Unit C-Fluid and Acid Base Balance

Question 1

1.A patient has dehydration. While planning care, the nurse considers that the majority of the
patient’s total water volume exists in with compartment?
a. Intracellular

b. Extracellular
c. Intravascular
d. Transcellular

Answer 1

ANS: A
Intracellular (inside the cells) fluid accounts for approximately two thirds of total body water.
Extracellular (outside the cells) is approximately one third of the total body water. Intravascular fluid
(liquid portion of the blood) and transcellular fluid are two major divisions of the extracellular
compartment.

Question 2

2.The nurse is teaching about the process of passively moving water from an area of lowerparticle
concentration to an area of higher particle concentration. Which process is the nursedescribing?
a. Osmosis

b. Filtration
c. Diffusion
d. Active transport

Answer 2

ANS: A
The process of moving water from an area of low particle concentration to an area of higher particle
concentration is known as osmosis. Filtration is mediated by fluid pressure from an area of higher
pressure to an area of lower pressure. Diffusion is passive movement of electrolytes or other particles
down the concentration gradient (from areas of higher concentration to areas of lower concentration).
Active transport requires energy in the form of adenosine triphosphate (ATP) to move electrolytes
across cell membranes against the concentration gradient (from areas of lower concentration to areas
of higher concentration).

Question 3

3.The nurse observes edema in a patient who has venous congestion from right heart failure.Which
type of pressure facilitated the formation of the patient’s edema?
a. Osmotic

b. Oncotic

c. Hydrostatic
d. Concentration

Answer 3

ANS;C
Venous congestion increases capillary hydrostatic pressure. Increased hydrostatic pressure causes
edema by causing increased movement of fluid into the interstitial area. Osmotic and oncotic
pressures involve the concentrations of solutes and can contribute to edema in other situations, such
as inflammation or malnutrition. Concentration pressure is not a nursing term.

Question 4

4.The nurse administers an intravenous (IV) hypertonic solution to a patient. In which directionwill
the fluid shift?
a. From intracellular to extracellular

b. From extracellular to intracellular
c. From intravascular to intracellular
d. From intravascular to interstitial

Answer 4

ANS: A
Hypertonic solutions will move fluid from the intracellular to the extracellular (intravascular). A
hypertonic solution has a concentration greater than normal body fluids, so water will shift out of
cells because of the osmotic pull of the extra particles. Movement of water from the extracellular
(intravascular) into cells (intracellular) occurs when hypotonic fluids are administered. Distribution
of fluid between intravascular and interstitial spaces occurs by filtration, the net sum of hydrostatic
and osmotic pressures.

Question 5

5.A nurse is preparing to start peripheral intravenous (IV) therapy. In which order will the nurse
perform the steps starting with the first one?
1. Clean site.
2. Select vein.
3. Apply tourniquet.
4. Release tourniquet.
5. Reapply tourniquet.
6. Advance and secure.
7. Insert vascular access device.
a. 1, 3, 2, 7, 5, 4, 6
b. 1, 3, 2, 5, 7, 6, 4
c. 3, 2, 1, 5, 7, 6, 4
d. 3, 2, 4, 1, 5, 7, 6

Answer 5

ANS: D
The steps for inserting an intravenous catheter are as follows: Apply tourniquet; select vein; release
tourniquet; clean site; reapply tourniquet; insert vascular access device; and advance and secure.

Question 6

6.The nurse is reviewing laboratory results. Which cation will the nurse observe is the most abundant
in the blood?

a. Sodium
b. Chloride
c. Potassium
d. Magnesium

Answer 6

ANS: A
Sodium is the most abundant cation in the blood. Potassium is the predominant intracellular cation.
Chloride is an anion (negatively charged) rather than a cation (positively charged). Magnesium is
found predominantly inside cells and in bone.

Question 7

7.The nurse receives the patient’s most recent blood work results. Which laboratory value isof
greatest concern?
a. Sodium of 145 mEq/L
b. Calcium of 15.5 mg/dL
c. Potassium of 3.5 mEq/L
d. Chloride of 100 mEq/L

Answer 7

ANS:B
Normal calcium range is 8.4 to 10.5 mg/dL; therefore, a value of 15.5 mg/dL is abnormally high and
of concern. The rest of the laboratory values are within their normal ranges: sodium 136 to 145
mEq/L; potassium 3.5 to 5.0 mEq/L; and chloride 98 to 106 mEq/L.

Question 8

8.The nurse observes that the patient’s calcium is elevated. When checking the phosphate level,what
does the nurse expect to see?
a. Increased
b. Decreased
c. Equal to calcium
d. No change in phosphate

Answer 8

ANS: B
Phosphate will decrease. Serum calcium and phosphate have an inverse relationship. When one is
elevated, the other decreases, except in some patients with end-stage renal disease.

Question 9

Four patients arrive at the emergency department at the same time. Which patient will the nurse
see first?
a. An infant with temperature of 102.2° F and diarrhea for 3 days

b. A teenager with a sprained ankle and excessive edema
c. A middle-aged adult with abdominal pain who is moaning and holding her stomach
d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60

Answer 9

ANS: A
The infant should be seen first. An infant’s proportion of total body water (70% to 80% total body
weight) is greater than that of children or adults. Infants and young children have greater water needs
and immature kidneys. They are at greater risk for extracellular volume deficit and hypernatremia
because body water loss is proportionately greater per kilogram of weight. A teenager with excessive
edema from a sprained ankle can wait. A middle-aged adult moaning in pain can wait as can an older
adult with a blood pressure of 112/60.

Question 10

The patient has an intravenous (IV) line and the nurse needs to remove the gown. In which order
will the nurse perform the steps, starting with the first one?
1. Remove the sleeve of the gown from the arm without the IV.
2. Remove the sleeve of the gown from the arm with the IV.
3. Remove the IV solution container from its stand.
4. Pass the IV bag and tubing through the sleeve.
a. 1, 2, 3, 4
b. 2, 3, 4, 1
c. 3, 4, 1, 2
d. 4, 1, 2, 3

Answer 10

ANS: A
Change regular gowns by following these steps for maximum speed and arm mobility: (1) To remove
a gown, remove the sleeve of the gown from the arm without the IV line, maintaining the patient’s
privacy. (2) Remove the sleeve of the gown from the arm with the IV line. (3) Remove the IV
solution container from its stand, and pass it and the tubing through the sleeve. (If this involves
removing the tubing from an EID, use the roller clamp to slow the infusion to prevent the accidental
infusion of a large volume of solution or medication.)

Question 11

11.A 2-year-old child is brought into the emergency department after ingesting a medication that
causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor
this child?
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic acidosis
d. Metabolic alkalosis

Answer 11

ANS: B
Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and
respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease in

CO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting,
diarrhea, or other conditions that affect metabolic acids.

Question 12

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent
suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe?
a. Respiratory alkalosis
b. Metabolic alkalosis
c. Metabolic acidosis
d. Respiratory acidosis

Answer 12

ANS: B
The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung
problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much
acid is in the body like kidney failure.

Question 13

A nurse is caring for a patient whose ECG presents with changes characteristic of hypokalemia.
Which assessment finding will the nurse expect?
a. Dry mucous membranes
b. Abdominal distention
c. Distended neck veins
d. Flushed skin

Answer 13

ANS: B
Signs and symptoms of hypokalemia are muscle weakness, abdominal distention, decreased bowel
sounds, and cardiac dysrhythmias. Distended neck veins occur in fluid overload. Thready peripheral
pulses indicate hypovolemia. Dry mucous membranes and flushed skin are indicative of dehydration
and hypernatremia.

Question 14

15. In which patient will the nurse expect to see a positive Chvostek sign?
    a. A 7-year-old child admitted for severe burns
    b. A 24-year-old adult admitted for chronic alcohol abuse
    c. A 50-year-old patient admitted for an acute exacerbation of hyperparathyroidism
    d. A 75-year-old patient admitted for a broken hip related to osteoporosis

Answer 14

ANS: B
A positive Chvostek sign is representative of hypocalcemia or hypomagnesemia. Hypomagnesemia
is common with alcohol abuse. Hypocalcemia can be brought on by alcohol abuse and pancreatitis
(which also can be affected by alcohol consumption). Burn patients frequently experience
extracellular fluid volume deficit. Hyperparathyroidism causes hypercalcemia. Immobility is
associated with hypercalcemia.

Question 15

A patient is experiencing respiratory acidosis. Which organ system is responsible for
compensation in this patient?
a. Renal

b. Endocrine

c. Respiratory
d. Gastrointestinal

Answer 15

16.A patient is experiencing respiratory acidosis. Which organ system is responsible for
compensation in this patient?
a. Renal

b. Endocrine

c. Respiratory
d. Gastrointestinal

Question 16

A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse
assign to the nursing assistive personnel?
a. Recording intake and output
b. Regulating intravenous flow rate
c. Starting peripheral intravenous therapy
d. Changing a peripheral intravenous dressing

Answer 16

ANS: A
A nursing assistive personnel (NAP) can record intake and output. An RN cannot delegate regulating
flow rate, starting an IV, or changing an IV dressing to an NAP.

Question 17

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention.
Which action will the nurse take first?
a. Offer calcium-rich foods.

b. Administer diuretic.
c. Raise head of bed.
d. Increase fluids.

Answer 17

ANS: C
The patient is in fluid overload. Raising the head of the bed to ease breathing is the first action.
Offering calcium-rich foods is for hypocalcemia, not fluid overload. Administering a diuretic is
the second action. Increasing fluids is contraindicated and would make the situation worse.

Question 18

20.A chemotherapy patient has gained 5 pounds in 2 days. Which assessment question by the nurse
is mostappropriate?
a. “Are you following any weight loss program?”
b. “How many calories a day do you consume?”
c. “Do you have dry mouth or feel thirsty?”
d. “How many times a day do you urinate?”

Answer 18

ANS: D
A rapid gain in weight usually indicates extracellular volume (ECV) excess if the person began with
normal ECV. Asking the patient about urination habits will help determine whether the body is trying
to excrete the excess fluid or if renal dysfunction is contributing to ECV excess. This is too rapid a
weight gain to be dietary; it is fluid retention. Asking about following a weight loss program will not
help determine the cause of the problem. Caloric intake does not account for rapid weight changes.
Dry mouth and thirst accompany ECV deficit, which would be associated with rapid weight loss.

Question 19

The health care provider has ordered a hypotonic intravenous (IV) solution to be administered.
Which IV bag will the nurse prepare?
a. 0.45% sodium chloride (1/2 NS)

b. 0.9% sodium chloride (NS)
c. Lactated Ringer’s (LR)
d. Dextrose 5% in Lactated Ringer’s (D5LR)

Answer 19

ANS: A

0.45% sodium chloride is a hypotonic solution. NS and LR are isotonic. D5LR is hypertonic.

Question 20

The health care provider asks the nurse to monitor the fluid volume status of a heart failurepatient
and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for
monitoring both of these patients?
a. Assess the patients for edema in extremities.
b. Ask the patients to record their intake and output.
c. Weigh the patients every morning before breakfast.
d. Measure the patients’ blood pressures every 4 hours.

Answer 20

ANS: C
An effective measure of fluid retention or loss is daily weights; each kilogram (2.2 pounds) change is
equivalent to 1 liter of fluid gained or lost. This measurement should be performed at the same time
every day using the same scale and the same amount of clothing. Although intake and output records
are important assessment measures, some patients are not able to keep their own records themselves.
Blood pressure can decrease with extracellular volume (ECV) deficit but will not necessarily increase
with recent ECV excess (heart failure patient). Edema occurs with ECV excess but not with clinical
dehydration.

Question 21

23.A nurse is caring for a cancer patient who presents with anorexia, blood pressure 100/60, and
elevated white blood cell count. Which primary purpose for starting total parenteral nutrition (TPN)
will the nurse add to the care plan?
a. Stimulate the patient’s appetite to eat.
b. Deliver antibiotics to fight off infection.
c. Replace fluid, electrolytes, and nutrients.
d. Provide medication to raise blood pressure.

Answer 21

ANS: C
Total parenteral nutrition is an intravenous solution composed of nutrients and electrolytes to replace
the ones the patient is not eating or losing. TPN does not stimulate the appetite. TPN does not contain
blood pressure medication or antibiotics.

Question 22

A patient presents to the emergency department with reports of vomiting and diarrhea for the past
48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse
prepare?
a. 0.225% sodium chloride (1/4 NS)
b. 0.45% sodium chloride (1/2 NS)
c. 0.9% sodium chloride (NS)
d. 3% sodium chloride (3% NaCl)

Answer 22

ANS: C
Patients with prolonged vomiting and diarrhea become hypovolemic. A solution to replace
extracellular volume is 0.9% sodium chloride, which is an isotonic solution. 0.225% and 0.45%
sodium chloride are hypotonic. 3% sodium chloride is hypertonic.

Question 23

25.A nurse is administering a diuretic to a patient and teaching the patient about foods to increase.
Which food choices by the patient will best indicate successful teaching?
a. Milk and cheese
b. Potatoes and fresh fruit
c. Canned soups and vegetables
d. Whole grains and dark green leafy vegetables

Answer 23

ANS: B
Potatoes and fruits are high in potassium. Milk and cheese are high in calcium. Canned soups and
vegetables are high in sodium. Whole grains and dark green leafy vegetables are high in magnesium.

Question 24

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patientwith

hypernatremia. Which finding indicates goal achievement?
a. Urine output increases to 150 mL/hr.
b. Systolic and diastolic blood pressure decreases.
c. Serum sodium concentration returns to normal.
d. Large amounts of emesis and diarrhea decrease.

Answer 24

ANS: C
Hypernatremia is diagnosed by elevated serum sodium concentration. Blood pressure is not an
accurate indicator of hypernatremia. Emesis and diarrhea will not stop because of intravenous
therapy. Urine output is influenced by many factors, including extracellular fluid volume. A large
dilute urine output can cause further hypernatremia.

Question 25

The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice
at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice
chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the
nurse document in the patient’s medical record?
a. Intake 255; output 375
b. Intake 285; output 375
c. Intake 505; output 125
d. Intake 535; output 125

Answer 25

ANS: A
Intake = 150 mL of orange juice, 60 mL of ice chips (but only counts as 30 since ice chips are half of
the amount), and 75 mL of chicken broth; 150 + 30 + 75 = 255. Output = 125 mL of urine (void) and
250 mL of vomitus; 125 + 250 = 375.

Question 26

A nurse is assessing a patient. Which assessment finding should cause a nurse to further assess for
extracellular fluid volume deficit?
a. Moist mucous membranes
b. Postural hypotension
c. Supple skin turgor
d. Pitting edema

Answer 26

ANS: B
Physical examination findings of deficit include postural hypotension, tachycardia, thready pulse, dry
mucous membranes, and poor skin turgor. Pitting edema indicates that the patient may be retaining
excess extracellular fluid.

Question 27

A nurse is caring for a diabetic patient with a bowel obstruction and has orders to ensure that the
volume of intake matches the output. In the past 4 hours, the patient received dextrose 5% with 0.9%
sodium chloride through a 22-gauge catheter infusing at 150 mL/hr and has eaten 200 mL of ice
chips. The patient also has an NG suction tube set to low continuous suction that had 300-mL output.
The patient has voided 400 mL of urine. After reporting these values to the health care provider,
which order does the nurse anticipate?
a. Add a potassium supplement to replace loss from output.
b. Decrease the rate of intravenous fluids to 100 mL/hr.

c. Administer a diuretic to prevent fluid volume excess.
d. Discontinue the nasogastric suctioning.

Answer 27

ANS: A
The total fluid intake and output equals 700 mL, which meets the provider goals. Patients with
nasogastric suctioning are at risk for potassium deficit, so the nurse would anticipate a potassium
supplement to correct this condition. Remember to record half the volume of ice chips when
calculating intake. The other measures would be unnecessary because the net fluid volume is equal.

Question 28

A nurse assesses clients at a family practice clinic for risk factors that could lead to

dehydration. Which client is at greatest risk for dehydration?
a. A 36 year old who is prescribed long-term steroid therapy.
b. A 55 year old who recently received intravenous fluids.
c. A 76 year old who is cognitively impaired.
d. An 83 year old with congestive heart failure.

Answer 28

ANS: C
Older adults, because they have less total body water than younger adults, are at greater risk
for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration.
The client with heart failure has a risk for both fluid imbalances. Long-term steroids and
recent IV fluid administration do not increase the risk of dehydration.

Question 29

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which
intervention by the nurse is best?
a. Measure intake and output every 4 hours.
b. Assess client further for fall risk.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler position.

Answer 29

ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing
confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic
hypotension, dysrhythmia, and/or muscle weakness. The nurse’s best response is to do a more
thorough evaluation of the client’s risk for falls. Measuring intake and output may need to
occur more frequently than every 4 hours, but does not address a critical need. The nurse
would not adjust the IV flow rate without a prescription or standing protocol. For an older
adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a
high-Fowler position may or may not be comfortable but still does not address the most
important issue which is safety.

Question 30

ter teaching a client who is being treated for dehydration, a nurse assesses the client’s

understanding. Which statement indicates that the client correctly understood the teaching?
a. “I must drink a quart (liter) of water or other liquid each day.”
b. “I will weigh myself each morning before I eat or drink.”
c. “I will use a salt substitute when making and eating my meals.”
d. “I will not drink liquids after 6 p.m. so I won’t have to get up at night.”

Answer 30

ANS: B
One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of
excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative
of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to
dehydration. Clients may want to limit fluids after dinner so they won’t have to get up, but
this does not address dehydration if the patient drinks the recommended amount of fluid
during the earlier parts of the day.

Question 31

A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse
identify as being at greatest risk for insensible water loss?
a. Client taking furosemide.
b. Anxious client who has tachypnea.
c. Client who is on fluid restrictions.
d. Client who is constipated with abdominal pain.

Answer 31

ANS: B
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for
insensible water loss include those being mechanically ventilated, those with rapid
respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis,
trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking
furosemide will have increased fluid loss, but not insensible water loss. The other two clients
on a fluid restriction and with constipation are not at risk for insensible fluid loss.

Question 32

A nurse is evaluating a client who is being treated for dehydration. Which assessment result
does the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 to 22 breaths/min
b. Decreased skin turgor on the client’s posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic changes when standing

Answer 32

ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal.
When blood volume is normal, orthostatic blood pressure and pulse changes will not occur.
This assessment finding shows a therapeutic response to treatment. Increased respirations,
decreased skin turgor, and higher urine specific gravity all are indicators of continuing
dehydration.

Question 33

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s
understanding. Which food choice for lunch indicates that the client correctly understood the
teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole-wheat crackers
d. Grilled chicken breast with glazed carrots

Answer 33

ANS: D
Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and
those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and
fresh produce. The ham, tomato soup, salami, and crackers are usually high in sodium.

Question 34

A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse
assess first for potential hyponatremia?
a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic.
c. A 67 year old who is experiencing pain and is prescribed ibuprofen.
d. A 73 year old with tachycardia who is receiving digoxin.

Answer 34

ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized
when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic
solutions can lead to hyponatremia. Because the client is not taking any food or fluids by
mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide
antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.

Question 35

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse
include in this client’s teaching?
a. “Have you spouse watch you for irritability and anxiety.”
b. “Notify the clinic if you notice muscle twitching.”
c. “Call your primary health care provider for diarrhea.”
d. “Bake or grill your meat rather than frying it.”

Answer 35

ANS: C
One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be
taught to call the primary health care provider if this is noticed. Irritability and anxiety are
common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia.
Cooking methods are not a cause of hyponatremia.

Question 36

A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L
(2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and
sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography

Answer 36

ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac
dysrhythmias, and muscle weakness resulting in shallow respirations and decreased
handgrips. The nurse would assess the client’s respiratory status first to ensure that
respirations are sufficient. The respiratory assessment would include rate and depth of
respirations, respiratory effort, and oxygen saturation. The other assessments are important
but are secondary to the client’s respiratory status.

Question 37

A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is
exhibiting cardiovascular changes. Which intervention will the nurse implement first?
a. Prepare to administer patiromer by mouth.
b. Provide a heart-healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d. Prepare the client for hemodialysis treatment.

Answer 37

ANS: C
A client with a critically high serum potassium level and cardiac changes would be treated
immediately to reduce the extracellular potassium level. Potassium movement into the cells is
enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will
decrease both serum potassium and glucose levels and therefore would be administered with
dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours
to reduce potassium levels. Dialysis may also be needed, but this treatment will take much
longer to implement and is not the first intervention the nurse would implement. Decreasing
potassium intake may help prevent hyperkalemia in the future but will not decrease the
client’s current potassium level.

Question 38

The nurse is caring for a client who has fluid overload. What action by the nurse takes
priority?
a. Administer high-ceiling (loop) diuretics.
b. Assess the client’s lung sounds every 2 hours.
c. Place a pressure-relieving overlay on the mattress.
d. Weigh the client daily at the same time on the same scale.

Answer 38

ANS:B
All interventions are appropriate for the client who is overhydrated. However, client safety is
the priority. A client with fluid overload can easily go into pulmonary edema, which can be
life threatening. The nurse would closely monitor the client’s respiratory status.

Question 39

A nurse is assessing a client with hypokalemia, and notes that the client’s handgrip strength
has diminished since the previous assessment 1 hour ago. What action does the nurse take
first?
a. Assess the client’s respiratory rate, rhythm, and depth.
b. Measure the client’s pulse and blood pressure.
c. Document findings and monitor the client.
d. Call the health care primary health care provider.

Answer 39

ANS: A
In a client with hypokalemia, progressive skeletal muscle weakness is associated with
increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is
respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment
first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also
associated with hypokalemia. The client’s pulse and blood pressure would be assessed after
assessing respiratory status. Next, the nurse would call the health care primary health care
provider to obtain orders for potassium replacement. Documenting findings and continuing to
monitor the client would occur during and after potassium replacement therapy.

Question 40

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What
action indicates the nurse needs to review this procedure?
a. Notifies the pharmacy of the IV potassium order.
b. Assesses the client’s IV site every hour during infusion.
c. Sets the IV pump to deliver 30 mEq of potassium an hour.
d. Double-checks the IV bag against the order with the precepting nurse.

Answer 40

ANS: C
IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances.
This action shows a need for further knowledge. The other actions are acceptable for this
high-alert drug.

Question 41

A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor
understanding of this condition?
a. Assesses the client’s Chvostek and Trousseau sign.
b. Keeps the client’s room quiet and dimly lit.
c. Moves the client carefully to avoid fracturing bones.
d. Administers bisphosphonates as prescribed.

Answer 41

ANS: D
Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used
to assess for hypocalcemia. Keeping the client in a low stimulus environment is important
because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia
can cause fragile, brittle bones which can be fractured.

Question 42

A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L).
Which primary health care provider order does the nurse implement first?
a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin.

Answer 42

ANS: B
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and
cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess
for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering
calcitonin are treatments for hypercalcemia, but are not the highest priority.

Question 43

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which
intervention will the nurse implement to prevent injury while in the hospital?
a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 L of fluids each shift.
d. Dangle the client on the bedside before ambulating.

Answer 43

ANS: D
An older adult with moderate dehydration may experience orthostatic hypotension. The client
needs to dangle on the bedside before ambulating. Although dehydration in an older adult may
cause confusion, speaking quietly will not help the client remain calm or decrease confusion.
Assessing the client’s urine may assist with the diagnosis of dehydration but would not
prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older
adult may cause respiratory distress and symptoms of fluid overload, especially if the client
has heart failure or renal insufficiency.

Question 44

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and
symptoms does the nurse expect to find? (Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure
d. Warm and pink skin
e. Skeletal muscle weakness
f. Visual disturbances

Answer 44

ANS: A, B, E, F
Signs and symptoms of fluid overload include increased pulse rate, distended neck veins,
increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual
disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is
a normal finding.

Question 45

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion
and release. For which potential complications will the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L)
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L (128 mmol/L)
e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)

Answer 45

ANS: B, E
Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the
reabsorption of water and sodium in the kidney at the same time that it promotes excretion of
potassium. Any drug or condition that disrupts aldosterone secretion or release increases the
client’s risk for excessive water loss (increased urine output), increased potassium
reabsorption, decreased blood osmolality, and increased urine specific gravity. The client
would not be at risk for sodium imbalance.

Question 46

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For
which potential complications of this electrolyte imbalance does the nurse assess? (Select all
that apply.)
a. Reports of palpitations
b. Slow, shallow respirations
c. Orthostatic hypotension
d. Paralytic ileus
e. Skeletal muscle weakness
f. Tall, peaked T waves on ECG

Answer 46

ANS: A, E, F
Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse
would assess for electrocardiogram changes, including tall, peaked T waves, reports of
palpitations or “skipped beats,” diarrhea, and skeletal muscle weakness in clients with
hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory
muscles may be affected with lethally high hyperkalemia.

Question 47

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which
clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance?
(Select all that apply.)
a. Hypokalemia—muscle weakness with respiratory depression
b. Hypermagnesemia—bradycardia and hypotension
c. Hyponatremia—decreased level of consciousness
d. Hypercalcemia—positive Trousseau and Chvostek signs
e. Hypomagnesemia—hyperactive deep tendon reflexes
f. Hypernatremia—weak peripheral pulses

Answer 47

ANS: A, B, C, E, F
Hypokalemia is associated with muscle weakness and respiratory depression.
Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present
with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive
deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau
and Chvostek signs are seen in hypocalcemia.

Question 48

After administering potassium chloride, a nurse evaluates the client’s response. Which signs
and symptoms indicate that treatment is improving the client’s hypokalemia? (Select all that
apply.)
a. Respiratory rate of 8 breaths/min
b. Absent deep tendon reflexes
c. Strong productive cough
d. Active bowel sounds
e. U waves present on the electrocardiogram (ECG)

Answer 48

ANS: C, D
A strong, productive cough indicates an increase in muscle strength and improved potassium
imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of
8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and
symptoms of hypokalemia and do not demonstrate that treatment is working.

Question 49

A nurse develops a plan of care for an older client who has a fluid overload. What
interventions will the nurse include in this client’s care plan? (Select all that apply.)
a. Calculate pulse pressure with each blood pressure reading.
b. Assess skin turgor using the back of the client’s hand.
c. Assess for pitting edema in dependent body areas.
d. Monitor trends in the client’s daily weights.
e. Assist the client to change positions frequently.
f. Teach client and family how to read food labels for sodium.

Answer 49

ANS: A, C, D, E, F
Appropriate interventions for the client who has overhydration include calculating the pulse
pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for
pitting edema in the client’s dependent body areas, monitoring trends in the client’s daily
weight as fluid retention is not always visible, protecting the client’s skin by helping him or
her change positions, and teaching the client and family to read food labels some type of
sodium restriction may be required at home. The nurse assesses skin turgor on the chest or
forehead.

Question 50

A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which
common causes are correctly paired with the corresponding electrolyte imbalance? (Select all
that apply.)
a. Hypomagnesemia—kidney failure
b. Hyperkalemia—salt substitutes
c. Hyponatremia—heart failure
d. Hypernatremia—hyperaldosteronism
e. Hypocalcemia—diarrhea
f. Hypokalemia—loop diuretics

Answer 50

ANS: B, C, D, E, F
Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be
caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and
diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney
function is a cause of magnesium excess, not deficit.

Question 51

A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are
paired with the correct potential imbalance? (Select all that apply.)
a. Sodium: 160 mEq/L (mmol/L): Overhydration
b. Potassium: 5.4 mEq/L (mmol/L): Dehydration
c. Osmolarity: 250 mOsm/L: Overhydration
d. Hematocrit: 68%: Dehydration
e. BUN: 39 mg/dL: Overhydration
f. Magnesium: 0.8 mg/dL: Dehydration

Answer 51

ANS: B, C, D, F
In dehydration, hemoconcentration usually results in higher levels of hemoglobin, hematocrit,
serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true
of overhydration. The sodium level is high, indicating dehydration. The potassium level is
high, also indicating possible dehydration. The osmolarity is low, indicating overhydration,
the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the
magnesium level is low, indicating possible dehydration and malnutrition from
diarrhea-causing diseases.

Question 52

A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance.
The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and
HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an
example of the client’s compensatory mechanisms?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys

Answer 52

ANS: A
This client has metabolic acidosis. The respiratory system compensates by increasing its
activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger
are signs and symptoms of hyperglycemia but are not compensatory mechanisms for
acid–base imbalances. The kidneys do not release acids.

Question 53

A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial
blood gas values are pH 7.2, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L (19
mmol/L). Which assessment would the nurse perform first?
a. Cardiac rate and rhythm
b. Skin and mucous membranes
c. Musculoskeletal strength
d. Level of orientation

Answer 53

ANS: A
Early cardiovascular changes for a client experiencing moderate acidosis include increased
heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and
electrocardiographic changes will be present. The nurse responds by performing a thorough
cardiovascular assessment. Changes will occur in the integumentary system, musculoskeletal
system, and neurologic system, but assessing for the cardiovascular complications comes first.

Question 54

A nurse assesses a client who is prescribed furosemide for hypertension. For which acid–base
imbalance does the nurse assess to prevent complications of this therapy?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

Answer 54

ANS: D
Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions,
leading to excess acid loss through the renal system. This situation is an actual acid deficit.

Question 55

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action
would the nurse take?
a. Monitor daily hemoglobin and hematocrit values.
b. Administer furosemide intravenously.
c. Encourage the client to take deep breaths.
d. Teach the client fall prevention measures.

Answer 55

ANS: D
The most important nursing care for a client who is experiencing moderate metabolic alkalosis
is providing client safety. Client’s with metabolic alkalosis have muscle weakness and are at
risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

Question 56

A nurse is assessing a client who has acute pancreatitis and is at risk for an acid–base

imbalance. For which manifestation of this acid–base imbalance would the nurse assess?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvostek sign

Answer 56

ANS: B
The pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic
acidosis through underproduction of bicarbonate ions. Signs and symptoms of acidosis
include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek sign
are signs and symptoms of the electrolyte imbalances that accompany alkalosis.

Question 57

A nurse assesses a client who is admitted with an acid–base imbalance. The client’s arterial
blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L
(16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse
take next?
a. Assess client’s rate, rhythm, and depth of respiration.
b. Measure the client’s pulse and blood pressure.
c. Document the findings and continue to monitor.
d. Notify the primary health care provider.

Answer 57

ANS:A
Progressive skeletal muscle weakness is associated with increasing severity of acidosis.
Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to
dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac
monitoring. Findings would be documented, but simply continuing to monitor is not
sufficient. Before notifying the primary care provider, the nurse must have more data to
report.

Question 58

A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56
mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does
the nurse correlate with these values?
a. Diabetic ketoacidosis in a person with emphysema
b. Bronchial obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent
d. Diarrhea for 36 hours in an older, frail woman

Answer 58

ANS: B
Arterial blood gas values indicate that the client has acidosis with normal levels of
bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen
and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this
client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate
level is normal indicates that this is an acute respiratory problem rather than a chronic
problem, because no renal compensation has occurred. The client who would have these ABG
values is the one with the new onset of airway obstruction.

Question 59

A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The
client’s arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3
22 mEq/L (22 mmol/L). What action would the nurse take first?
a. Apply oxygen by mask or nasal cannula.
b. Apply a paper bag over the client’s nose and mouth.
c. Administer 50 mL of sodium bicarbonate intravenously.
d. Administer 50 mL of 20% glucose and 20 units of regular insulin.

Answer 59

ANS: A
This client is severely hypoxic and needs oxygen. Now that the seizure has ended, the client
can breathe again normally, so oxygen administration will rapidly increase the PaO2.
Rebreathing carbon dioxide with a paper bag would make the acidosis worse. Bicarbonate is
only indicated with extremely low pH and serum bicarbonate levels. Glucose and insulin are
administered to decrease the high potassium levels associated with acidosis, but this situation
should reverse itself with oxygen and breathing.

Question 60

After teaching a client who was malnourished and is being discharged, a nurse assesses the
client’s understanding. Which statement indicates that the client correctly understood
teaching to decrease risk for the development of metabolic acidosis?
a. “I will drink at least three glasses of milk each day.”
b. “I will eat three well-balanced meals and a snack daily.”
c. “I will not take pain medication and antihistamines together.”
d. “I will avoid salting my food when cooking or during meals.”

Answer 60

ANS: B
Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells
to switch to using fats for fuel and by creating ketoacids as a by-product of excessive fat
metabolism. Eating sufficient calories from all food groups helps reduce this risk. Milk, taking
pain medications with antihistamines, and salting food are not related.

Question 61

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm
Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the
nurse correlate with these results?
a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease (COPD)
d. Diabetic ketoacidosis and emphysema

Answer 61

ANS: B
The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the
oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would
occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic acidosis
and COPD would lead to respiratory acidosis. The client with emphysema most likely would
have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

Question 62

After providing discharge teaching, a nurse assesses the client’s understanding regarding
increased risk for metabolic alkalosis. Which statement indicates that the client needs
additional teaching?
a. “I don’t drink milk because it gives me gas and diarrhea.”
b. “I have been taking digoxin every day for the last 15 years.”
c. “I take sodium bicarbonate after every meal to prevent heartburn.”
d. “In hot weather, I sweat so much that I drink six glasses of water each day.”

Answer 62

ANS: C
Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can
cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to
increased risk of metabolic alkalosis.

Question 63

A nurse is caring for a client who is experiencing excessive diarrhea. The client’s arterial
blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16
mmol/L). Which primary health care provider order does the nurse expect to receive?
a. Furosemide 40 mg
b. Sodium bicarbonate
c. Mechanical ventilation
d. Indwelling urinary catheter

Answer 63

ANS: B
This client’s arterial blood gas values represent metabolic acidosis related to a loss of
bicarbonate ions from diarrhea. The bicarbonate would be replaced to help restore this client’s
acid–base balance as the pH is below 7.2 and the bicarbonate level is low. Furosemide would
cause an increase in acid fluid and acid elimination via the urinary tract; although this may
improve the client’s pH, the client has excessive diarrhea and cannot afford to lose more fluid.
Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their
oxygen saturation at 90%, or who have respiratory muscle fatigue. Mechanical ventilation and
an indwelling urinary catheter would not be prescribed for that client.

Question 64

A nurse evaluates a client’s arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg,
PaCO2 55 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which intervention does the nurse
implement first?
a. Assess the airway.
b. Administer prescribed bronchodilators.
c. Provide oxygen.
d. Administer prescribed mucolytics.

Answer 64

ANS: A
All interventions are important for clients with respiratory acidosis; this is indicated by the
ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway,
other interventions will not be helpful.

Question 65

A nurse is planning care for a client who is hyperventilating. The client’s arterial blood gas
values are pH 7.52, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L (26 mmol/L).
Which question would the nurse ask when developing this client’s plan of care?
a. “Do you take any over-the-counter medications?”
b. “You appear anxious. What is causing your distress?”
c. “Do you have a history of anxiety attacks?”
d. “You are breathing fast. Is this causing you to feel light-headed?

Answer 65

ANS:B
The nurse would assist the client who is experiencing anxiety-induced respiratory alkalosis to
identify causes of the anxiety. The other questions will not identify the cause of the acid–base
imbalance. The other three questions are also yes/no and close-ended.

Question 66

A diabetic client becomes septic after a bowel resection and is having problems with
respiratory distress. The nurse reviews the labs and finds the following ABG results: pH 7.50,
PaCO2 30, HCO3 : 24, and PaO2 68. What does the nurse recognize as the primary factor
causing this the acid–base imbalance?
a. Atelectasis due to respiratory muscle fatigue
b. Hyperventilation due to poor oxygenation
c. Hypoventilation due to morphine PCA
d. Kussmaul respirations due to glucose of 102 mg/dL (5.7 mmol/L)

Answer 66

ANS: B
The ABG results indicate respiratory alkalosis. The client has low oxygenation as indicated by
low partial pressure of arterial oxygen causing a compensatory mechanism of increased
respirations and hyperventilation. Respiratory muscle fatigue and hypoventilation would
cause respiratory acidosis with a low pH and high PaCO2. Kussmaul respirations are
characterized by deep labored breathing and are a compensatory mechanism to metabolic
acidosis, not hypoxemia or alkalosis.

Question 67

A nurse is planning interventions that regulate acid–base balance to ensure that the pH of a
client’s blood remains within the normal range. Which abnormal physiologic functions may
occur if the client experiences an acid–base imbalance? (Select all that apply.)
a. Reduction in the function of hormones
b. Fluid and electrolyte imbalances
c. Increase in the function of selected enzymes
d. Excitable cardiac muscle membranes
e. Increase in the effectiveness of many drugs
f. Changes in GI tract excitability

Answer 67

ANS: A, B, D, F
Acid–base imbalances interfere with normal physiology, including reducing the function of
hormones and enzymes, causing fluid and electrolyte imbalances, causing heart membranes
and GI tract to be more or less excitable, and decreasing the effectiveness of many drugs.

Question 68

A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial
blood gas values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L (18
mmol/L). For which clinical signs and symptoms would the nurse assess? (Select all that
apply.)
a. Reduced deep tendon reflexes
b. Drowsiness
c. Increased respiratory rate
d. Decreased urinary output
e. Positive Trousseau sign
f. Flaccid paralysis

Answer 68

ANS: A, B, C
Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep
tendon reflexes. Clients usually present with lethargy and drowsiness. The respiratory system
will attempt to compensate for the metabolic acidosis; therefore, respirations will increase rate
and depth. Flaccid paralysis can occur. A positive Trousseau sign is associated with alkalosis.
Decreased urine output is not a sign of metabolic acidosis.

Question 69

A nurse is assessing clients who are at risk for acid–base imbalance. Which clients are
correctly paired with the acid–base imbalance? (Select all that apply.)
a. Metabolic alkalosis—young adult who is prescribed intravenous morphine sulfate
for pain
b. Metabolic acidosis—older adult who is following a carbohydrate-free diet
c. Respiratory alkalosis—client on mechanical ventilation at a rate of 28 breaths/min
d. Respiratory acidosis—postoperative client who received 6 units of packed red
blood cells
e. Metabolic alkalosis—older client prescribed antacids for gastroesophageal reflux
disease

Answer 69

ANS: B, C, E
Respiratory acidosis often occurs as the result of underventilation. The client who is taking
opioids, especially IV opioids, is at risk for respiratory depression and respiratory acidosis.
One cause of metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate
content. Such a diet increases the rate of fat catabolism and results in the formation of
excessive ketoacids. A ventilator set at a high respiratory rate or tidal volume will cause the
client to lose too much carbon dioxide, leading to an acid deficit and respiratory alkalosis.
Citrate is a substance used as a preservative in blood products. It is not only a base, but also a
precursor for bicarbonate. Multiple units of packed red blood cells could cause metabolic
alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.

Question 70

A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects
related to an acid–base imbalance would the nurse assess? (Select all that apply.)
a. Positive Chvostek sign
b. Elevated blood pressure
c. Bradycardia
d. Increased muscle strength
e. Anxiety and irritability
f. Tetany

Answer 70

ANS: A, E
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Signs and
symptoms of metabolic alkalosis include positive Chvostek sign, normal or low blood
pressure, increased heart rate, skeletal muscle weakness, possible tetany and seizures, and
anxiety and irritability.

Question 71

A nurse is planning care for a client who is lethargic and confused. The client’s arterial blood
gas values are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L (19
mmol/L). Which questions would the nurse ask the client and spouse when developing the
plan of care? (Select all that apply.)
a. “Are you taking any antacid medications?”
b. “Is your spouse’s current behavior typical?”
c. “Do you drink any alcoholic beverages?”
d. “Have you been participating in strenuous activity?”
e. “Are you experiencing any shortness of breath?”

Answer 71

ANS: B, C, D
This client’s symptoms of lethargy and confusion are related to a state of metabolic acidosis.
The nurse would ask the client’s spouse or family members if the client’s behavior is typical
for him or her, and establish a baseline for comparison with later assessment findings. The
nurse would also assess for alcohol intake because alcohol can cause metabolic acidosis.
Excessive and strenuous activity can lead to overproduction of hydrogen ions. The other
options are not causes of metabolic acidosis.