Fluid & Electrolyte

Question 1

LAB VALUE: Potassium (K)

Answer 1

3.5-5.0

Question 2

LAB VALUE: Calcium (Ca)

Answer 2

8.2-10.2

Question 3

LAB VALUE: Magnesium (Mg)

Answer 3

1.6-2.6

Question 4

LAB VALUE: pH

Answer 4

(Acidosis)7.35-7.45(Alkalosis)

Question 5

LAB VALUE: PaCO2

Answer 5

(Alkalosis)35-45(Acidosis)

Question 6

LAB VALUE: HCO3

Answer 6

(Acidosis)22-26(Alkalosis)

Question 7

LAB VALUE: Sodium (Na)

Answer 7

135-145

Question 8

A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth. The nurse would assess for what electrolyte imbalance?
A. Hyponatremia
B. Hypocalcemia
C. Hyperkalemia
D. Hypermagnesemia

Answer 8

ANS: B

“Calcium calms nerves” = Hypocalcemia

Clinical manifestations: Muscle spasms (+Chvostek/Trousseau)

Question 9

The nurse evaluates which of the following clients to be at risk for developing hypernatremia?
A. 50-year-old with pneumonia, diaphoresis, and high fevers
B. 62-year-old with congestive heart failure taking loop diuretics
C. 39-year-old with diarrhea and vomiting
D. 60-year-old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

Answer 9

ANS: A

Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.

Question 10

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand. The client’s serum potassium level was 4.5 mEq/L yesterday. Today the level is 7 mEq/L. Which of the following is the next appropriate nursing action?
A. Call the physician and report results
B. Question the results and redraw the specimen
C. Encourage the client to increase the intake of bananas
D. Initiate seizure precautions

Answer 10

ANS: B

When the serum potassium goes from 4.5 mEq/L to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of hemolysis of the specimen.

Question 11

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion?
A. Absent patellar reflex
B. Diarrhea
C. Premature ventricular contractions
D. Increase in blood pressure

Answer 11

ANS: A

An intravenous magnesium infusion may be used to treat a low serum magnesium level. Normal serum magnesium is 1.5 to 2.5 mEq/L. Clinical manifestations of hypermagnesemia are the result of depressed neuromuscular transmission.

Question 12

An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client’s behavior, the nurse would respond most appropriately by stating:
A: “The client may be suffering from dementia, and the hospitalization has worsened the confusion.”
B: “Most older adults get confused in the hospital.”
C: “The sodium level is low, and the confusion will resolve as the levels normalize.”
D: “The sodium level is high and the behavior is a result of dehydration.”

Answer 12

ANS: C

Normal serum level is 135 to 145 mEq/L. Neurological symptoms occur when sodium levels fall below 120 mEq/L. The confusion is an acute condition that will go away as the sodium levels normalize.

Question 13

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority?

A. Turn down the infusion
B. Check the latest sodium level
C. Assess for signs of fluid overload
D. Place a call to the physician

Answer 13

ANS: C

A complication of hypertonic sodium solution administration is fluid overload. While turning down the infusion, checking the latest sodium level, and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next.

Question 14

A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home?

A. Bisacodyl (Dulcolax) suppository
B. Fiber supplements
C. Docusate sodium
D. Milk of magnesia

Answer 14

ANS: D

Milk of magnesia contains magnesium, an electrolyte that is excreted by kidneys. Clients with renal failure are at risk for hypermagnesemia, since their bodies cannot excrete the excess magnesium. The client should avoid magnesium-containing laxatives.

Question 15

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention?

A. Administer a sedative
B. Place client in left lateral position
C. Place client in high-Fowler’s position
D. Assist the client to breathe into a paper bag

Answer 15

ANS: C

The client with a pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis. Placing the client in high-Fowler’s position will facilitate the expansion of the lungs and help the client blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher.

Question 16

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning’s ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse’s first intervention?

A. Call the physician and report the change in client’s condition
B. Turn the client’s O2 up to 4 liters nasal cannula
C. Encourage the client to sit down and to take deep breaths
D. Encourage the client to rest and to use pursed-lip breathing technique

Answer 16

ANS:D

Clients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations. Deep breaths are not helpful, because clients with COPD have difficulty with air trapping in alveoli.

Question 17

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition?

A. D5.45 NS at 50 ml/hr
B. 0.9 NS at an open rate
C. D5W at 125 ml/hr
D. 0.45 NS at open rate

Answer 17

ANS: B

A client who recently had surgery, is vomiting, becomes dizzy when standing up, has a blood pressure of 55/30, and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume. Hypotonic fluids such as 0.45 NS will leave the intravascular space.

Question 18

A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?

A. PH of 7.43, PCO2 of 36, HCO3 of 26
B. PH of 7.41, PCO2 of 49, HCO3 of 30
C. PH of 7.33, PCO2 of 35, HCO3 of 17
D. PH of 7.25, PCO2 of 56, HCO3 of 28

Answer 18

ANS: C

These ABGs indicate Metabolic Acidosis:
Low pH, normal CO2 level, low HCO3.

Question 19

A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder?

A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosis

Answer 19

ANS: C

Clients with gastric suctioning can lose hydrogen ions resulting in a metabolic alkalosis.

Question 20

A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low?

A. Bone pain
B. Depressed deep tendon reflexes
C. Positive Chvostek’s sign
D. Nausea

Answer 20

ANS: C

Numbness and tingling around the mouth indicate hypocalcemia, which results in neuromuscular irritability. A positive Chvostek’s sign is the contraction of facial muscles when the facial nerve in front of the ear is tapped.

Question 21

The nurse evaluates which of the following clients to have hypermagnesemia?

A. A client who has chronic alcoholism and a magnesium level of 1.3 mEq/L
B. A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L
C. A client who has renal failure, takes antacids, and has a magnesium level of 3.4 mEq/L
D. A client who has congestive heart disease, takes a diuretic, and has a magnesium level of 2.3 mEq/L

Answer 21

ANS: C

Normal serum magnesium is 1.5 to 2.5 mEq/L.

Question 22

The nurse writes the nursing problem of “fluid volume excess” (FVE). Which intervention should be included in the plan of care?

A. Change the IV fluid from 0.9% NS to D5W.
B. Restrict the client’s sodium in the diet.
C. Monitor blood glucose levels.
D. Prepare the client for hemodialysis.

Answer 22

ANS: B

Fluid volume excess refers to an isotonic expansion of the extracellular fluid by an abnormal expansion of water and sodium. Therefore sodium is restricted to allow the body to excrete the extra volume.

Question 23

A nurse is reading a physician’s progress notes in the client’s record and reads that the physician has documented “insensible fluid loss of approximately 800 mL daily.” The nurse understands that this type of fluid loss can occur through:

A. The skin
B. Urinary output
C. Wound drainage
D. The gastrointestinal tract

Answer 23

ANS: A

Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the person’s awareness. Insensible losses occur daily through the skin and the lungs.

Question 24

A nurse is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for deficient fluid volume?

A. A client with a colostomy
B. A client with congestive heart failure
C. A client with decreased kidney function
D. A client receiving frequent wound irrigations

Answer 24

ANS: A

Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy.

Question 25

A nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?

A. Twitching
B. Negative Trousseau’s sign
C. Hypoactive bowel sounds
D. Hypoactive deep tendon reflexes

Answer 25

ANS: A

Signs of hypocalcemia include paresthesias followed by numbness, hyperactive deep tendon reflexes, and a positive Trousseau’s or Chvostek’s sign. Additional signs of hypocalcemia include increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.