Chapter 13: Fluid and Electrolytes

Question 0

Patients diagnosed with hypervolemia should avoid sweet or dry food because

Answer 0

It increases the patient’s desire to consume fluid

Question 1

Which of the following are the insensible mechanisms of fluid loss?

Answer 1

Breathing

Question 2

Air embolism is a potential complication of IV therapy. The nurse should alert to which clinical manifestation associated with air embolism?

Answer 2

Chest pain

Question 3

Below which sodium level may convulsions or coma can occur?

Answer 3

135 mEq/L

Question 4

Which of the following electrolytes is a major cation in body fluid?

Answer 4

Potassion

Question 5

Oncotic pressure refers to the

Answer 5

Osmotic pressure exerted by proteins

Question 6

Which of the following is the most common cause of symptomatic hypomagnesemia?

Answer 6

Alcoholism

Question 7

Which nerve is implicated in the Chvostek’s sign?

Answer 7

Facial

Question 8

Oral intake is controlled by the thirst center, located in which of the following cerebral areas?

Answer 8

Hypothalamus

Question 9

A client hospitalized for treatment of pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Answer 9

Light-headedness or paresthesia

Question 10

A 57 y.o. homeless female with a history of alcohol abuse has been admitted to your hospital unit with signs and symptoms of hypovolemia—minus the weight loss. She exhibits a localized enlargement of her abdomen. What condition could she be presenting?

Answer 10

Third-spacing

Question 11

A 64- y.o. client is brought in to the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and is lethargic. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for the client?

Answer 11

No, sodium intake should be restricted

Question 12

The calcium level of blood is regulated by which mechanism?

Answer 12

Parathyroid hormone (PTH)

Question 13

To confirm an acid-base imbalance, it is necessary to assess which of the following findings from the results of a client’s arterial blood gas (ABG) results? Select all that apply.

Answer 13

HCO3, PaCO2, pH

Question 14

Translocation is a term used to describe the general movement of fluid and chemicals within body fluids. In every client’s body, fluid and electrolyte balance is maintained through the process of translocation. What specific process allows water to pass through a membrane from a dilute to a more concentrated area?

Answer 14

Osmosis

Question 15

A client was admitted to your unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.

Answer 15

Drink water as an inexpensive way to meet fluid needs
Respond to thirst
Drink at least eight glasses of fluid each day

Question 16

A pt is being treated in the ICU 24 hrs after having a radical neck dissection completed. The pt’s serum calcium level is 7.6 mg/dL. Which of the following physical examination findings is consistent with this electrolyte imbalance?

Answer 16

Pressence of Trousseau’s sign

Question 17

A 42 y.o. client has chronic hyponatremia, which requires weekly blood labs to keep him from lapsing into convulsions or a coma. What is the level of serum sodium below which convulsions or coma can occur?

Answer 17

135 mEq/L

Question 18

An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Answer 18

Hypokalemia

Question 19

A 64 yo client is brought into the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, and rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for the client?

Answer 19

No, sodium intake should be restricted.

Question 20

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Answer 20

Metabolic Acidosis

Question 21

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His ABG analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Answer 21

Metabolic alkalosis

Question 22

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?

Answer 22

Tachycardia

• Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid.

Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.

Question 23

Which of the following solutions is hypotonic?

Answer 23

0.45% NaCl - Half-strength saline is hypotonic.

Lactated Ringer’s solution is isotonic.
Normal saline (0.9% NaCl) is isotonic.
A solution that is 5% NaCl is hypertonic.

Question 24

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?

Answer 24

Respiratory alkalosis

• A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client’s elevated pH value. With respiratory alkalosis, the kidneys’ bicarbonate (HCO3-) response is delayed, so the client’s HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

Question 25

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

Answer 25

3rd Spacing

• Third-spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. The client manifests signs and symptoms of hypovolemia with the exception of weight loss. There may be signs of localized enlargement of organ cavities (such as the abdomen) if they fill with fluid, a condition referred to as ascites.

Question 26

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Answer 26

Serum bicarbonate of 28 mEq/L

• Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.

Question 27

A group of nursing students are studying for a test over acid-base imbalance. One student asks another what the major chemical regulator of plasma pH is. What should the second student respond?

Answer 27

Bicarbonate-carbonic acid buffer system

• The major chemical regulator of plasma pH is the bicarbonate-carbonic acid buffer system.

Question 28

A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer?

Answer 28

Lactated Ringer’s solution

• Lactated Ringer’s solution, with an osmolality of approximately 273 mOsm/L, is isotonic. The nurse shouldn’t give half-normal saline solution because it’s hypotonic, with an osmolality of 154 mOsm/L. Giving 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) also would be incorrect because these solutions are hypertonic.

Question 29

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Answer 29

Light-headedness or paresthesia

• The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.

Question 30

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?

Answer 30

Instruct the client to breathe into a paper bag.

• The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn’t raise the lowered PaCO2 level.

Question 31

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??’) of 26 mEq/L. What disorder is indicated by these findings?

Answer 31

Respiratory alkalosis

• Respiratory alkalosis results from alveolar hyperventilation. It’s marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.

Question 32

Oral intake is controlled by the thirst center, located in which of the following cerebral areas?

Answer 32

Hypothalamus

Question 33

Below which serum sodium level may convulsions or coma can occur?

Answer 33

135 mEq/L

• Normal serum concentration level ranges from 135 to 145 mEq/L. When the level dips below 135 mEq/L, there is hyponatremia. Manifestations of hyponatremia include mental confusion, muscular weakness, anorexia, restlessness, elevated body temperature, tachycardia, nausea, vomiting, and personality changes. Convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L are within the normal range.

Question 34

When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

Answer 34

pH 7.48

• Metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration. The HCO value is below normal. The PaCO value and the oxygen saturation level are within a normal range.

Question 35

You are caring for a 72-year-old client who has been admitted to your unit for a fluid volume imbalance. You know which of the following is the most common fluid imbalance in older adults?

Answer 35

Dehydration

• The most common fluid imbalance in older adults is dehydration. Because of reduced thirst sensation that often accompanies aging, older adults tend to drink less water. Use of diuretic medications, laxatives, or enemas may also deplete fluid volume in older adults. Chronic fluid volume deficit can lead to other problems such as electrolyte imbalances.

Question 36

Which of the following electrolytes is a major cation in body fluid?

Answer 36

Potassium

• Potassium is a major cation that affects cardiac muscle functioning. Chloride is an anion. Bicarbonate is an anion. Phosphate is an anion.

Question 37

The calcium level of the blood is regulated by which mechanism?

Answer 37

Parathyroid hormone (PTH)

• The serum calcium level is controlled by PTH and calcitonin. The thyroid hormone, adrenal gland, or androgens do not regulate the calcium level in the blood.

Question 38

Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality?

Answer 38

Sodium

• Sodium is the primary determinant of ECF osmolality. Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body. Potassium, calcium, and magnesium are not primary determinants of ECF osmolality.

Question 39

Which of the following is a correct route of administration for potassium?

Answer 39

Oral

• Potassium may be administered through the oral route. Potassium is never administered by IV push or intramuscularly to avoid replacing potassium too quickly. Potassium is not administered subcutaneously.

Question 40

A nurse is reviewing a report of a client’s routine urinalysis. Which value requires further investigation?

Answer 40

Urine pH of 3.0

• Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client’s value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.

Question 41

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Answer 41

Acidic

• Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.

Question 42

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

Answer 42

The client had a liver transplant 2 years ago.

• A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized.

Question 43

A client is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this client, the nurse’s priority should be to assess her:

Answer 43

electrocardiogram (ECG) results.

• Although changes in all these findings are seen in hyperkalemia, ECG results should take priority because changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn’t be appropriate to assess the client’s neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.

Question 44

A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder?

Answer 44

Metabolic Acidosis

• This client’s pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.

Question 45

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Answer 45

Prepare to assist with ventilation.

• Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain’s respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client’s respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

Question 46

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

Answer 46

Respiratory alkalosis

• This client’s above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn’t occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

Question 47

A priority nursing intervention for a client with hypervolemia involves which of the following?

Answer 47

Monitoring respiratory status for signs and symptoms of pulmonary complications.

• Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.

Question 48

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

Answer 48

pH, 7.25; PaCO2 50 mm Hg

• In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.

Question 49

An elderly client takes 40 mg of Lasix twice a day. Which electrolyte imbalance is the most serious adverse effect of diuretic use?

Answer 49

Hypokalemia

• Hypokalemia (potassium level below 3.5 mEq/L) usually indicates a defict in total potassium stores. Potassium-losing diuretics, such as loop diuretics, can induce hypokalemia.

Question 50

In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply.

Answer 50

• Heart failure
• Pulmonary edema
• Renal impairment

- Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries.

Question 51

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Answer 51

Arterial blood gas (ABG) analysis

• Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client’s oxygenation status.

Question 52

A nurse is caring for a client with metastatic breast cancer who is extremely lethargic and very slow to respond to stimuli. The laboratory report indicates a serum calcium level of 12.0 mg/dl, a serum potassium level of 3.9 mEq/L, a serum chloride level of 101 mEq/L, and a serum sodium level of 140 mEq/L. Based on this information, the nurse determines that the client’s symptoms are most likely associated with which electrolyte imbalance?

Answer 52

Hypercalcemia

• The normal reference range for serum calcium is 9 to 11 mg/dl. A serum calcium level of 12 mg/dl clearly indicates hypercalcemia. The client’s other laboratory findings are within their normal ranges, so the client doesn’t have hypernatremia, hypochloremia, or hypokalemia.

Question 53

A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Answer 53

Metabolic Alkalosis

• A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn’t experiencing respiratory alkalosis because the PaCO2 is normal. The client isn’t experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

Question 54

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Answer 54

Serum bicarbonate of 28 mEq/L

• Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.

Question 55

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus?

Answer 55

Confusion and seizures

• Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

Question 56

A client comes to the emergency department with status asthmaticus. His respiratory rate is 48 breaths/minute, and he is wheezing. An arterial blood gas analysis reveals a pH of 7.52, a partial pressure of arterial carbon dioxide (PaCO2) of 30 mm Hg, PaO2 of 70 mm Hg, and bicarbonate (HCO3??’) of 26 mEq/L. What disorder is indicated by these findings?

Answer 56

Respiratory alkalosis

• Respiratory alkalosis results from alveolar hyperventilation. It’s marked by a decrease in PaCO2 to less than 35 mm Hg and an increase in blood pH over 7.45. Metabolic acidosis is marked by a decrease in HCO3? to less than 22 mEq/L, and a decrease in blood pH to less than 7.35. In respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg. In metabolic alkalosis, the HCO3? is greater than 26 mEq/L and the pH is greater than 7.45.

Question 57

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client’s medical history. Which condition is a predisposing factor for respiratory alkalosis?

Answer 57

Extreme Anxiety

• Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain’s respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul’s respirations) don’t cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

Question 58

Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism?

Answer 58

Chest Pain

• Manifestations of air embolism include dyspnea and cyanosis; hypotension; weak, rapid pulse; loss of consciousness; and chest, shoulder, and low back pain. Jaundice is not associated with air embolism.

Question 59

To compensate for decreased fluid volume (hypovolemia), the nurse can anticipate which response by the body?

Answer 59

Tachycardia

• Fluid volume deficit, or hypovolemia, occurs when the loss of extracellular fluid exceeds the intake of fluid. Clinical signs include oliguia, rapid heart rate, vasoconstriction, cool and clammy skin, and muscle weakness. The nurse monitors for rapid, weak pulse and orthostatic hypotension.

Question 60

To evaluate a client for hypoxia, the physician is most likely to order which laboratory test?

Answer 60

Arterial blood gas (ABG) analysis

• Red blood cell count, sputum culture, total hemoglobin, and ABG analysis all help evaluate a client with respiratory problems. However, ABG analysis is the only test that evaluates gas exchange in the lungs, providing information about the client’s oxygenation status.

Question 61

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3–, 24 mEq/L. What do these values indicate?

Answer 61

Respiratory Alkalosis

• A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client’s elevated pH value. With respiratory alkalosis, the kidneys’ bicarbonate (HCO3-) response is delayed, so the client’s HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.

Question 62

The nursing student asks their instructor what the term is for the amount of hydrogen ions in a solution. What should the instructor respond?

Answer 62

pH

• The symbol pH refers to the amount of hydrogen ions in a solution; pH can range from 1, which is highly acidic, to 14, which is highly basic. All other options are incorrect.

Question 63

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Answer 63

Prepare to assist with ventilation.

• Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain’s respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client’s respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

Question 64

You are caring for a new client on your unit who is third-spacing fluid. You know to assess for what type of edema?

Answer 64

Generalized

• There may be generalized edema in all the interstitial spaces, which sometimes is called brawny edema or anasarca.

Question 65

You are making rounds on your clients. You find one of your clients struggling to breathe, appears confused, has tachycardia, and the skin appears dusky. What should you do to restore normal pH if ventilation efforts are not very successful?

Answer 65

Administer Sodium Bicarbonate IV

• When the client makes frantic efforts to breathe, breathes slowly, or stops breathing, and has tachycardia, and the skin appears dusky (cyanosis), the condition is likely to be acute respiratory acidosis. The accumulation of CO2 leads to behavioral changes, including confusion. Excess carbonic acid pulls pH below 7.35. The nurse should administer sodium bicarbonate IV to balance the acid and bring the pH to a normal level. Bronchodilators may be useful in chronic respiratory acidosis but not in the acute version. Potassium (needed in hypokalemia) and magnesium sulfate (needed in hypomagnesemia) have no role in acute respiratory acidosis

Question 66

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

Answer 66

Respiratory Alkalosis

• This client’s above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn’t occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.

Question 67

The human body is an intricate mechanism which maintains homeostasis through a multitude of chemical reactions. The measureable chemical levels disclose how well the body is (or is not) functioning. Which of these chemical substances release hydrogen into fluid?

Answer 67

Acids

• Acids are substances that release hydrogen into fluid. The delicate balance of fluid, electrolytes, acids, and bases is ensured by an adequate intake of water and nutrients, physiologic mechanisms that regulate fluid volume, and chemical processes that buffer the blood to keep its pH nearly neutral.

Question 68

Early signs of hypervolemia include

Answer 68

Increased breathing effort and weight gain

• Early signs of hypervolemia are weight gain, elevated blood pressure, and increased breathing effort. Eventually, fluid congestion in the lungs leads to moist breath sounds. An earliest symptom of hypovolemia is thirst

Question 69

The Emergency Department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?

Answer 69

Bicarbonate

• Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.

Question 70

A nurse is assessing a client with syndrome of inappropriate antidiuretic hormone. Which finding requires further action?

Answer 70

Jugular Vein Distension

• Jugular vein distention requires further action because this finding signals vascular fluid overload. Tetanic contractions aren’t associated with this disorder, but weight gain and fluid retention from oliguria are. Polyuria is associated with diabetes insipidus, which occurs with inadequate production of antidiuretic hormone.

Question 71

As Americans live longer, relatively rare conditions are becoming more commonplace - one of which is hypervolemia. What are early signs of hypervolemia? Choose all correct options.

Answer 71

Weight Gain & Increased breathing effort

• Early signs of hypervolemia are elevated BP, increased breathing effort, etc. Eventually, fluid congestion in the lungs leads to moist breath sounds. An earliest symptom of hypovolemia is thirst.

Question 72

Which of the following arterial blood gas results would be consistent with metabolic alkalosis?

Answer 72

Serum bicarbonate of 28 mEq/L

• Evaluation of arterial blood gases reveals a pH greater than 7.45 and a serum bicarbonate concentration greater than 26 mEq/L.

Question 73

A nurse correctly identifies a urine specimen with a pH of 4.3 as being which type of solution?

Answer 73

Acidic

• Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral.

Question 74

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows:
Na + 147 mEq/L
K + 3.0 mEq/L
Cl - 112 mEq/L
Mg ++ 2.3 mg/dL
Ca ++ 1.5 mg/dL
Which of the following is consistent with the client’s findings?

Answer 74

Hypokalemia

• Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a d…(more)
Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias.

Question 75

A nurse is caring for an adult client with numerous draining wounds from gunshots. The client’s pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following?

Answer 75

Extracellular Fluid Volume Deficit

• Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreaesd fluid intake. A cause of this loss is hemorrhage.

Question 76

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

Answer 76

Muscle Weakness

• Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren’t seen in hyperkalemia.

Question 77

A client has a respiratory rate of 38 breaths/min. What effect does breathing faster have on arterial pH level?

Answer 77

Increased arterial pH

• Respiratory alkalosis is always caused by hyperventilation, which is a decrease in plasma carbonic acid concentration. The pH is elevated above normal as a result of a low PaCO2.

Question 78

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should anticipate which laboratory test result?

Answer 78

Serum sodium level of 124 mEq/L

• In SIADH, the posterior pituitary gland produces excess antidiuretic hormone (vasopressin), which decreases water excretion by the kidneys. This, in turn, reduces the serum sodium level, causing hyponatremia, as indicated by a serum sodium level of 124 mEq/L. In SIADH, the serum creatinine level isn’t affected by the client’s fluid status and remains within normal limits. A hematocrit of 52% and a BUN level of 8.6 mg/dl are elevated. Typically, the hematocrit and BUN level decrease.

Question 79

Which of the following is a factor affecting an increase in serum osmolality?

Answer 79

Free Water Loss

• Free water loss is a factor increasing serum osmolality. Diuretic use, overhydration, and hyponatremia are factors decreasing serum osmolality.

Question 80

A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client’s laboratory values.
Na + 130 mEq/L
K + 4.6 mEq/L
Cl - 94 mEq/L
Mg ++ 2.8 mg/dL
Ca ++ 13 mg/dL
Which of the following alterations is consistent with the client’s findings?

Answer 80

Hypercalcemia

• More than 99% of the body’s calcium is found in the skeletal system. Hypercalcemia (greater than 10.2 mg/dL) can be a dangerous imbalance. The client presents with anorexia, nausea and vomiting, constipation, abdominal pain, bone pain, and confusion.

Question 81

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client’s medical history. Which condition is a predisposing factor for respiratory alkalosis?

Answer 81

Extreme Anxiety

• Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain’s respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul’s respirations) don’t cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

Question 82

Which of the following is a factor affecting an increase in urine osmolality?

Answer 82

Syndrome of inappropriate antidiuretic hormone release (SIADH)

• Factors increasing urine osmolality include SIADH, fluid volume deficit, acidosis, and congestive heart failure. Myocardial infarction typically is not a factor that increases urine osmolality.

Question 83

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?

Answer 83

Pulse

• An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client’s pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly. The client’s blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also may delay assessing respirations and temperature because these aren’t affected by the serum potassium level.

Question 84

In which of the following medical conditions would administering IV normal saline solution be inappropriate? Select all that apply.
• Severe hemorrhage
• Pulmonary edema
• Heart failure 
• Burns
• Renal Impairment

Answer 84

Heart Failure, Pulmonary Edema, Renal Impairment

• Normal saline is not used for heart failure, pulmonary edema, renal impairment, or sodium retention. It is used with administration of blood transfusions and to replace large sodium losses, as in burn injuries.

Question 85

A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing?

Answer 85

Metabolic Alkalosis

• Metabolic alkalosis is a clinical disturbance characterized by a high pH and a high plasma biacarbonate concentration. The most common cuase of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and choloride ions. Gastric fluid has an acid pH, and loss of this acidic fluid increases the alkalinity of body fluids.

Question 86

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis?

Answer 86

Shock

• Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren’t associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.

Question 87

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse informs the client that the physician will order diuretic therapy and restrict fluid and sodium intake to treat the disorder. If the client doesn’t comply with the recommended treatment, which complication may arise?

Answer 87

Cerebral Edema

• Noncompliance with treatment for SIADH may lead to water intoxication from fluid retention caused by excessive antidiuretic hormone. This, in turn, limits water excretion and increases the risk for cerebral edema. Hypovolemic shock results from, severe deficient fluid volume; in contrast, SIADH causes excess fluid volume. The major electrolyte disturbance in SIADH is dilutional hyponatremia, not hyperkalemia. Because SIADH doesn’t alter renal function, potassium excretion remains normal; therefore, severe hyperkalemia doesn’t occur. Tetany results from hypocalcemia, an electrolyte disturbance not associated with SIADH.

Question 88

A client presents with muscle weakness, tremors, slow muscle movements, and vertigo. The following are the client’s laboratory values:
Na+ 134 mEq/L
K+ 3.2 mEq/L
Cl- 111 mEq/L
Mg++ 1.1 mg/dL
Ca++ 8.4 mg/dL
Identify which of the following alterations is consistent with the client’s findings.

Answer 88

Hypomagnesemia

• Magnesium, the second most abundant intracellular cation, plays a role in both carbohydrate and protein metabolism. The most common cause of this imbalance is loss in the gastrointestinal tract. Hypomagnesemia is a value less than 1.3 mg/dL. Signs and symptoms include muscle weakness, tremors, irregular movements, tetany, vertigo, focal seizures, and positive Chvostek’s and Trousseau’s signs.

Question 89

Which of the following conditions does the nurse need to confirm when he or she taps the facial nerve of a client who has dysphagia?

Answer 89

Hypomagnesemia

• If there is a unilateral spasm of facial muscles when the nurse taps over the facial muscle, it is known as Chvostek’s sign, which is a sign of hypocalcemia and hypomagnesemia. The additional symptom of dysphagia reinforces the possibility of hypomagnesemia rather than hypocalcemia. A positive Chvostek’s sign does not apply to hypercalcemia, hypervolemia, or hypermagnesemia.

Question 90

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance?

Answer 90

Respiratory Acidosis

• Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.

Question 91

Following a unilateral adrenalectomy, a nurse should assess for hyperkalemia as indicated by:

Answer 91

Muscle weakness

• Muscle weakness, bradycardia, nausea, diarrhea, and paresthesia of the hands, feet, tongue, and face are findings associated with hyperkalemia, which is transient and results from transient hypoaldosteronism when the adenoma is removed. Tremors, diaphoresis, and constipation aren’t seen in hyperkalemia.

Question 92

A client presents with fatigue, nausea, vomiting, muscle weakness, and leg cramps. Laboratory values are as follows:
Na + 147 mEq/L
K + 3.0 mEq/L
Cl - 112 mEq/L
Mg ++ 2.3 mg/dL
Ca ++ 1.5 mg/dL
Which of the following is consistent with the client’s findings?

Answer 92

Hypokalemia

• Potassium is the major intracellular electrolyte. Hypocalemia (below 3.5 mEq/L) usually indicates a deficit in total potassium stores. Potassium deficiency can result in derangements in physiology. Clinical signs include fatigue, anorexia, nausea, vomiting, muscles weakness, leg cramps, decreased bowel motility, and paresthesias.

Question 93

You are caring for a client that has been admitted with a possible clotting disorder. The client is complaining of excessive bleeding and bruising without cause. You know that you should take extra care to check for signs of bruising or bleeding in what condition?

Answer 93

Hypocalcemia

• Hypocalcemia or low serum calcium levels can affect clotting. Therefore, in this condition the nurse should take extra care to check for bruising or bleeding. There is no such risk in dehydration, hypokalemia, or hypomagnesemia

Question 94

A physician orders regular insulin 10 units I.V. along with 50 ml of dextrose 50% for a client with acute renal failure. What electrolyte imbalance is this client most likely experiencing?

Answer 94

Hyperkalemia

• Administering regular insulin I.V. concomitantly with 50 ml of dextrose 50% helps shift potassium from the extracellular fluid into the cell, which normalizes serum potassium levels in the client with hyperkalemia. This combination doesn’t help reverse the effects of hypercalcemia, hypernatremia, or hyperglycemia.

Question 95

A client with an intravenous infusion is rubbing his arm. The nurse assesses the site and decides to discontinue the current infusion because of concern that the client has developed phlebitis. Which of the following clinical manifestations would the nurse assess with phlebitis? Select all that apply.
• Reddended area along the path of the vein
• Tender area around the insertion site
• Ecchymosis at the insertion site
• Rapid, shallow respirations
• Cool area around the insertion site

Answer 95

Reddended area along the path of the vein & Tender area around the insertion site

-Phlebitis is inflammation of a vein and is characterized by a reddened, warm area around an insertion site or along the path of a vein. The involved area is also tender and swollen. The nurse assesses infusion sites and determines the proper action to take. If indications lead to suspected phlebitis, the nurse will discontinue the intravenous line and restart with a different vessel.

Question 96

Your client’s lab values are sodium 166 mEq/L, potassium 5.0 mEq/L, chloride 115 mEq/L, and bicarbonate 35 mEq/L. What condition is this client likely to have, judging by anion gap?

Answer 96

Metabolic Acidsosis

• The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds 16 mEq/L indicates metabolic acidosis. In this case, the anion gap is (166 + 5) minus (115 + 35), yielding 21 mEq/L, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis

Question 97

Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply.

Answer 97

Clinical manifestations of FVE include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.

Question 98

Which of the following is a factor that increases blood urea nitrogen (BUN)?

Answer 98

GI Bleeding - Factors that increase BUN include GI bleeding, dehydration, increased protein intake, and fever.

Question 99

The Emergency Department (ED) nurse is caring for a client who is known to make excessive use of laxatives who is showing signs of bradycardia. The client is admitted for hemodialysis. The ED nurse knows that a major goal of managing this client is what?

Answer 99

Flush out Excess magnesium

• The main objective is to flush out excess magnesium. Laxatives contain magnesium, and their excessive use may cause hypermagnesemia. Bradycardia or slow heart rate is one of the signs of this imbalance. In severe cases, hemodialysis may be necessary. Magnesium sulfate is administered in hypomagnesemia and not hypermagnesemia. Mechanical ventilation is necessary only if there is a change in respiratory rate, rhythm, or depth. The physician may permit the use of magnesium-free laxatives and the client should follow the recommended frequency of their use.

Question 100

A nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:

Answer 100

Hyperkalemia

• Hyperkalemia is a common complication of acute renal failure. It’s life-threatening if immediate action isn’t taken to reverse it. Administering glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don’t usually occur with acute renal failure and aren’t treated with glucose, insulin, or sodium bicarbonate.

Question 101

Which of the following may occur with respiratory acidosis?

Answer 101

Increased Intracranial Pressure (ICP)

• If respiratory acidosis is severe, intracranial pressure may increase, resulting in papilledema and dilated conjunctival blood vessels. Increased blood pressure, increased pulse, and decreased mental alertness occur with respiratory acidosis.

Question 102

A fluid volume deficit can be caused by either dehydration or hypovolemia. What is the distinction between the two?
a) In hypovolemia all fluid compartments have decreased volumes.
b) In dehydration intracellular fluid volume is depleted.
c) In hypovolemia only blood volume is low.
d) In dehydration only blood volume is low.

Answer 102

In hypovolemia only blood volume is low

• Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. This makes options A, B, and D incorrect.

Question 103

Which of the following is a function of calcitonin? Select all that apply.

Answer 103

Reduces bone resorption, Increases urinary excretion of calcium, Increases deposition of calcium in bones

• Calcitonin reduces bones resorption, increasing deposition of calcium and phosphorous in the bones, and increases urinary excretion of calcium and phosphate.

Question 104

You notify the physician that your client is third-spacing fluid. What orders would you expect the physician to give you?

Answer 104

Start IV fluids and blood products

• This is done by administering IV solutions—sometimes at rapid rates—and blood products, such as albumin, to restore colloidal osmotic pressure. The restriction of fluids; the administration of diuretics and the increase of sodium in the diet are not orders the physician would be expected to give for a client is third-spacing fluids.