2204 Fluid & Electrolyte NCLEX Practice Questions

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NURS 2204 CH 10

What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused?
1. risk of dehydration
2. risk of kidney damage
3. risk of stroke
4. risk of bleeding

Answer: 1

Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality.
Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & electrolyte issues.
Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues.
Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues.

The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit

Answer: 1

Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.
Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.
Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.
Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.

A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, & decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following?
1. the body's natural compensatory mechanisms
2. pharmacological effects of a diuretic
3. effects of rapidly infused intravenous fluids
4. cardiac failure

Answer: 1

Rationale 1: The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain & heart.
Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output.
Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.

A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate?
1. Risk for Imbalanced Fluid Volume
2. Excess Fluid Volume
3. Imbalanced Nutrition
4. Ineffective Tissue Perfusion

Answer: 1

Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can increase the serum levels of sodium.
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially during the early stages of treatment.
Rationale 3: Imbalanced Nutrition does not apply.
Rationale 4: Ineffective Tissue Perfusion does not apply

A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the pt's primary healthcare provider with which of the following 24-hour urine output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL

Answer: 1
Rationale 1: A urine output of less than 30 mL per hour must be reported to the primary healthcare provider. This indicates inadequate renal perfusion, placing the pt at increased risk for acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).

A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication?
1. fluid volume excess
2. fluid volume deficit
3. seizure activity
4. liver failure

Answer: 1
Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following the stress response before, during, & immediately after surgery. This increase leads to sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system.
Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, & stress upon the heart & circulatory system.
Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances.
Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid administration.

A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented?
1. seizure
2. infection
3. neutropenic
4. high-risk fall

Answer: 1
Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included.
Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia.
Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia.
Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.

A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the following might have contributed to the pt's health problem?
1. corticosteroid
2. thiazide diuretic
3. narcotic
4. muscle relaxer

Answer: 1
Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.
Rationale 2: Excessive sodium is lost with the use of thiazide diuretics.
Rationale 3: Narcotics do not typically affect electrolyte balance.
Rationale 4: Muscle relaxants do not typically affect electrolyte balance.

A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse realizes this pt is exhibiting signs of which of the following?
1. hyperkalemia
2. hypokalemia
3. hypercalcemia
4. hypocalcemia

Answer: 1
Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes.
Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide.
Rationale 3: Hypercalcemia has been associated with thiazide diuretics.
Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is not associated with diuretic use.

The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt's plan of care?
1. Restrict fluids.
2. Administer intravenous fluids.
3. Provide Kayexalate.
4. Administer intravenous normal saline with furosemide.

Answer: 1
Rationale 1: The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from dropping further due to dilution.
Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit & hypernatremia.
Rationale 3: Kayexalate is used in pts with hyperkalemia.
Rationale 4: The administration of normal saline with furosemide is used to increase calcium secretion.

When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the pt?
1. other electrolyte disturbances
2. hypertension
3. visual disturbances
4. drug toxicity

Answer: 1
Rationale 1: The pt diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels.
Rationale 2: The pt with hypocalcemia may exhibit hypotension, & not hypertension.
Rationale 3: Visual disturbances do not occur with hypocalcemia.
Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.

A pt with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this pt's plan of care?
1. Request a dietitian consult for selecting foods high in phosphorous.
2. Provide aluminum hydroxide antacids as prescribed.
3. Instruct pt to avoid poultry, peanuts, & seeds.
4. Instruct to avoid the intake of sodium phosphate.

Answer: 1
Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause & promoting a high phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans & peas, eggs, fish, organ meats, Brazil nuts & peanuts, poultry, seeds & whole grains.
Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided.
Rationale 3: Poultry, peanuts, & seeds are part of a high phosphate diet.
Rationale 4: Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate.

When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms?
1. The kidneys retain bicarbonate.
2. The kidneys excrete bicarbonate.
3. The lungs will retain carbon dioxide.
4. The lungs will excrete carbon dioxide.

Answer: 1
Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate.
Rationale 2: Excreting bicarbonate causes acidosis to develop.
Rationale 3: Retaining carbon dioxide causes respiratory acidosis.
Rationale 4: Excreting carbon dioxide causes respiratory alkalosis

The nurse is caring for a pt diagnosed with renal failure. Which of the following does the nurse recognize as compensation for the acid-base disturbance found in pts with renal failure?
1. The pt breathes rapidly to eliminate carbon dioxide.
2. The pt will retain bicarbonate in excess of normal.
3. The pH will decrease from the present value.
4. The pt's oxygen saturation level will improve.

Answer: 1
Rationale 1: In metabolic acidosis compensation is accomplished through increased ventilation or "blowing off" C02. This raises the pH by eliminating the volatile respiratory acid & compensates for the acidosis.
Rationale 2: Because compensation must be performed by the system other than the affected system, the pt cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal bicarbonate value.
Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation.
Rationale 4: Oxygenation disturbance is not part of the acid-base status of the pt with renal failure.

When caring for a group of pts, the nurse realizes that which of the following health problems increases the risk for metabolic alkalosis?
1. bulimia
2. dialysis
3. venous stasis ulcer
4. COPD

Answer: 1
Rationale 1: Metabolic alkalosis is cause by vomiting, diuretic therapy or nasogastric suction, among others. A pt with bulimia may engage in vomiting or indiscriminate use of diuretics.
Rationale 2: A pt receiving dialysis has kidney failure, which causes metabolic acidosis.
Rationale 3: A venous stasis ulcer does not result in an acid-base disorder.
Rationale 4: The pt diagnosed with COPD typically has hypercapnea & respiratory acidosis.

The nurse is caring for a pt who is anxious & dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, & HCO3 24. The nurse would anticipate which initial intervention to correct this problem?
1. Encourage the pt to breathe in & out slowly into a paper bag.
2. Immediately administer oxygen via a mask & monitor oxygen saturation.
3. Prepare to start an intravenous fluid bolus using isotonic fluids.
4. Anticipate the administration of intravenous sodium bicarbonate.

Answer: 1
Rationale 1: This pt is exhibiting signs of hyperventilation that is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the pt to retain carbon dioxide & lower oxygen levels to normal, correcting the cause of the problem.
Rationale 2: The oxygen levels are high, so oxygen is not indicated, & would exacerbate the problem if given. Intravenous fluids would not be the initial intervention.
Rationale 3: Not enough information is given to determine the need for intravenous fluids.
Rationale 4: Bicarbonate would be contraindicated as the pH is already high.

A pt is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the pt is receiving this replacement is
1. to sustain respiratory function.
2. to help regulate acid-base balance.
3. to keep a vein open.
4. to encourage urine output.

Answer: 2
Rationale 1: Potassium does not sustain respiratory function.
Rationale 2: Electrolytes have many functions. They assist in regulating water balance, help regulate & maintain acid-base balance, contribute to enzyme reactions, & are essential for neuromuscular activity.
Rationale 3: Intravenous fluids are used to keep venous access not potassium.
Rationale 4: Urinary output is impacted by fluid intake not potassium.

An elderly pt does not complain of thirst. What should the nurse do to assess that this pt is not dehydrated?
1. Ask the physician for an order to begin intravenous fluid replacement.
2. Ask the physician to order a chest x-ray.
3. Assess the urine for osmolality.
4. Ask the physician for an order for a brain scan.

Answer: 3
Rationale 1: It is inappropriate to seek an IV at this stage.
Rationale 2: There is no indication the pt is experiencing pulmonary complications thus a cheat x-ray is not indicated.
Rationale 3: The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration & hyperosmolality. The nurse should check the pt's urine for osmolality as a 1st step in determining hydration status before other detailed & invasive testing is done.
Rationale 4: There is no data to support the need for a brain scan.

An elderly pt who is being medicated for pain had an episode of incontinence. The nurse realizes that this pt is at risk for developing
1. dehydration.
2. over-hydration.
3. fecal incontinence.
4. a stroke.

Correct Answer: 1
Rationale 1: Functional changes of aging also affect fluid balance. Older adults who have self-care deficits, or who are confused, depressed, tube-fed, on bed rest, or taking medications (such as sedatives, tranquilizers, diuretics, & laxatives), are at greatest risk for fluid volume imbalance.
Rationale 2: There is inadequate evidence to support the risk of over-hydration.
Rationale 3: There is inadequate evidence to support the risk of fecal incontinence.
Rationale 4: There is inadequate evidence to support the risk of a stroke.

The nurse assesses a pt's weight loss as being 22 lbs. How many liters of fluid did this pt lose?

Correct Answer: 10
Rationale: Each liter of body fluid weighs 1 kg or 2.2 lbs. This pt has lost 10 liters of fluid.

A postoperative pt with a fluid volume deficit is prescribed progressive ambulation yet is weak from an inadequate fluid status. What can the nurse do to help this pt?
1. Assist the pt to maintain a standing position for several minutes.
2. This pt should be on bed rest.
3. Assist the pt to move into different positions in stages.
4. Contact physical therapy to provide a walker.

Answer: 3
Rationale 1: The pt should avoid prolonged standing.
Rationale 2: Bed rest can promote skin breakdown.
Rationale 3: The pt needs to be taught how to avoid orthostatic hypotension which would include assisting & teaching the pt how to move from one position to another in stages.
Rationale 4: A physician referral is needed for physical therapy intervention & is not indicated in this situation.

A postoperative pt is diagnosed with fluid volume overload. Which of the following should the nurse assess in this pt?
1. poor skin turgor
2. decreased urine output
3. distended neck veins
4. concentrated hemoglobin & hematocrit levels

Answer: 3
Rationale 1: Poor skin turgor is associated with fluid volume deficit.
Rationale 2: Decreased urine output is associated with fluid volume deficit.
Rationale 3: Circulatory overload causes manifestations such as a full, bounding pulse; distended neck & peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit & blood urea nitrogen (BUN); & possible cerebral edema.
Rationale 4: Increased hemoglobin & hematocrit values are associated with fluid volume deficit.

An elderly pt is at home after being diagnosed with fluid volume overload. Which of the following should the home care nurse instruct this pt to do?
1. Wear support hose.
2. Keep legs in a dependent position.
3. Avoid wearing shoes while in the home.
4. Try to sleep without extra pillows.

Answer: 1
Rationale 1: The home care nurse should instruct this pt about ways to decrease dependent edema, which include wearing support hose, elevating feet when in a sitting position, & resting in a recliner or bed with extra pillows.
Rationale 2: The pt should elevate the legs.
Rationale 3: As long as the shoes are well fitting, there is not reason to avoid wearing them.
Rationale 4: It is appropriate for the pt to use extra pillows to keep the head up while sleeping.

A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this pt could possibly have which of the following electrolyte imbalances?
1. hypokalemia
2. hypernatremia
3. carbon dioxide
4. magnesium

Answer: 2
Rationale 1: The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations potassium levels.
Rationale 2: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia.
Rationale 3: Carbon dioxide abnormalities are not normally seen in this type of pt.
Rationale 4: Magnesium abnormalities are not normally seen in this type of pt.

An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following?
1. hypernatremia
2. hyponatremia
3. fluid volume excess
4. hyperkalemia

Answer: 2
Rationale 1: Hypernatremia is associated with fluid retention & overload. FVE is associated with hypernatremia.
Rationale 2: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The abdominal & muscle cramps are manifestations of a low serum sodium level.
Rationale 3: This pt is more likely to develop clinical manifestations associated with fluid volume deficit.
Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias.

A pt is admitted with hypernatremia caused by being str&ed on a boat in the Atlantic Ocean for five days without a fresh water source. Which of the following is this pt at risk for developing?
1. pulmonary edema
2. atrial dysrhythmias
3. cerebral bleeding
4. stress fractures

Answer: 3
Rationale 1: Pulmonary edema is not associated with dehydration.
Rationale 2: Atrial dysrhythmias are not a factor for this pt.
Rationale 3: The brain experiences the most serious effects of cellular dehydration. As brain cells contract, the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, & lead to cerebral vascular bleeding.
Rationale 4: There have been no activities to support the development or occurrence of stress fractures.

The nurse is admitting a pt who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder?
1. calcium
2. magnesium
3. phosphorous
4. potassium

Answer: 4
Rationale 1: This pt will be less likely to develop a calcium imbalance.
Rationale 2: This pt will be less likely to develop a magnesium imbalance.
Rationale 3: This pt will be less likely to develop a phosphorous imbalance.
Rationale 4: Because the kidneys are the principal organs involved in the elimination of potassium, renal failure

A pt who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following does the nurse realize might occur with this pt?
1. Digoxin toxicity may occur.
2. A higher dose of digoxin (Lanoxin) may be needed.
3. A diuretic may be needed.
4. Fluid volume deficit may occur.

Answer: 1
Rationale 1: Hypokalemia increases the risk of digitalis toxicity in pts who receive this drug for heart failure.
Rationale 2: More digoxin is not needed.
Rationale 3: A diuretic may cause further fluid loss.
Rationale 4: There is inadequate information to assess for concerns related to fluid volume deficits.

A pt is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement should be administered
1. directly into the venous access line.
2. mixed in the prescribed intravenous fluid.
3. via a rectal suppository.
4. via intramuscular injection.

Answer: 2
Rationale 1: Never administer undiluted potassium directly into a vein.
Rationale 2: The intravenous route is the recommended route for diluted potassium.
Rationale 3: The nurse should administer diluted potassium into the pt's intravenous line.
Rationale 4: The nurse should administer diluted potassium into the pt's intravenous line.

An elderly pt with a history of sodium retention arrives to the clinic with the complaints of "heart skipping beats" & leg tremors. Which of the following should the nurse ask this pt regarding these symptoms?

1. "Have you stopped taking your digoxin medication?"
2. "When was the last time you had a bowel movement?"
3. "Were you doing any unusual physical activity?"
4. "Are you using a salt substitute?"

Answer: 4
Rationale 1: Although this pt may be prescribed digoxin this is not the primary focus of this question.
Rationale 2: The pt's bowel habits are not of concern at this time.
Rationale 3: The cardiac & musculoskeletal discomforts being reported are not consistent with physical exertion.
Rationale 4: The pt has a history of sodium retention & might think that a salt substitute can be used. Advise pts who are taking a potassium supplement or potassium-sparing diuretic to avoid salt substitutes, which usually contain potassium.

A 35-year-old female pt comes into the clinic postoperative parathyroidectomy. Which of the following should the nurse instruct this pt?
1. Drink one glass of red wine per day.
2. Avoid the sun.
3. Milk & milk-based products will ensure an adequate calcium intake.
4. Red meat is the protein source of choice.

Answer: 3
Rationale 1: This pt should avoid alcohol.
Rationale 2: This pt can benefit from sun exposure.
Rationale 3: This pt is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk & milk-based products.
Rationale 4: Protein monitoring is not indicated.

A pt is admitted for treatment of hypercalcemia. The nurse realizes that this pt's intravenous fluids will most likely be which of the following?
1. dextrose 5% & water
2. dextrose 5% & ? normal saline
3. dextrose 5% & ? normal saline
4. normal saline

Answer: 4
Rationale 1: If isotonic saline is not used, the pt is at risk for hyponatremia in addition to the hypercalcemia.
Rationale 2: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.
Rationale 3: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.
Rationale 4: Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.

A 28-year-old male pt is admitted with diabetic ketoacidosis. The nurse realizes that this pt will have a need for which of the following electrolytes?
1. sodium
2. potassium
3. calcium
4. magnesium

Answer: 4
Rationale 4: One risk factor for hypomagnesaemia is an endocrine disorder, including diabetic ketoacidosis.

An elderly pt with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypomagnesaemia?
1. hypotension, warmth, & sweating
2. nausea & vomiting
3. hyperreflexia
4. excessive urination

Answer: 1
Rationale 1: Elevations in magnesium levels are accompanied by hypotension, warmth, & sweating.
Rationale 2: Lower levels of magnesium are associated with nausea & vomiting.
Rationale 3: Lower levels of magnesium are associated & hyperreflexia.
Rationale 4: Urinary changes are not noted.

A pt is admitted with burns over 50% of his body. The nurse realizes that this pt is at risk for which of the following electrolyte imbalances?
1. hypercalcemia
2. hypophosphatemia
3. hypernatremia
4. hypermagnesemia

Correct Answer: 2

Rationale 1: Pts who experience burns are not at an increased risk for developing increased blood calcium levels.
Rationale 2: Causes of hypophosphatemia include stress responses & extensive burns.
Rationale 3: Pts who experience burns are not at an increased risk for developing increased blood sodium levels.
Rationale 4: Pts who experience burns are not at an increased risk for developing increased blood magnesium levels.

A pt is diagnosed with hyperphosphatemia. The nurse realizes that this pt might also have an imbalance of which of the following electrolytes?
1. calcium
2. sodium
3. potassium
4. chloride

Answer: 1
Rationale 1: Excessive serum phosphate levels cause few specific symptoms. The effects of high serum phosphate levels on nerves & muscles are more likely the result of hypocalcemia that develops secondary to an elevated serum phosphorus level. The phosphate in the serum combines with ionized calcium, & the ionized serum calcium level falls.

The nurse is reviewing a pt's blood pH level. Which of the systems in the body regulate blood pH? Select all that apply.
1. renal
2. cardiac
3. buffers
4. respiratory

Answer: 1,3
Rationale 1: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, & the renal system.
Rationale 2: The cardiac system is responsible for circulating blood to the body. It does not help maintain the body's pH.
Rationale 3: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, & the renal system.
Rationale 4: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, & the renal system.

The nurse observes a pt's respirations & notes that the rate is 30 per minute & the respirations are very deep. The metabolic disorder this pt might be demonstrating is which of the following?
1. hypernatremia
2. increasing carbon dioxide in the blood
3. hypertension
4. pain

Answer: 2
Rationale 1: Hypernatremia is associated with profuse sweating & diarrhea.
Rationale 2: Acute increases in either carbon dioxide or hydrogen ions in the blood stimulate the respiratory center in the brain. As a result, both the rate & depth of respiration increase. The increased rate & depth of lung ventilation eliminates carbon dioxide from the body, & carbonic acid levels fall, which brings the pH to a more normal range.
Rationale 3: The respiratory rate in a pt exhibiting hypertension is not altered.
Rationale 4: Pain may be manifested in rapid, shallow respirations.

The blood gases of a pt with an acid-base disorder show a blood pH outside of normal limits. The nurse realizes that this pt is
1. fully compensated.
2. demonstrating anaerobic metabolism.
3. partially compensated.
4. in need of intravenous fluids

Answer: 3

Rationale 1: If the pH is restored to within normal limits, the disorder is said to be fully compensated.
Rationale 2: Anaerobic metabolism results when the body's cells become hypoxic.
Rationale 3: If the pH is restored to within normal limits, the disorder is said to be fully compensated. When these changes are reflected in arterial blood gas (ABG) values but the pH remains outside normal limits, the disorder is said to be partially compensated.
Rationale 4: Although the pt may be in need of intravenous fluids, this is not the most correct or definitive answer.

A pt's blood gases show a pH greater of 7.53 & bicarbonate level of 36 mEq/L. The nurse realizes that the acid-base disorder this pt is demonstrating is which of the following?
1. respiratory acidosis
2. metabolic acidosis
3. respiratory alkalosis
4. metabolic alkalosis

Answer: 4
Rationale 1& 2: Respiratory acidosis & metabolic acidosis are both consistent with pH less than 7.35.
Rationale 3: Respiratory alkalosis is associated with a pH greater than 7.45 & a PaCO2 of less than 35 mmHG. It is caused by respiratory related conditions.
Rationale 4: Arterial blood gases (ABGs) show a pH greater than 7.45 & bicarbonate level greater than 26 mEq/L when the pt is in metabolic alkalosis.

An elderly postoperative pt is demonstrating lethargy, confusion, & a resp rate of 8 per minute. The nurse sees that the last dose of pain medication administered via a pt controlled anesthesia (PCA) pump was within 30 minutes. Which of the following acid-base disorders might this pt be experiencing?
1. respiratory acidosis
2. metabolic acidosis
3. respiratory alkalosis
4. metabolic alkalosis

Answer: 1
Rationale 1: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition.
Rationale 2: The pt condition being described is respiratory not metabolic in nature.
Rationale 3: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition.
Rationale 4: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition. The pt condition being described is respiratory not metabolic in nature.

The pt has been placed on a 1200 mL daily fluid restriction. The pt's IV is infusing at a keep open rate of 10 mL/hr. The pt has no additional IV medications. How much fluid should the pt be allowed from 0700 until 1500 daily?

Answer: 540
Rationale: Fluid allowed is calculated by figuring the total daily IV intake (in this case 10 mL/hr × 24 hours = 240 mL/day), subtracting that total from the daily allowance (in this case 1200mL - 240 mL = 960mL). The amount calculated is then distributed as 50% for the traditional day shift, 25%-35% for the traditional evening shift, & the remainder for the traditional night shift. In this case, 50% of 960 is 540 mL.

The pt is receiving intravenous potassium (KCL). Which nursing actions are required? Select all that apply.
1. Administer the dose IV push over 3 minutes.
2. Monitor the injection site for redness.
3. Add the ordered dose to the IV hanging.
4. Use an infusion controller for the IV.
5. Monitor fluid intake & output.

Answer: 2,4,5

Which pts are at risk for the development of hypercalcemia? Select all that apply.
1. the pt with a malignancy
2. the pt taking lithium
3. the pt who uses sunscreen to excess
4. the pt with hyperparathyroidism
5. the pt who overuses antacids

Correct Answer: 1,2,4,5
Rationale 1: Pts with malignancy are at risk for development of hypercalcemia due to destruction of bone or the production of hormone-like substances by the malignancy.
Rationale 2: Lithium & overuse of antacids can result in hypercalcemia. Hypercalcemia can result from hyperparathyroidism which causes release of calcium from the bones, increased calcium absorption in the intestines & retention of calcium by the kidneys.
Rationale 3: The pt who uses sunscreen to excess is more likely to have a vitamin D deficiency which would result in hypocalcemia.
Rationale 4: Hypercalcemia can result from hyperparathyroidism which causes release of calcium from the bones, increased calcium absorption in the intestines & retention of calcium by the kidneys.
Rationale 5: Lithium & overuse of antacids can result in hypercalcemia.

The pt who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this pt? Select all that apply.
1. bananas
2. seafood
3. white rice
4. lean red meat
5. chocolate

Answer: 1,2,5
Rationale: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this pt should be counseled to eat foods high in magnesium. Foods high in magnesium include green leafy vegetables, seafood, milk, bananas, citrus fruits, & chocolate. White rice & lean red meat are not included.

The pt has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse expect for this pt? Select all that apply.
1. IV normal saline
2. calcium containing antacids
3. IV potassium phosphate
4. encouraging milk intake
5. increasing vitamin D intake

Answer: 1,2
Rationale: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excretion of phosphate.

The pt, newly diagnosed with diabetes mellitus, is admitted to the emergency department with nausea, vomiting, & abdominal pain. ABG results reveal a pH of 7.2 & a bicarbonate level of 20 mEq/L. Which other assessment findings would the nurse anticipate in this pt? Select all that apply.
1. tachycardia
2. weakness
3. dysrhythmias
4. Kussmaul's respirations
5. cold, clammy skin

Answer: 2,3,4
Rationale: Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, & Kussmaul's respirations.

Rationale: These ABG results, coupled with the pt's recent diagnosis of diabetes mellitus & history of vomiting would lead the nurse to suspect metabolic acidosis. Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, & Kussmaul's respirations.

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