present.
3. The patient is normovolemic.
4. The patient’s glomerular filtration rate is decreased.

Answer 9

Correct Answer: 3

Rationale 1: A BUN/creatinine ratio of 13:1 does not indicate hypervolemia.

Rationale 2: There is no information that supports this interpretation.

Rationale 3: The normal ration of BUN to creatinine is 10:1 to 20:1. Based on this value alone, the nurse would evaluate this patient as normovolemic.

Rationale 4: There is not enough information to make this determination.

Question 10

Which laboratory value would require that the nurse closely monitor a patient’s cardiac rhythm?

1. Chloride 94 mEq/L
2. Calcium 2.2 mmol/L
3. Potassium 3.3 mEq/L
4. Phosphate 3.0 mg/dL

Answer 10

Correct Answer: 3

Rationale 1: This chloride level is slightly lower than normal but would not cause cardiac rhythm disturbances.

Rationale 2: This normal calcium level would not be implicated in cardiac rhythm disturbances.

Rationale 3: Both high and low potassium levels can adversely affect cardiac rhythm.

Rationale 4: This normal phosphate level would not adversely affect cardiac rhythm.

Question 12

A patient with fluid volume excess has a hemoglobin level of 9.0 mg/dL. How would the nurse explain the more likely cause of this laboratory value?

1. An undiagnosed bleeding disorder exists.
2. The patient has chronic anemia.
3. The patient has iron deficiency anemia.
4. Plasma dilution has occurred due to excess fluid.

Answer 12

Correct Answer: 4

Rationale 1: While this may be the case it is not the most likely reason for this lab value.

Rationale 2: While this may be the case it is not the most likely reason for this lab value.

Rationale 3: While this may be the case it is not the most likely reason for this lab value.

Rationale 4: Since this patient has fluid volume excess the most likely etiology of a low hemoglobin level is plasma dilution from excess extracellular fluid volume.

Question 14

Which patient would the nurse expect to have the least amount of body fluid?

1. A 75-year-old woman with a BMI in the obese range
2. A 23-year-old female with history of type 1 diabetes
3. A 72-year-old male who had a myocardial infarction at age 50
4. A 16-year-old male who plays football on his high school team

Answer 14

Correct Answer: 1

Rationale 1: Fat cells contain little water, so obese individuals have less fluid. Women have more body fat than men, so they have less fluid. Older patients tend to have reduced body water.

Rationale 2: Since this female is young, she will have more body fluid than older females. Diabetes is not a factor.

Rationale 3: Since this older adult is male, he tends to have less body fluid than women at that age.

Rationale 4: This patient is young and male, which tends to decrease fluid level. The fact that he plays football is not a factor.

Question 15

A patient diagnosed with chronic renal failure has a magnesium level of 6.0 mg/dL. Which history data would the nurse evaluate as contributing to this electrolyte imbalance?

1. The patient had an episode of nasal congestion last week and took decongestant.
2. The patient had a resent sprain injury treated with rest and compression wrapping.
3. The patient has been trying to reduce intake of caffeine-containing fluids.
4. The patient has been taking over-the-counter laxative for chronic constipation.

Answer 15

Correct Answer: 4

Rationale 1: Taking a decongestant would not contribute to hypermagnesemia.

Rationale 2: A sprain injury treated with rest and compression would not cause hypermagnesemia.

Rationale 3: Reduction of caffeine-containing beverages would not contribute to hypermagnesemia.

Rationale 4: Many over-the-counter laxatives contain magnesium. Chronic overuse of these laxatives may result in hypermagnesemia.

Question 15

An elderly patient is scheduled for a CT scan with contrast. The nurse would anticipate preprocedure administration of which medication to help prevent renal damage?

1. N-acetylcysteine
2. Vitamin B12
3. Intravenous infusion of 5% dextrose
4. Vitamin D

Answer 15

Correct Answer: 1

Rationale 1: Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity. N-acetylcysteine may be given orally or intravenously before contrast administration. N-acetylcysteine acts as a free radical scavenger, counteracts vasoconstriction from contrast agents, and indirectly exhibits cytoprotective effects.

Rationale 2: Vitamin B12 does not offer kidney protection from contrast dyes.

Rationale 3: Since the use of contrast dyes can be nephrotoxic, steps must be taken to minimize nephrotoxicity. The patient should be adequately hydrated with sodium chloride.

Rationale 4: Vitamin D does not provide kidney protection from contrast dyes.

Question 16

A patient with acute kidney injury is receiving renal replacement therapy. Which assessment finding would the nurse evaluate as best indicating this therapy is having its desired effects?

1. The patient had a soft formed stool this morning.
2. The patient’s lung sounds have improved.
3. The patient slept for 2 hours without awakening.
4. The patient’s serum protein level is normal.

Answer 16

Correct Answer: 2

Rationale 1: Soft formed stools are outcome criteria for the nursing diagnosis of altered nutrition.

Rationale 2: In fluid volume overload, the patient will demonstrate signs of pulmonary edema, peripheral edema, and increased weight. Evidence of successful treatment would be improved lung sounds, reduction in peripheral edema, and stabilization of weight towards normal.

Rationale 3: Improved quality of sleep is not an outcome measure for CRRT.

Rationale 4: A normal serum protein level would be outcome criteria for the nursing diagnosis of altered nutrition.

Question 17

A patient has a serum calcium level of 11.0 mg/dL. The nurse would review this patient’s medical record for which conditions? Select all that apply.

1. History of taking thiazide diuretics
2. Diagnosis of hyperparathyroidism
3. Diagnosis of acute pancreatitis
4. Low serum magnesium level
5. Long term bedrest

Answer 17

Correct Answer: 1,2,5

Rationale 1: Hypercalcemia may result from use of thiazide diuretics.

Rationale 2: Primary hyperparathyroidism is associated with hypercalcemia.

Rationale 3: The diagnosis acute pancreatitis is associated with hypocalcemia.

Rationale 4: A low serum magnesium level is also seen in hypocalcemia.

Rationale 5: Immobility can cause hypercalcemia.

Question 18

A patient comes into the emergency department with complaints of feeling weak, confused, and having abdominal cramps after spending several hours in the hot sun attending a baseball game. The patient’s blood pressure is 96/58 mm Hg. The nurse would conduct additional assessment for which condition?

1. Hyponatremia
2. Hypercalcemia
3. Hypernatremia
4. Hypocalcemia

Answer 18

Correct Answer: 1

Rationale 1: Manifestations of hyponatremia include hypotension, confusion, headache, lethargy, seizures, decreased muscle tone, muscle twitching, tremors, vomiting, diarrhea, and cramping. The patient is complaining of feeling weak and confused with abdominal cramps, which are symptoms associated with hyponatremia. The blood pressure of 96/58 mm Hg is another indication of hyponatremia. Because of these findings and the patient history the nurse should assess for additional symptoms of hyponatremia.

Rationale 2: The symptoms and the patient history do not suggest hypercalcemia.

Rationale 3: Manifestations of hypernatremia include hypertension, thirst, nausea, and vomiting. Hypernatremia would be unlikely in the patient with this history.

Rationale 4: These symptoms and this history do not support a diagnosis of hypocalcemia.

Question 18

A patient with acute kidney injury is demonstrating signs of gastrointestinal bleeding. The nurse would explain this bleeding to be secondary to which event?

1. Low creatinine level
2. Elevated potassium level
3. Increased ammonia level
4. Low calcium level

Answer 18

Correct Answer: 3

Rationale 1: Gastrointestinal bleeding in the patient with an acute kidney injury is not due to low creatinine level.

Rationale 2: Elevated potassium level results in cardiac dysrhythmia, not gastrointestinal bleeding.

Rationale 3: Electrolyte imbalances and increasing levels of uremic toxins are the primary contributors to gastrointestinal manifestations. As urea decomposes in the gastrointestinal tract, it releases ammonia. Ammonia in the gastrointestinal tract increases capillary fragility and gastrointestinal mucosal irritation resulting in small mucosal ulcerations and the potential for pain, decreased appetite, and gastrointestinal bleeding.

Rationale 4: Low calcium levels do not cause gastrointestinal bleeding.

Question 19

The nurse is assessing the effectiveness of fluid replacement therapy in a patient with the nursing diagnosis of Fluid Volume Deficit. Which assessment findings would indicate the therapy is effective? Select all that apply.

1. Blood pressure 90/48 mm Hg
2. Weight gain of 2 pounds since yesterday
3. Urine output increase to 40 mL per hour
4. Tenting of skin
5. Serum osmolality of 284 mOm/kg

Answer 19

Correct Answer: 2,3,5

Rationale 1: Low blood pressure indicates that the therapy has not been effective.

Rationale 2: Increase in weight of 2 pounds in 1 day indicates a change in fluid balance.

Rationale 3: Increase in urine output indicates improvement of fluid balance status.

Rationale 4: Tenting of skin indicates poor skin turgor and fluid volume deficit.

Rationale 5: Normal serum osmolality is 280–300 mOm/kg. Presence of normal serum osmolality indicates normal fluid volume status.

Question 21

A patient is receiving slow continuous ultrafiltration to treat an acute kidney injury. Which nursing assessment will this treatment specifically require?

1. Electrolyte levels
2. White blood cell count
3. Appetite
4. Urine output

Answer 21

Correct Answer: 1

Rationale 1: Slow continuous ultrafiltration is a method of continuous renal replacement that uses both arterial and venous access and, using the patient’s blood pressure, circulates blood through the hemofilter. The goal of this therapy is to remove fluid only, and the patient does not receive any replacement fluid. Toxins are not removed with this treatment and urea levels and electrolytes are not corrected. The nurse will need to continue to assess this patient’s electrolyte levels.

Rationale 2: The white blood count is monitored for development of infection in all patients. This level is not the most specific assessment necessary for this patient.

Rationale 3: Appetite assessment is necessary for all patients who are able to eat. This assessment is not specifically indicated for this patient.

Rationale 4: The patient is experiencing acute renal failure and may or may not have a urine output. Introduction of this technique to filter the blood will not change whether output is or is not present.

Question 23

A patient in the intensive care unit has developed gastrointestinal hemorrhage. The nurse would prepare to fluid resuscitate this patient with which intravenous fluid?

1. 5% dextrose and 0.45% normal saline
2. 2.5% dextrose
3. 0.45% normal saline
4. 0.9% normal saline

Answer 23

Correct Answer: 4

Rationale 1: The solution 5% dextrose and 0.45% normal saline is a hypertonic solution and is not the best choice for expanding the patient’s blood volume.

Rationale 2: The 2.5% dextrose is a hypotonic solution and would not help expand the patient’s blood volume.

Rationale 3: The 0.45% normal saline is a hypotonic solution and would not help expand the patient’s blood volume.

Rationale 4: The patient needs an isotonic solution to expand the blood volume. The appropriate intravenous solution is 0.9% normal saline.

Question 25

A patient’s serum creatinine level is increasing, but the urine creatinine clearance is decreasing. How would the nurse evaluate these two findings?

1. The patient may be experiencing the onset of heart failure.
2. The patient will probably have associated hypokalemia.
3. The patient is malnourished.
4. There is a decrease in glomerular function.

Answer 25

Correct Answer: 4

Rationale 1: These two laboratory values would not be indicative of heart failure.

Rationale 2: There is no reason to assume that a patient with these two laboratory findings would also be hypokalemic.

Rationale 3: Malnutrition cannot be diagnosed with these two findings.

Rationale 4: Creatinine is the end-product of muscle metabolism and is released into the blood at a constant rate. Creatinine is larger in size compared to urea and is not reabsorbed back into the blood, but is eliminated at a rate related to the level of renal function. For this reason, it is a more reliable measure of the state of renal health. A decrease in the urinary creatinine clearance rate indicates a decrease in glomerular function. A rise in serum creatinine level also indicates a decrease in glomerular functioning.

Question 26

A patient diagnosed with kidney injury is on fluid restriction. Which nursing interventions should the nurse add to the patient’s plan of care? Select all that apply.

1. Provide all fluid in the form of ice chips.
2. Provide frequent oral care.
3. Allow the patient to decide when the fluid will be ingested.
4. Provide fluids only when the patient complains of thirst.
5. Consider the amount of fluids that can be provided over a shift.

Answer 26

Correct Answer: 2,5

Rationale 1: Using small amounts of ice chips or frozen popsicles can provide comfort with less volume, but there is no indication that all fluids should be in this form.

Rationale 2: Oral care is an extremely important intervention to minimize oral mucosal damage and to increase patient comfort.

Rationale 3: The nurse should not let the patient decide when the fluid will be ingested since there might not be available fluid for medications and treatments.

Rationale 4: Fluids must be provided for medication administration, so providing fluids only when the patient complains of thirst is not a logical intervention.

Rationale 5: The nurse must consider individual patient variants such as treatments and medication administration to determine how to divide the available free water over a 24-hour period.

Question 28

The nurse caring for a patient receiving digoxin plans to monitor which electrolyte because of increased risk of digitalis toxicity?

1. Potassium
2. Chloride
3. Calcium
4. Sodium

Answer 28

Correct Answer: 1

Rationale 1: In patients receiving digoxin therapy, low serum potassium levels can increase the risk for development of dysrhythmias.

Rationale 2: Chloride levels do not increase risk for digitalis toxicity.

Rationale 3: Calcium levels do not increase risk for digitalis toxicity.

Rationale 4: Sodium levels do not increase risk for digitalis toxicity.

Question 29

A patient is admitted with bleeding from the gastrointestinal tract. The nurse plans interventions to support the balance of which fluid volume compartment?

1. Transcellular

2. Intravascular

3. Interstitial

4. Intracellular

Answer 29

Correct Answer: 2

Rationale 1: Transcellular fluid is cerebral spinal fluid, peritoneal fluid, and synovial fluid.

Rationale 2: Intravascular fluid is one extracellular compartment that consists of plasma. In the case of bleeding, the fluid compartment that will be affected first will be the intravascular fluid.

Rationale 3: Interstitial fluid is found between the cells.

Rationale 4: Intracellular fluid is that fluid found within the cells. Interstitial fluid is found between the cells.

Question 31

A patient with reduced glomerular filtration has a blood pressure of 168/100 mm Hg. The nurse suspects which pathophysiological effect is occurring?

1. Rebound hypertension due to fluid volume deficit
2. Sluggish response by the renin-angiotensin system
3. Kidneys hyper-excreting hydrogen ions
4. Increased renin production causing the retention of water and electrolytes

Answer 31

Correct Answer: 4

Rationale 1: The patient has fluid volume excess and not deficit.

Rationale 2: In the presence of renal ischemia, the renin-angiotensin system is triggered and not sluggish.

Rationale 3: The kidneys are not able to excrete hydrogen ions or hyper-excreting hydrogen ions.

Rationale 4: Hypertension is a common manifestation of renal failure. It is caused by systemic and central fluid volume excess and increased renin production. In the presence of renal ischemia, the renin-angiotensin system is triggered.

Question 32

A urine electrolyte test is ordered to evaluate aldosterone disorder in a patient just admitted to the intensive care unit. How would the nurse collect this specimen?

1. Collect the first specimen voided in the morning.
2. Prepare a 24-hour urine collection system.
3. Collect the specimen from the indwelling urinary catheter inserted in the emergency department.
4. Use a temporary straight catheter to collect the specimen.

Answer 32

Correct Answer: 2

Rationale 1: This specimen should be collected in a different manner.

Rationale 2: Urine electrolytes typically require a 24-hour urine specimen.

Rationale 3: This specimen is not collected in this manner.

Rationale 4: This specimen is not collected in this manner.

Question 34

A patient with hypoxia is at risk for disruption of the sodium potassium pump. Which would the nurse expect if this occurs?

1. Decreased serum potassium
2. Cell death
3. Increase in the cells’ ability to use active transport
4. Decreased extracellular fluid

Answer 34

Correct Answer: 2

Rationale 1: The amount of potassium in the extracellular fluids would increase.

Rationale 2: Without the counterregulating forces provided by the sodium potassium pump, cells will fill with fluid and will rupture and die.

Rationale 3: Dysfunction of the sodium potassium pump will not increase the cells’ ability to use active transport.

Rationale 4: Since the cells can no longer hold fluid, the extracellular fluid component increases.

Question 34

A patient’s potassium level is 6.5 mEq/L. The nurse would prepare for which intervention?

1. Administration of intravenous fluids supplemented with 40 mEq of potassium in each liter of fluid
2. Administration of oral potassium 2 or 3 times daily until levels are normal
3. Administration of Kayexalate by rectum
4. Administration of a D50W bolus

Answer 34

Correct Answer: 3

Rationale 1: This patient does not require additional intravenous potassium.

Rationale 2: This patient does not require administration of oral potassium.

Rationale 3: Kayexalate is a sodium polystyrene sulfonate used to bind to and eliminate excess potassium. It is given orally or by enema. Since this patient’s potassium level is elevated, this intervention is indicated.

Rationale 4: D50W is not given to reduce potassium.

Question 36

A patient being treated for fluid volume excess has blood glucose elevation. The nurse would review the patient’s medication history for which medication?

1. Furosemide (Lasix)
2. Spironolactone (Aldactone)
3. Potassium chloride (K-Dur)
4. Hydrochlorothiazide (Esidrix)

Answer 36

Correct Answer: 4

Rationale 1: Furosemide does not cause hyperglycemia.

Rationale 2: Spironolactone does not result in hyperglycemia.

Rationale 3: Potassium supplements do not cause hyperglycemia.

Rationale 4: Hydrochlorothiazide has hyperglycemia as a major side effect.

Question 37

Laboratory testing reveals a patient’s serum osmolality to be 240 mOsm/kg. The nurse would assess for which conditions? Select all that apply.

1. Excessive infusion of D5W
2. Dehydration
3. Hyperglycemia
4. Syndrome of inappropriate ADH (SIADH)
5. Acute kidney injury

Answer 37

Correct Answer: 1,4

Rationale 1: Excessive D5W IV intake will result in decrease serum osmolality.

Rationale 2: Dehydration results in increased serum osmolality.

Rationale 3: Hyperglycemia results in increased serum osmolality.

Rationale 4: SIADH will result in serum osmolality.

Rationale 5: Acute kidney injury results in decreased urine osmolality.

Question 38

The nurse is assessing for the presence of Trousseau sign. Which findings would the nurse evaluate as indicating this sign is present? Select all that apply.

1. The fingers hyperflex.
2. The thumb flexes toward the palm.
3. The fingers hyperextend.
4. The thumb hyperextends.
5. The hand makes a fist.

Answer 38

Correct Answer: 2,3

Rationale 1: Flexion of the fingers does not indicate positive Trousseau sign.

Rationale 2: Flexion of the thumb toward the palm indicates a positive Trousseau sign.

Rationale 3: Hyperextension of the fingers indicates a positive Trousseau sign.

Rationale 4: Hyperextension of the thumb does not indicate a positive Trousseau sign.

Rationale 5: Fisting of the hand does not indicate a positive Trousseau sign.

Question 40

A patient’s laboratory report indicates critically low serum calcium levels. The nurse would conduct further assessment for which conditions? Select all that apply.

1. Disruption of the parathyroid glands
2. Decreased supply of vitamin D
3. Low levels of calcitonin
4. Insufficient levels of calcitriol
5. Insufficient levels of calcidiol

Answer 40

Correct Answer: 1,2,4,5

Rationale 1: Parathyroid hormone is essential to the release of calcium from bony tissue into the blood and the conversion of calcidiol to calcitriol.

Rationale 2: If insufficient amounts of vitamin D are present, calcium absorption in the intestine is reduced.

Rationale 3: Low levels of calcitonin would result in high calcium levels.

Rationale 4: Calcitriol is the active form of vitamin D, which causes the small intestine to absorb more calcium. Insufficient levels of calcitriol would result in low serum calcium levels.

Rationale 5: Calcidiol converts to calcitriol. Insufficient levels would result in low calcium levels.

Question 41

A hospitalized patient has a phosphorus level of 4.8 mg/dL. The nurse would review this patient’s history for the presence of which conditions? Select all that apply.

1. Chronic kidney failure
2. Hyperthyroidism
3. Recent cardiac surgery
4. Alcoholism
5. Treatment for gram-negative sepsis

Answer 41

Correct Answer: 1,2

Rationale 1: Hyperphosphatemia is predominantly associated with chronic kidney failure.

Rationale 2: Hyperthyroidism can precipitate hypocalcemia, which leads to hyperphosphatemia.

Rationale 3: Cardiac surgery is associated with hypophosphatemia.

Rationale 4: Alcoholism is associated with hypophosphatemia.

Rationale 5: Gram-negative sepsis is associated with hypophosphatemia.

Question 42

A patient has a serum calcium level of 7.9 mg/dL. Which nursing interventions would be appropriate for this patient? Select all that apply.

Standard Text: Select all that apply.

1. Treat tachycardia.
2. Monitor for the development of hypertension.
3. Place on seizure precautions.
4. Strain all urine.
5. Reorient as indicated.

Answer 42

Correct Answer: 3,5

Rationale 1: Bradycardia is the expected result of this calcium level.

Rationale 2: Hypotension is the expected effect of this calcium level.

Rationale 3: A serum calcium level of less than 8.5 mg/dL is indicative of hypocalcemia. Nursing interventions appropriate for the patient would include monitoring the patient for seizures.

Rationale 4: Straining urine is associated with the possibility of kidney stones. This calcium level is not associated with kidney stone development.

Rationale 5: This calcium level indicates hypocalcemia. Reduce cognitive ability is a common finding associated with hypocalcemia. The nurse should reorient this patient as needed.

Question 43

A patient’s electrocardiogram reveals a prolonged P-R interval and ST segment depression. The nurse should review laboratory results for which electrolyte imbalance?

1. Hypokalemia
2. Hyperkalemia
3. Hypocalcemia
4. Hypernatremia

Answer 43

Correct Answer: 2

Rationale 1: Prolongation of the PR interval is not an ECG finding associated with hypokalemia.

Rationale 2: Cardiovascular manifestations of hyperkalemia include prolonged P-R interval; flat or absent P wave; slurring of QRS; tall peaked T wave; and ST segment depression.

Rationale 3: Hypocalcemia causes prolongation of the QT interval and a long ST segment.

Rationale 4: Cardiovascular manifestations of hypernatremia include hypertension and tachycardia.

Question 44

A patient with a history of heart failure is admitted with dehydration, malnutrition, and fatigue. The nurse learns that the patient has been taking multiple doses of a thiazide diuretic. The nurse would review laboratory reports for which electrolyte imbalance?

1. Hypernatremia
2. Hypophosphatemia
3. Hypocalcemia
4. Hypermagnesemia

Answer 44

Correct Answer: 2

Rationale 1: Hypernatremia is not associated with dehydration.

Rationale 2: Hypophosphatemia is associated with malnourished states and is a relatively common imbalance in the high-acuity patient. Other conditions that can cause hypophosphatemia include those disorders that cause hypercalcemia, such as taking thiazide diuretics.

Rationale 3: Thiazide diuretics can cause hypercalcemia.

Rationale 4: Dehydration, malnutrition, and fatigue are not directly linked to hypermagnesemia.

Question 45

The nurse is planning the care of a 50-year-old patient with the risk of developing fluid volume deficit. Which assessment finding would have the greatest contribution to this risk?

1. Loose bowel movement one per day
2. First-degree steam burn on hand and forearm
3. Temperature of 99.6° F
4. Diuretic therapy two doses per day

Answer 45

Correct Answer: 4

Rationale 1: Diarrhea does contribute to fluid volume deficit, but one loose bowel movement per day does not constitute diarrhea.

Rationale 2: Burns also can cause a fluid volume deficit but it is unlikely that a first-degree burn on the hand forearm will produce a significant amount of fluid loss.

Rationale 3: Fever does increase fluid loss, but this is a low-grade temperature whose affect would be minimal.

Rationale 4: The patient receiving two doses of diuretic therapy per day is at risk for high volumes of urine output that could increase the risk of developing a fluid volume deficit.

Question 46

A patient in the intensive care unit has low blood pressure. If the patient’s baroreceptors are functioning appropriately, what will the nurse assess in this patient?

1. Reduced urine output
2. Weak hand grasps
3. Decreased level of consciousness
4. Peripheral edema

Answer 46

Correct Answer: 1

Rationale 1: Arterial baroreceptors are located in the arch of the aorta and carotid sinus. These receptors detect arterial pressure changes. When they sense a decrease in arterial blood pressure, they signal the autonomic nervous system, which will cause peripheral vasoconstriction to raise the blood pressure. Vasoconstriction of the renal arteries decreases glomerular filtration, which will reduce the urine output.

Rationale 2: Weak hand grasps may or may not occur in the patient with hypotension and are not associated with baroreceptor response.

Rationale 3: Decreased LOC is not always present in patients with hypotension. Decreased LOC is not related to baroreceptor response.

Rationale 4: Peripheral edema may or may not be seen in patients with low blood pressure. Peripheral edema is not related to baroreceptor response.

Question 46

A patient admitted to the intensive care unit has been taking high levels of magnesium supplements. The nurse would add which information to this patient’s plan of care?

1. Monitor closely for hypotension.
2. Monitor for sudden decrease in respiratory rate.
3. Monitor for bradycardia.
4. Monitor for hyperthermia.

Answer 46

Correct Answer: 3

Rationale 1: Magnesium levels do not affect blood pressure directly.

Rationale 2: A low respiratory rate can be seen with a low magnesium level.

Rationale 3: A low pulse rate has been associated with a high magnesium level.

Rationale 4: Magnesium does not affect temperature.

Question 48

A patient with chronic renal failure is diagnosed with anemia. The nurse anticipates providing which therapy for this patient?

1. Vitamin B12 injections
2. Routine whole blood transfusions
3. Recombinant erythropoietin supplementation
4. Protein restriction

Answer 48

Correct Answer: 3

Rationale 1: Vitamin B12 injections would not help treat the anemia associated with renal failure.

Rationale 2: Routine whole blood transfusions are not indicated for this patient.

Rationale 3: The anemia of chronic renal failure is treated with recombinant human erythropoietin and iron supplementation.

Rationale 4: Protein restriction may be necessary for this patient, but it is not done to treat anemia.

Question 50

The nurse is transferring to a high-acuity unit where many patients receive intermittent hemodialysis. Which patient characteristic would the nurse expect?

1. Patients whose hemodynamic status requires slow removal of waste products
2. Patients whose kidney injury will resolve since intermittent dialysis is only done temporarily
3. Patients whose blood pressure and heart rate can be stabilized
4. Patients who have few imbalances in electrolyte levels

Answer 50

Correct Answer: 3

Rationale 1: Intermittent hemodialysis will result in rapid removal of waste products.

Rationale 2: Intermittent hemodialysis may be performed temporarily or the patient may require intermittent dialysis on an outpatient basis for life.

Rationale 3: Even though intermittent hemodialysis provides more efficient and effective clearance of excess fluids and solutes, it is destabilizing to the hemodynamic and electrolyte status of the patient. The patient receiving intermittent hemodialysis will need to have a stable blood pressure and heart rate.

Rationale 4: One of the indications for intermittent dialysis is to balance electrolyte levels. There is no indication that this will be successful only if the patient has few imbalances.

Question 51

A patient in the intensive care unit is receiving continuous venovenous hemofiltration for acute kidney injury. In order for the nurse to successfully provide the treatment for the patient, what needs to occur?

1. Infusion of a dialysate through the hemofilter
2. Creation of a fistula
3. Connection to a small pump
4. Successful placement of the catheter in an artery and a vein

Answer 51

Correct Answer: 3

Rationale 1: Continuous venovenous hemofiltration uses a pressure gradient rather than a concentration gradient (dialysate).

Rationale 2: A fistula is needed when the patient will be on long-term hemodialysis.

Rationale 3: Without the arterial pressure to “drive” the system, a small pump propels the blood from one lumen of the catheter through the hemofilter and back into the vein through the second lumen. The pump controls the blood flow and therefore the fluid removal rate.

Rationale 4: Continuous venovenous hemofiltration uses a double-lumen catheter placed in a vein. This eliminates the need for an arterial catheter and the associated risks of this device.

Question 52

After reviewing a patient’s laboratory values, the nurse determines the patient is experiencing fluid volume deficit. Which laboratory value would the nurse cite as supporting this determination?

1. Serum sodium 140 mEq/L
2. Urine specific gravity of 1.003
3. Urine osmolality 1500 mOsm/L
4. Serum potassium 4.3 mEq/L

Answer 52

Correct Answer: 3

Rationale 1: This serum sodium level is within normal limits and would not help determine the patient’s hydration status.

Rationale 2: Low urine specific gravity develops in conditions that cause fluid volume excess.

Rationale 3: Normal urine osmolality is 300 to 1200 mOsm/L. The urine osmolality will increase during fluid volume deficit because the kidneys hold onto water. This is the laboratory value that indicates the patient is experiencing fluid volume deficit.

Rationale 4: This normal serum potassium level would not help determine if the patient is experiencing a fluid volume deficit.

Question 53

Which findings would the nurse evaluate as indication that a pregnant female is hypovolemic? Select all that apply.

1. Flat neck veins
2. Bilateral adventitious lung sounds
3. Flat hand veins when dependent
4. Sunken eyes
5. Tenting of the skin

Answer 53

Correct Answer: 3,4,5

Rationale 1: Flat neck veins are normal and do not indicate hypovolemia. Distended neck veins do indicate hypervolemia.

Rationale 2: Adventitious lung sounds indicate hypervolemia.

Rationale 3: If hand veins remain flat when in the dependent position, the nurse should suspect that the patient is hypovolemic.

Rationale 4: Eyes that are sunken in their sockets may indicate hypovolemia.

Rationale 5: Tenting of the skin reveals poor skin turgor, which can be a result of hypovolemia. This finding is not reliable in older adults.

Question 54

A patient with an acute kidney injury is identified as being at risk for infection. Which nursing interventions are indicated? Select all that apply

1. Turn and reposition when necessary.
2. Avoid manipulation of venous access devices.
3. Post signs to remind visitors and staff to wash their hands.
4. Limit the use of antibiotic therapy.
5. Remove invasive devices as soon as medically possible.

Answer 54

Correct Answer: 3,5

Rationale 1: The patient should be turned and repositioned every 2 hours to prevent the pooling of secretions in the lungs and reduce the likelihood of pressure ulcer development.

Rationale 2: Vascular access devices should receive routine care according to agency policies.

Rationale 3: Frequent scrupulous hand washing is necessary to protect this patient. Hand washing is necessary for both staff and visitors.

Rationale 4: Antibiotic therapy is indicated in the patient with an acute kidney injury; however, the dosage will need adjustment according to the patient’s renal clearance rate.

Rationale 5: The nurse should attend to orders for removal of invasive devices as soon as possible.

Question 55

Potassium phosphate IV has been prescribed for a patient who has hypophosphatemia. Which nursing interventions are indicated when administering this medication?

1. Dilute the dose in 100 mL of normal saline and administer over 20 minutes.
2. Monitor the patient for respiratory distress.
3. Monitor for the development of hypotension.
4. Ensure that pharmacy has mixed the medication with a local anesthetic.

Answer 55

Correct Answer: 2

Rationale 1: The dose should be diluted in 500 mL of 0.45 NS and given over 6 hours.

Rationale 2: Replacement of phosphorus may cause respiratory changes. The patient should be monitored for respiratory distress.

Rationale 3: Hypotension is not an expected effect of phosphorus replacement.

Rationale 4: There is no indication that mixing this medication with a local anesthetic is required.

Question 56

A patient admitted with hyperphosphatemia is to be treated with the administration of intravenous fluids. Which fluid would the nurse anticipate providing?

1. 0.9% normal saline
2. Lactated Ringer’s solute
3. 5% dextrose and 0.25% normal saline
4. 5% dextrose and water

Answer 56

Correct Answer: 1

Rationale 1: Treatment of hyperphosphatemia is directed at lowering serum levels. This is accomplished by either administering agents that bind phosphate in the gastrointestinal tract or administering an intravenous solution with saline since saline promotes the renal excretion of phosphate. The intravenous solution of choice for this patient would be 0.9% normal saline.

Rationale 2: Lactated Ringer’s solution does not provide the most benefit to this patient.

Rationale 3: 5% dextrose and 0.25% normal saline is not the best fluid choice as it has insufficient amounts of an essential ingredient.

Rationale 4: 5% dextrose and water is not the best fluid choice as it lacks an essential ingredient.

Question 57

The nurse is planning the care of a patient in the intensive care unit. With regards to maintaining adequate fluid volume for this patient, the nurse realizes that interventions should be planned to reduce the risk of which condition?

1. Retention of potassium
2. Retention of sodium
3. Loss of calcium
4. Loss of magnesium

Answer 57

Correct Answer: 2

Rationale 1: Most intensive care patients experience a reduced potassium level and do not retain potassium. As retention of a different electrolyte occurs, potassium is excreted by the kidney.

Rationale 2: Under normal situations, the regulation of water is through the thirst mechanism. In the intensive care unit, however, many patients have altered levels of consciousness and will not have this mechanism in place. Because of this, hypernatremia or retention of sodium is a common electrolyte imbalance in these types of patients.

Rationale 3: Calcium balance is not typically associated with fluid volume.

Rationale 4: Magnesium balance is not typically associated with fluid volume.

Question 58

A patient who has acute kidney injury and who weighs 90 kg had a urine output of 25 mL over the last 12 hours. The nurse would place this patient in which RIFLE category?

1. Injury
2. Risk
3. Failure
4. Loss

Answer 58

Correct Answer: 3

Rationale 1: The injury level of RIFLE criteria is urine output less than 0.5mL/kg for 12 hours. This patient’s output is lower than that level.

Rationale 2: The risk level of RIFLE criteria is urine output less than 0.5 mL/kg for 6 hours. This patient’s output is lower than that level.

Rationale 3: According to the RIFLE criteria, failure is a urine output of less than 0.3 ml per kg of body weight or anuria for 12 hours. The patient’s urine output over the last 12 hours has been 25 mL, which would be comparable to the failure category within the RIFLE criteria.

Rationale 4: Loss is considered a complete loss of renal function for at least 4 weeks.

Question 59

The nurse is assessing the neurological status of a patient with chronic renal failure. Which finding would the nurse attribute to chronic renal failure?

1. Numbness and pain of the lower extremities
2. Expressive aphasia
3. Flaccid paralysis on the left side
4. Weak hand grasps

Answer 59

Correct Answer: 1

Rationale 1: Neurological symptoms are nonspecific and progressive in the patient with CRF. These symptoms include: sleep disorders, memory loss, impaired judgment, muscle cramps, and twitching. These may progress to asterixis, seizures, and coma. Peripheral neuropathy is also a component of chronic renal failure and is evidenced by numbness, tingling, or pain, especially in the lower extremities.

Rationale 2: The development of expressive aphasia is not normal in a patient with chronic renal failure and should be further evaluated.

Rationale 3: Flaccid paralysis is not normal in a patient with chronic renal failure and should be further evaluated.

Rationale 4: The development of weak hand grasps is not normal in a patient with chronic renal failure and should the further evaluated.