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NUR243 - Medical-Surgical II > Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances > Flashcards

Chapter 17: Fluid, Electrolyte, and Acid-Base Imbalances Flashcards

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USMLE® Step 1 flashcards
1
Q

Substances whose molecules dissociate into ions when placed in water.

A

electrolytes

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2
Q

Cations are __________ charged.

A

positively

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3
Q

Anions are _________ charged.

A

negatively

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4
Q

ICF prevalent cation is:

A. K+
B. PO43-
C. Na+
D. CL-

A

A. K+

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5
Q

ECF prevalent cation is:

A. K+
B. PO43-
C. Na+
D. CL-

A

C. Na+

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6
Q

ICF prevalent anion is:

A. K+
B. PO43-
C. Na+
D. CL-

A

B. PO43-

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7
Q

ECF prevalent anion is:

A. K+
B. PO43-
C. Na+
D. CL-

A

D. CL-

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8
Q

What is the body primarily composed of?

A. blood
B. water
C. tissue
D. bone

A

B. water

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9
Q

T/F

Lean body mass has a lower percentage of water weight.

A

false; a higher percentage

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10
Q

T/F

Fat tissue has a lesser percentage of water weight.

A

true

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11
Q

inside the cells

A

intracellular space

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12
Q

spaces between cells

A

extracellular space

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13
Q

bicarbonate range

A

22-26 mEq/L

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14
Q

chloride range

A

98-106 mEq/L

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15
Q

phosphate range

A

3.0-4.5 mg/dL

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16
Q

calcium range

A

9.0-10.5 mg/dL

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17
Q

magnesium range

A

1.3-2.1 mEq/L

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18
Q

potassium range

A

3.5-5.0 mEq/L

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19
Q

sodium range

A

136-145 mEq/L

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20
Q

Capillary hydrostatic pressure and interstitial oncotic pressure move water __________ of the capillaries.

A

out

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21
Q

Plasma oncotic pressure and interstitial hydrostatic pressure move fluid __________ the capillaries.

A

into

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22
Q

T/F

If capillary or interstitial pressure changes, fluid may abnormally shift from one compartment to another.

A

true

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23
Q

Edema occurs if venous hydrostatic pressure __________, plasma oncotic pressure __________, or interstitial oncotic pressure __________.

A. increases, decreases, increases
B. decreased, decreases, increased
C. increases, increases, decreases
D. decreases, increases, increases

A

A. increases, decreases, increases

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24
Q

Edema is swelling of the __________ space.

A

interstitial

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25
Q

term used to describe the distribution of body water

A

fluid spacing

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26
Q

describes the normal distribution of fluid in ICF and ECF compartments

A. first spacing
B. second spacing
C. third spacing

A

A. first spacing

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27
Q

refers to an abnormal accumulation of interstitial fluid (i.e., edema)

A. first spacing
B. second spacing
C. third spacing

A

B. second spacing

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28
Q

occurs when excess fluid collects in the nonfunctional area between the cells

A. first spacing
B. second spacing
C. third spacing

A

C. third spacing

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29
Q

__________ can occur with abdominal body fluid loss, inadequate fluid intake, or a shift from plasma to interstitial fluid.

A. hypernatremia
B. hyponatremia
C. fluid volume deficit
D. fluid volume excess

A

C. fluid volume deficit

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30
Q

T/F

Fluid volume deficit and dehydration are the same thing.

A

false

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31
Q

For rapid fluid replacement, __________ is preferred.

A. 45% isotonic
B. lactated ringers
C. 33% sodium chloride
D. 0.9% sodium chloride

A

D. 0.9% sodium chloride

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32
Q

__________ fluid volume excess may result from excess fluid intake, abnormal fluid retention, or a shift from interstitial fluid into plasma fluid.

A. hypernatremia
B. hyponatremia
C. fluid volume deficit
D. fluid volume excess

A

D. fluid volume excess

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33
Q

What is the most consistent manifestation of fluid volume excess?

A. mood swings
B. weight gain
C. abdominal cramping
D. lightheadedness

A

B. weight gain

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34
Q

T/F

Many prescription drugs can cause fluid imbalance.

A

true

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35
Q

The patient with a fluid volume deficit often has __________ BUN, sodium, and hematocrit levels with _________ plasma and urine osmolarity.

A

increased ; increased

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36
Q

The patient with fluid volume excess will have __________ BUN, sodium, and hematocrit levels, with __________ plasma and urine osmolarity.

A

decreased ; decreased

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37
Q

What does the serum sodium level reflect?

A. the amount of sodium in the body
B. the amount of sodium being excreted in the body
C. the ratio of sodium to water
D. the ratio of sodium and water to platelets and RBC

A

C. the ratio of sodium to water

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38
Q

Sodium imbalances are typically associated with imbalances in __________ volume.

A. ECF
B. ICF
C. ETC
D. ITF

A

A. ECF

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39
Q

How does sodium leave the body?

A

through urine, sweat, and feces

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40
Q

The __________ mainly regulates sodium balance.

A. liver
B. kidneys
C. heart
D. large intestine

A

B. kidneys

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41
Q

high serum sodium

A

hypernatremia

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42
Q

T/F

Hyponatremia causes hyperosmolarity.

A

false; hypernatremia

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43
Q

The primary protection against our developing hyperosmolarity is __________.

A. vision
B. cerebrum
C. thirst
D. tactile receptors

A

C. thirst

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44
Q

__________ of brain cells results in changes in mental status, ranging from drowsiness, restlessness, confusion, and lethargy to seizures and coma.

A

dehydration

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45
Q

Serum sodium levels should not decrease by more than 8-15 mEq/L in an __________ hour period.

A. 5
B. 6
C. 7
D. 8

A

D. 8

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46
Q

Do not decrease serum sodium levels by more than __________ mEq/L in an 8-hour period.

A. 8-15
B. 22-26
C. 3-9
D. 1-4

A

A. 8-15

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47
Q

low serum sodium

A

hyponatremia

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48
Q

T/F

Inappropriate use of sodium-free or hypotonic IV fluids causes hyponatremia from water excess.

A

true

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49
Q

Where do the manifestations of hyponatremia FIRST appear?

A

in the CNS

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50
Q

Mild or severe hyponatremia?

headache, irritability, and difficulty concentrating

A

mild hyponatremia

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51
Q

Mild or severe hyponatremia?

confusion, vomiting, seizures, and even coma

A

severe hyponatremia

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52
Q

In mild hyponatremia caused by water excess, __________ may be the only treatment.

A

fluid restriction

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53
Q

__________ is given IV to hospitalized patients with severe hyponatremia from water excess.

A

conivaptan (Vapriol)

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54
Q

__________ is given orally to treat hyponatremia from heart failure or SIADH.

A

tolvaptan (Samsca)

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55
Q

98% of the body __________ is inside the cells

A

potassium

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56
Q

What helps stimulate the sodium-potassium pump?

A

insulin

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57
Q

_________ is involved with regulating intracellular osmolarity and promoting cellular growth; it is required for glycogen to be deposited in muscle and liver cells.

A

potassium

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58
Q

__________ is the main source for potassium.

A

diet

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59
Q

What is the primary route for potassium loss?

A

the kidneys

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60
Q

high serum potassium

A

hyperkalemia

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61
Q

__________ may result from impaired renal excretion, a shift of potassium from ICF to ECF, a massive intake of potassium, or a combination of these factors

A

hyperkalemia

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62
Q

Adrenal insufficiency with subsequent aldosterone deficiency leads to __________.

A

potassium retention

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63
Q

In __________, potassium ions shift from ICF to ECF in exchange for hydrogen ions moving into the cell.

A. metabolic acidosis
B. metabolic alkalosis
C. respiratory acidosis
D. respiratory alkalosis

A

A. metabolic acidosis

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64
Q

initial finding of hyperkalemia on a cardiac rhythm

A

tall, peaked T-waves

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65
Q

As potassium __________, cardiac depolarization __________.

A

increases ; decreases

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66
Q

T/F

Low and high potassium is very dangerous for CV patients.

A

true

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67
Q

hyperkalemia or hypokalemia

ECG changes → tall, peaked T waves, as K+ increases, cardiac depolarization decreases, leading to loss of P waves, a prolonged PR interval, ST segment depression, and widening QRS complex

A

hyperkalemia

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68
Q

T/F

The hyperkalemia patient does not need continuous ECG monitoring.

A

false

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69
Q

Patients experiencing dangerous cardiac dysrhythmias should receive __________ immediately.

A

IV calcium

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70
Q

low serum potassium

A

hypokalemia

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71
Q

__________ can result from an increased loss of potassium, an increased shift of potassium from ECF to ICF, or, rarely, from decreased dietary intake.

A

hypokalemia

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72
Q

__________ can cause a shift of potassium into cells in exchange for hydrogen, which lowers potassium in ECF.

A

alkalosis

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73
Q

hyperkalemia or hypokalemia

clinical manifestations → constipation/nausea/paralytic ileus, fatigue, hyperglycemia, irregular/weak pulse, muscles soft/flabby, muscle weakness/leg cramps, paresthesias/decreased reflexes, shallow respirations

A

hypokalemia

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74
Q

hyperkalemia or hypokalemia

ECG changes → impaired repolarization, resulting in a flattened T wave, depressed ST segment, and the presence of a U wave

A

hypokalemia

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75
Q

T/F

Hypokalemia impairs insulin secretion

A

true

76
Q

Potassium IV infusion Infusion rates should not exceed __________ mEq/hr unless monitored closely.

A

10

77
Q

__________ is the main cation in bones and teeth.

A

calcium

78
Q

__________ plays a role in blood clotting, transmission of nerve impulses, myocardial contractions, and muscle contractions.

A

calcium

79
Q

What is the main source for calcium?

A

dietary intake

80
Q

calcium absorption requires the active form of __________

A

vitamin D

81
Q

T/F

Serum pH influences how much calcium is ionized or bound to albumin.

A

true

82
Q

high serum calcium

A

hypercalcemia

83
Q

T/F

Total calcium values increase or decrease indirectly with serum albumin levels.

A

false; directly

84
Q

Parathyroid hormone (PTH) and calcitonin regulate __________ levels.

A

calcium

85
Q

__________ is caused by hyperparathyroidism in about 2/3 of persons.

A

hypercalcemia

86
Q

hypocalcemia or hypercalcemia

rare causes → thiazide diuretic use, prolonged immobilization, and increased calcium intake (use of calcium-containing antacids)

A

hypercalcemia

87
Q

hypocalcemia or hypercalcemia

neurological manifestations → fatigue, lethargy, weakness, and confusion and progress to hallucinations, seizures, and coma

A

hypercalcemia

88
Q

hypocalcemia or hypercalcemia

manifestations → increased BP, bone pain/fractures, confusion/psychosis, fatigue/lethargy/weakness/ depressed reflexes, decreased memory, kidney stones, nausea/vomiting/anorexia, polyuria/dehydration, seizures

A

hypercalcemia

89
Q

hypocalcemia or hypercalcemia

ECG changes → short ST segment, short QT interval, ventricular dysthymias, increased digitalis effect

A

hypercalcemia

90
Q

mild or severe hypercalcemia

interventions → stop any medications r/t hypercalcemia, start diet low in calcium, increase weight-bearing activity, maintain adequate hydration

A

mild hypercalcemia

91
Q

mild or severe hypercalcemia

interventions
- Administer saline, a bisphosphonate, and calcitonin
- Hydrate patient with IV isotonic saline to maintain urine output of 100-150 mL/hour

A

severe hypercalcemia

92
Q

hypocalcemia or hypercalcemia

manifestations → decreased BP, Chvostek sign, confusion/depression/irritability. fatigue/weakness, hyperreflexia/muscle cramps, laryngeal and bronchial spasms, numbness and tingling in extremities and around mouth, tetany/seizures, Trousseau sign

A

hypocalcemia

93
Q

hypocalcemia or hypercalcemia

ECG changes → elongated ST segment, prolonged QT interval, ventricular tachycardia

A

hypocalcemia

94
Q

low serum sodium

A

hypocalcemia

95
Q

results from any condition associated with PTH deficiency

A

hypocalcemia

96
Q

__________ are the major route for phosphate excretion.

A

kidneys

97
Q

T/F

Phosphate imbalances are common in chemotherapy patients.

A

false; dialysis patients

98
Q
A
99
Q

high serum phosphate

A

hyperphosphatemia

100
Q

common in patients with acute kidney injury or chronic kidney disease

A

hyperphosphatemia

101
Q

Excess phosphate intake from
Shift from ICF to ECF
Hypoparathyroidism
Vitamin D intoxication

A

hyperphosphatemia

102
Q

hyperphosphatemia or hypophosphatemia

causes → excess ingestion, hyperthermia, hypoparathyroidism, renal failure, rhabdomyolysis, sickle cell, thyrotoxicosis

A

hyperphosphatemia

103
Q

hyperphosphatemia or hypophosphatemia

manifestations → hyperreflexia/muscle cramps, hypocalcemia, numbness and tingling in extremities and around mouth, tetany/seizure

A

hyperphosphatemia

104
Q

hyperphosphatemia or hypophosphatemia

causes → chronic alcohol use, chronic diarrhea, DKA, malabsorption syndrome, hyperparathyroidism, parenteral nutrition, respiratory alkalosis

A

hypophosphatemia

105
Q

hyperphosphatemia or hypophosphatemia

manifestations → CNS depression, heart problems, muscle weakness, seizures, rhabdomyolysis, osteomalacia

A

hypophosphatemia

106
Q

mild or severe hyperphosphatemia

interventions → restrict dietary intake of foods and fluids high in phosphorus (dairy products)

A

mild

107
Q

mild or severe hyperphosphatemia

interventions
- Hemodialysis used to rapidly decrease levels
- Volume expansion and forced diuresis with a loop diuretic may increase phosphate excretion

A

severe

108
Q

__________ is used to fix hyperphosphatemia

A

calcium carbonate

109
Q

low serum potassium

A

hypophosphatemia

110
Q

Decreased intestinal absorption
Increased urinary excretion
ECF to ICF shifts

A

hypophosphatemia

111
Q

mild or severe hypophosphatemia

often asymptomatic

A

mild

112
Q

mild or severe hypophosphatemia

fatal because of decreased cellular function

A

severe

113
Q

alters bone metabolism, resulting in rickets and osteomalacia

A

chronic hypophosphatemia

114
Q

T/F

Always give magnesium using an infusion pump.

A

true

115
Q
  • second most abundant intracellular cation
  • is important for cellular processes
  • cofactor in many enzyme systems
A

magnesium

116
Q

high serum magnesium level

A

hypermagnesemia

117
Q

occurs only with increased magnesium intake accompanied by renal insufficiency or failure

A

hypermagnesemia

118
Q

hypomagnesmia tratment

A

magnesium sulfate

119
Q

low serum magnesium level

A

hypomagnesemia

120
Q

hypermagnesemia or hypomagnesemia

causes → adrenal insufficiency, antacids/laxatives, hypothyroidism, IV administration of magnesium, metastatic bone disease, renal failure

A

hypermagnesemia

121
Q

hypermagnesemia or hypomagnesemia

causes → acute pancreatitis, chronic alcohol use, GI tract fluid losses, hyperglycemia, malabsorption syndrome, prolonged malnutrition, PP inhibitor therapy, increased urine output

A

hypomagnesemia

122
Q

hypermagnesemia or hypomagnesemia

manifestations → decreased deep tendon reflexes, flushed/warm skin, lethargy/drowsiness, nausea/vomiting, muscle weakness, decreased HR and BP, urinary retention

A

hypermagnesemia

123
Q

hypermagnesemia or hypomagnesemia

manifestations → Chvostek and Trousseau signs, confusion, hyperactive deep tendon reflexes, muscle cramps, increased BP and HR, tremors/seizures, vertigo

A

hypomagnesemia

124
Q

An increase in H+ concentration leads to __________.

A

acidity

125
Q

A decrease in H+ concentration leads to __________.

A

alkalinity

126
Q

Name this acid-base imbalance based on the causes.

atelectasis
chest wall abnormality
chronic respiratory disease
mechanical hypoventilation

A

respiratory acidosis

127
Q

Name this acid-base imbalance based on the causes.

severe pneumonia
pulmonary edema
respiratory muscle weakness
sedative overdose

A

respiratory acidosis

128
Q

Name this acid-base imbalance based on the laboratory findings.

↓ plasma pH
↑ PaCO2 normal

A

respiratory acidosis

129
Q

Name this acid-base imbalance based on the causes.

hyperventilation
liver failure
mechanical hyperventilation
stimulated respiratory center

A

respiratory alkalosis

130
Q

Name this acid-base imbalance based on the causes.

DKA
diarrhea
GI fistulas
lactic acidosis

A

metabolic acidosis

131
Q

Name this acid-base imbalance based on the causes.

renal failure
renal tubular acidosis
shock
starvation

A

metabolic acidosis

132
Q

Name this acid-base imbalance based on the causes.

diuretic therapy
excess NaHCO3 intake
hypokalemia

A

metabolic alkalosis

133
Q

Name this acid-base imbalance based on the causes.

mineralocorticoid use
NG suctioning
vomiting

A

metabolic alkalosis

134
Q

pH range

A

7.35-7.45

135
Q

PaCO2 range

A

35-45 mm Hg

136
Q

PaO2 range

A

80-100 mm Hg

137
Q

Name this acid-base imbalance.

pH is ↑ and the PaCO2 is ↓

A

respiratory alkalosis

138
Q

Name this acid-base imbalance.

pH is ↓ and the PaCO2 is ↑

A

respiratory acidosis

139
Q

Name this acid-base imbalance.

pH and HCO3 are ↑ and the PaCO2 is ↑ or normal

A

metabolic alkalosis

140
Q

Name this acid-base imbalance.

pH and HCO3 and ↓ and the PaCO2 is ↓ or normal

A

metabolic acidosis

141
Q

During the postoperative care of a 76-ear-old patient, the nurse monitors the patient’s intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because

A. older adults have an impaired thirst mechanism and need reminding to drink fluids
B. older adults are more likely than younger adults to lose extracellular fluid during surgeries
C. water accounts for a greater percentage of body weight in the older adult than in younger adults
D. small losses or fluid are significant because body fluids account for 45% to 50% of body weight in older adults

A

D. small losses or fluid are significant because body fluids account for 45% to 50% of body weight in older adults

142
Q

During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is (recognize)

A. osmosis
B. diffusion
C. active transport
D. facilitated diffusion

A

A. osmosis

143
Q

An older adult is admitted to the medical unit with GI bleeding. Assessment findings that occur with fluid volume deficit include: (SATA)

A. weight loss
B. dry oral mucosa
C. full bounding pulse
D. engorged neck veins
E. orthostatic

A

A. weight loss
B. dry oral mucosa
E. orthostatic

144
Q

The nursing care for a patient with hyponatremia and fluid volume excess includes:

A. administration of hypotonic IV fluids
B. administration of a cation-exchange resin
C. placement of an indwelling urinary catheter
D. fluid restriction

A

D. fluid restriction

145
Q

The nurse should be alert for which manifestation in a patient receiving a loop diuretic?

A.restlessness and agitation
B. paresthesias and irritability
C. weak, irregular pulse and poor muscle tone
D. increased blood pressure and muscle spasms

A

C. weak, irregular pulse and poor muscle tone

146
Q

Which patient is at greatest risk for developing hypermagnesmia?

A. 83-year-old man with lung cancer and hypertension
B. 65-year-old woman with hypertension taking B-adrenergic blockers
C. 42-year-old woman with systemic lupus erythematosus and renal failure
D. 50-year-old man with benign prostatic hyperplasia and a UTI

A

C. 42-year-old woman with systemic lupus erythematosus and renal failure

147
Q

It is important for the nurse to assess for which manifestation(s) in a patient who has just undergone a total thyroidectomy? (SATA)

A. confusion
B. weight gain
C. depressed reflexes
D. circumoral numbness
E. positive Chvestek sign

A

A. confusion
D. circumoral numbness
E. positive Chvestek sign

148
Q

The nurse expects the long-term treatment of a patient with hyperphosphatemia from renal failure will include:

A. fluid restriction
B. calcium supplements
C. magnesium supplements
D. increased intake of dairy products

A

B. calcium supplements

149
Q

The lungs act as an acid-base buffer by:

A. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load

B. increasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load

C. decreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load

D. decreasing respiratory rate and depth when CO2 levels in the blood are low, reducing acid load

A

A. increasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load

150
Q

A patient has the following arterial blood gas results: pH 7.52, PaCO2, 30 mm Hg, HCO3 24 mEq/L. The nurse demonstrates that these results indicate

A. metabolic acidosis
B. metabolic alkalosis
C. respiratory acidosis
D. respiratory alkalosis

A

D. respiratory alkalosis

151
Q

The typical fluid replacement for the patient with a fluid volume deficit is

A. dextran
B. 0.45% saline
C. lactated Ringer’s solution
D. 5% dextrose in 0.45% saline

A

C. lactated Ringer’s solution

152
Q

sodium serum level

> 145 mEq/L

A

hypernatremia

153
Q

serum sodium level

< 136 mEq/L

A

hyponatremia

154
Q

serum potassium level

> 5.0 mEq/L

A

hyperkalemia

155
Q

serum potassium level

< 3.5 mEq/L

A

hypokalemia

156
Q

serum calcium level

> 10.5 mg/dL

A

hypercalcemia

157
Q

serum calcium level < 9.0 mg/dL

A

hypocalcemia

158
Q

serum phosphate level

> 4.5 mg/dL

A

hyperphosphatemia

159
Q

serum phosphate level

< 3.0 mg/dL

A

hypophosphatemia

160
Q

serum magnesium level

> 2.1 mEq/L

A

hypermagnesemia

161
Q

serum magnesium level

< 1.3 mEq/L

A

hypomagnesemia

162
Q

Examples of insensible fluid loss:

A. blood
B. perspiration
C. nasogastric drainage
D. third spacing
E. wound drainage

A

B. perspiration
D. third spacing

163
Q

The nurse is caring for a client with an electrolyte imbalance. Which should the nurse consider as contributing to this client’s health problem? (SATA)

A. vomiting
B. constipation
C. medications
D. imaging studies
E. cosmetic procedures

A

A. vomiting
C. medications

164
Q

Upon assessment of a client in renal failure, the nurse observes a mental status change with hyperactive deep tendon reflexes. She inflates the blood pressure cuff to a level above his systolic pressure for 3 minutes and Trousseau’s sign is positive. The nurse recognizes this as which electrolyte imbalance?

A. hypermagnesemia
B. hypomagnesemia
C. hypercalcemia
D. hypocalcemia

A

D. hypocalcemia

165
Q

The nurse is caring for a client with acute digoxin toxicity. Serial electrocardiograms have been performed and the client is placed on continuous cardiac monitoring for which electrolyte disturbance?

A. hypomagnesemia
B. hypercalcemia
C. hyperkalemia
D. hypokalemia

A

C. hyperkalemia

166
Q

A person who has gastroesophageal reflux disease (GERD) and overuses calcium carbonate tablets would be at risk for which acid-base disorder?

A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis

A

D. metabolic alkalosis

167
Q

The nurse is caring for a bulimic client who abuses laxatives. The nurse will monitor the client for which acid-base illness?

A. metabolic alkalosis
B. metabolic acidosis
C. repsitaory alkalosis
D. respiratory acidosis

A

B. metabolic acidosis

168
Q

A nurse is caring for a nulligravida preoperative C-section client who reports tingling of the fingers. Lab studies reveal pH 7.46, PCO2 31. Which action by the nurse is most appropriate?

A. administer oxygen and reposition the client in the semi-Fowler’s position
B. instruct the client to deep breath and cough, and utilize incentive spirometry
C. plan rest periods to maximize client’s energy along with appropriate activities
D. provide a paper bag to rebreathe into for the client, as well as reassurance

A

D. provide a paper bag to rebreathe into for the client, as well as reassurance

169
Q

A client is admitted to the ER with confusion, restlessness, and diaphoresis. Lab studies reveal pH 7.1, PCO2 48, and a potassium of 5.6. Which acid-base balance disorder does the data collected indicate?

A. respiratory acidosis
B. respiratory alkalosis
C. metabolic acidosis
D. metabolic alkalosis

A

A. respiratory acidosis

170
Q

A nurse is caring for a postoperative hemicolectomy client undergoing continuous suction for postoperative ileus. Which information from the client’s medical history should the nurse question?

A. the client is taking lisinopril/hydrochlorothiazide for hypertension
B. the client has a past medical history of exacerbation of COPD
C. the client is a diabetic on sliding-scale insulin
D. the client is a diabetic on hemodialysis therapy

A

A. the client is taking lisinopril/hydrochlorothiazide for hypertension

171
Q

A nurse is assessing a client who reports nausea, vomiting, and weakness. Which of the following findings are manifestations of fluid volume deficit? (SATA)

A. potassium level
B. urine specific gravity
C. heart rate
D. temperature
E. oxygen saturation

A

B. urine specific gravity
C. heart rate
D. temperature

172
Q

A nurse is planning care for a client who has fluid volume excess. Which of the following interventions should the nurse include in the plan of care? (SATA)

A. check the client’s weight 2 times per weeks
B. place the client in a semi-Fowler’s position
C. monitor the client’s breath sounds
D. change the client’s position every 4 hours
E. assess the client for peripheral edema

A

B. place the client in a semi-Fowler’s position
C. monitor the client’s breath sounds
E. assess the client for peripheral edema

173
Q

A nurse is teaching a class about electrolyte imbalances. The nurse should include that which of the following conditions places a client at risk for hyperkalemia?

A. DKA
B. HF
C. Cushing’s syndrome
D. thyroidectomy

A

A. DKA

174
Q

hypoactive bowel sounds

A

hyponatremia with

175
Q

tall, peaked t-waves

A

hypocalcemia

176
Q

positive Trousseau’s sign

A

hyperkalemia

177
Q

bounding pulse

A

hypokalemia

178
Q

The nurse is assessing the client for Chvostek’s sign. Which of the following actions should the nurse take?

A. apply a BP cuff to the client’s arm
B. place a stethoscope bell over the client’s carotid artery
C. ask the client to lower their chin to their chest
D. tap lightly on the client’s cheek

A

D. tap lightly on the client’s cheek

179
Q

The nurse is assessing the client who reports nausea, vomiting, and weakness. Which of the following findings are manifestations of hypocalcemia?

A. tingling in fingers
B. poor skin turgor
C. abdominal pain
D. elevated temperature
E. muscle twitching

A

A. tingling in fingers
C. abdominal pain
E. muscle twitching

180
Q

A nurse is caring for a client who was in a motor vehicle accident and reports chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the following ABG results should the nurse expect?

A. pH 7.25, PaCO2 52 mm Hg, HCO3- 24 mEq/L

B. pH 7.42, PaCO2 38 mm Hg, HCO3- 23 mEq/L

C. pH 7.30, PaCO2 36 mm Hg, MCO3- 18 mEq/L

D. pH 7.50, PaCO2 29 mmHg, MCO3- 26 mEq/L

A

B. pH 7.42, PaCO2 38 mm Hg, HCO3- 23 mEq/L

181
Q

pH 7.30, PaCO2 48 mm Hg, HCO3- 26 mEq/L

A. respiratory alkalosis
B. metabolic alkalosis
C. respiratory acidosis
D. metabolic acidosis

A

C. respiratory acidosis

182
Q

pH 7.50, PaCO2 28 mm Hg, HCO3- 24 mEq/L

A. respiratory alkalosis
B. metabolic alkalosis
C. respiratory acidosis
D. metabolic acidosis

A

A. respiratory alkalosis

183
Q

pH 7.32, PaCO2 35 mm Hg, HCO3- 18 mEq/L

A. respiratory alkalosis
B. metabolic alkalosis
C. respiratory acidosis
D. metabolic acidosis

A

D. metabolic acidosis

184
Q

pH 7.50, PaCO2 38 mm Hg, HCO3- 30 mEq/L

A. respiratory alkalosis
B. metabolic alkalosis
C. respiratory acidosis
D. metabolic acidosis

A

B. metabolic alkalosis

185
Q

A nurse is teaching a group of nurses about conditions what can cause metabolic acidosis. Which of the following conditions should the nurse include?

A. DKA
B. myasthenia gravis
C. asthma
D. laxative overuse

A

A. DKA

186
Q

fluid volume deficit or fluid volume excess

sunken eyeballs
poor skin turgor
fever

A

fluid volume deficit

187
Q

fluid volume deficit or fluid volume excess

bounding pulse
crackles heard in lung fields
distended neck veins

A

fluid volume excess

NUR243 - Medical-Surgical II (19 decks)

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