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FLUIDS AND ELECTROLYTES; ACID-BASE

BALANCE
100 ITEMS
1. What is the nurse's primary concern
regarding fluid & electrolytes when caring for
an elderly pt who is intermittently confused?
A. risk of dehydration
B. risk of kidney damage
C. risk of stroke
D. 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.
2. The nurse is planning care for a pt with
severe burns. Which of the following is this pt
at risk for developing?
A. intracellular fluid deficit
B. intracellular fluid overload
C. extracellular fluid deficit
D. 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.

3. 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?
A. the body's natural compensatory
mechanisms
B. pharmacological effects of a diuretic
C. effects of rapidly infused intravenous
fluids
D. 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.
4. 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?
A. Risk for Imbalanced Fluid Volume
B. Excess Fluid Volume
C. Imbalanced Nutrition
D. 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
5. 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?
A. 600 mL
B. 750 mL
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C. 1000 mL
D. 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).
6. A pt is receiving intravenous fluids
postoperatively following cardiac surgery.
Nursing assessments should focus on which
postoperative complication?
A. fluid volume excess
B. fluid volume deficit
C. seizure activity
D. 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.
7. A pt is diagnosed with severe
hyponatremia. The nurse realizes this pt will
mostly likely need which of the following
precautions implemented?
A. seizure
B. infection
C. neutropenic
D. 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.
8. 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?
A. corticosteroid
B. thiazide diuretic
C. narcotic
D. 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.
9. 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?
A. hyperkalemia
B. hypokalemia
C. hypercalcemia
D. 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 nonpotassium 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.
10. 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?
A. Restrict fluids.
B. Administer intravenous fluids.
C. Provide Kayexalate.
D. Administer intravenous normal saline with
furosemide.
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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.
11. When caring for a pt diagnosed with
hypocalcemia, which of the following should
the nurse additionally assess in the pt?
A. other electrolyte disturbances
B. hypertension
C. visual disturbances
D. 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.
12. 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?
A. Request a dietitian consult for selecting
foods high in phosphorous.
B. Provide aluminum hydroxide antacids as
prescribed.
C. Instruct pt to avoid poultry, peanuts, &
seeds.
D. 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.
13. 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?
A. The kidneys retain bicarbonate.
B. The kidneys excrete bicarbonate.
C. The lungs will retain carbon dioxide.
D. 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
14. 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?
A. The pt breathes rapidly to eliminate
carbon dioxide.
B. The pt will retain bicarbonate in excess of
normal.
C. The pH will decrease from the present
value.
D. 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.

15. When caring for a group of pts, the nurse


realizes that which of the following health
problems increases the risk for metabolic
alkalosis?
A. bulimia
B. dialysis
C. venous stasis ulcer
D. 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.
16. 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?
A. Encourage the pt to breathe in & out
slowly into a paper bag.
B. Immediately administer oxygen via a
mask & monitor oxygen saturation.
C. Prepare to start an intravenous fluid bolus
using isotonic fluids.
D. 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.
17. A pt is prescribed 20 mEq of potassium
chloride. The nurse realizes that the reason
the pt is receiving this replacement is
A. to sustain respiratory function.
B. to help regulate acid-base balance.

C. to keep a vein open.


D. 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.
18. An elderly pt does not complain of thirst.
What should the nurse do to assess that this
pt is not dehydrated?
A. Ask the physician for an order to begin
intravenous fluid replacement.
B. Ask the physician to order a chest x-ray.
C. Assess the urine for osmolality.
D. 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.
19. 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
A. dehydration.
B. over-hydration.
C. fecal incontinence.
D. 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.
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Rationale 4: There is inadequate evidence to


support the risk of a stroke.
20. The nurse assesses a pt's weight loss as
being 22 lbs. How many liters of fluid did this
pt lose?
A. 10
B. 15
C. 20
D. 5
Correct Answer: A
Rationale: Each liter of body fluid weighs 1
kg or 2.2 lbs. This pt has lost 10 liters of
fluid.
21. 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?
A. Assist the pt to maintain a standing
position for several minutes.
B. This pt should be on bed rest.
C. Assist the pt to move into different
positions in stages.
D. 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.
22. A postoperative pt is diagnosed with fluid
volume overload. Which of the following
should the nurse assess in this pt?
A. poor skin turgor
B. decreased urine output
C. distended neck veins
D. 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.
23. 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?
A. Wear support hose.
B. Keep legs in a dependent position.
C. Avoid wearing shoes while in the home.
D. 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.
24. 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?
A. hypokalemia
B. hypernatremia
C. carbon dioxide
D. 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.
25. 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
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demonstrating which of the following?


A. hypernatremia
B. hyponatremia
C. fluid volume excess
D. 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.
26. 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?
A. pulmonary edema
B. atrial dysrhythmias
C. cerebral bleeding
D. 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.
27. 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?
A. calcium
B. magnesium
C. phosphorous
D. 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
28. 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?
A. Digoxin toxicity may occur.
B. A higher dose of digoxin (Lanoxin) may be
needed.
C. A diuretic may be needed.
D. 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.
29. A pt is prescribed 40 mEq potassium as a
replacement. The nurse realizes that this
replacement should be administered
A. directly into the venous access line.
B. mixed in the prescribed intravenous fluid.
C. via a rectal suppository.
D. 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.
30. 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?
A. "Have you stopped taking your digoxin
medication?"
B. "When was the last time you had a bowel
movement?"
C. "Were you doing any unusual physical
activity?"
D. "Are you using a salt substitute?"
Answer: 4
Rationale 1: Although this pt may be
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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.
31. A 35-year-old female pt comes into the
clinic postoperative parathyroidectomy.
Which of the following should the nurse
instruct this pt?
A. Drink one glass of red wine per day.
B. Avoid the sun.
C. Milk & milk-based products will ensure an
adequate calcium intake.
D. 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.
32. 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?
A. dextrose 5% & water
B. dextrose 5% & ? normal saline
C. dextrose 5% & ? normal saline
D. 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.

33. 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?
A. sodium
B. potassium
C. calcium
D. Magnesium
Answer: 4
Rationale 4: One risk factor for
hypomagnesaemia is an endocrine disorder,
including diabetic ketoacidosis.
34. An elderly pt with peripheral neuropathy
has been taking magnesium supplements.
The nurse realizes that which of the following
symptoms can indicate hypomagnesaemia?
A. hypotension, warmth, & sweating
B. nausea & vomiting
C. hyperreflexia
D. 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.
35. 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?
A. hypercalcemia
B. hypophosphatemia
C. hypernatremia
D. 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.
36. A pt is diagnosed with
hyperphosphatemia. The nurse realizes that
this pt might also have an imbalance of
which of the following electrolytes?
A. calcium
B. sodium
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C. potassium
D. 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.
37. The nurse is reviewing a pt's blood pH
level. Which of the systems in the body
regulate blood pH? Select all that apply.
A. renal
B. cardiac
C. buffers
D. 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.
38. 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?
A. hypernatremia
B. increasing carbon dioxide in the blood
C. hypertension
D. 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.
39. 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
A. fully compensated.
B. demonstrating anaerobic metabolism.
C. partially compensated.
D. 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.
40. 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?
A. respiratory acidosis
B. metabolic acidosis
C. respiratory alkalosis
D. 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.
41. 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?
8

A. respiratory acidosis
B. metabolic acidosis
C. respiratory alkalosis
D. 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.
42. 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?
A. 540 ml
B. 300 ml
C. 600 ml
D. 590 ml
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.
43. The pt is receiving intravenous potassium
(KCL). Which nursing actions are required?
Select all that apply.
A. Administer the dose IV push over 3
minutes.
B. Monitor the injection site for redness.
C. Add the ordered dose to the IV hanging.
D. Use an infusion controller for the IV.
E. Monitor fluid intake & output.
Answer: 2,4,5
44. Which pts are at risk for the development
of hypercalcemia? Select all that apply.

A. the pt with a malignancy


B. the pt taking lithium
C. the pt who uses sunscreen to excess
D. the pt with hyperparathyroidism
E. 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.
45. 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.
A. bananas
B. seafood
C. white rice
D. lean red meat
E. 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.
46. 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.
A. IV normal saline
B. calcium containing antacids
C. IV potassium phosphate
D. encouraging milk intake
E. increasing vitamin D intake
Answer: 1,2
Rationale: Serum phosphate level of 4.7
mg/dL indicates hyperphosphatemia. IV
9

normal saline promotes renal excretion of


phosphate.
47. 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.
A. tachycardia
B. weakness
C. dysrhythmias
D. Kussmaul's respirations
E. 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.
48. A clients nursing diagnosis is Deficient
Fluid Volume related to excessive fluid loss.
Which action related to the fluid
management should be delegated to a
nursing assistant?
a. Administer IV fluids as prescribed by the
physician.
b. Provide straws and offer fluids between
meals.
c. Develop plan for added fluid intake over
24 hours
d. Teach family members to assist client with
fluid intake
1. ANSWER B The nursing assistant
can reinforce additional fluild intake once it is
part of the care plan. Administering IV fluids,
developing plans, and teaching families
require additional education and skills that
are within the scope of practice for the RN.
49. The client also has the nursing diagnosis
Decreased Cardiac Output related to
decrease plasma volume. Which finding on
assessment supports this nursing diagnosis?
a. Flattened neck veins when client is in
supine position
b. Full and bounding pedal and post-tibial
pulses
c. Pitting edema located in feet, ankles, and
calves

d. Shallow respirations with crackles on


auscultation
2. ANSWER A Normally, neck veins
are distended when the client is in the supine
position. The veins flatten as the client
moves to a sitting position. The other three
responses are characteristic of Excess Fluid
Volume.
50. The nursing care plan for the client with
dehydration includes interventions for oral
health. Which interventions are within the
scope of practice for the LPN/LVN being
supervised by the nurse? (Choose all that
apply.)
a. Remind client to avoid commercial
mouthwashes.
b. Encourage mouth rinsing with warm
saline.
c. Assess lips, tongue, and mucous
membranes
d. Provide mouth care every 2 hours while
client is awake
e. Seek dietary consult to increase fluids on
meal trays.
3. ANSWER A, B, C, D - The LPN/LVNs
scope of practice and educational
preparation includes oral care and routine
observation. State practice acts vary as to
whether LPN/LVNs are permitted to perform
assessment. The client should be reminded
to avoid most commercial mouthwashes that
contain alcohol, a drying agent. Initiating a
dietary consult is within the purview of the
RN or physician.
51. The physician has written the following
orders for the client with Excess Fluid
volume. The clients morning assessment
includes bounding peripheral pulses, weight
gain of 2 pounds, pitting ankle edema, and
moist crackles bilaterally. Which order takes
priority at this time?
a. Weight client every morning.
b. Maintain accurate intake and output.
c. Restrict fluid to 1500 mL per day
d. Administer furosemide (Lasix) 40 mg IV
push
4. ANSWER D Bilateral moist crackles
indicate fluid-filled alveoli, which interferes
with gas exchange. Furosemide is a potent
loop diuretic that will help mobilize the fluid
in the lungs. The other orders are important
but not urgent.
52. You have been pulled to the telemetry
unit for the day. The monitor informs you
that the client has developed prominent U
waves. Which laboratory value should you
check immediately?
a. Sodium
b. Potassium
c. Magnesium
d. Calcium
5. ANSWER B Suspect hypokalemia
and check the clients potassium level.
10

Common ECG changes with hypokalemia


include ST depression, inverted T waves, and
prominent U waves. Client with hypokalemia
may also develop heart block.
53. The clients potassium level is 6.7 mEq/L.
Which intervention should you delegate to
the student nurse under your supervision?
a. Administer Kayexalate 15 g orally
b. Administer spironolactone 25 mg orally
c. Assess WCG strip for tall T waves
d. Administer potassium 10 mEq orally
6. ANSWER A The clients potassium
level is high (normal range 3.5-5.0).
Kayexalate removes potassium from the
body through the gastrointestinal system.
Spironolactone is a potassium-sparing
diuretic that may cause the clients
potassium level to go even higher. The
nursing student may not have the skill to
assess ECG strips and this should be done by
the RN.
54. A client is admitted to the unit with a
diagnosis of syndrome of inappropriate
antidiuretic hormone secretion (SIADH). For
which electrolyte abnormality will you be
sure to monitor?
a. Hypokalemia
b. Hyperkalemia
c. Hyponatremia
d. Hypernatremia
7. ANSWER C - SIADH causes a relative
sodium deficit due to excessive retention of
water.
55. The charge nurse assigned in the care for
a client with acute renal failure and
hypernatremia to you, a newly graduated
RN. Which actions can you delegate to the
nursing assistant?
a. Provide oral care every 3-4 hours
b. Monitor for indications of dehydration
c. Administer 0.45% saline by IV line
d. Assess daily weights for trends
8. ANSWER A Providing oral care is
within the scope of practice for the nursing
assistant. Monitoring and assessing clients,
as well as administering IV fluids, require the
additional education and skill of the RN.
56. The experienced LPN/LVN reports that a
clients blood pressure and heart rate have
decreased and that when the face is
assessed, one side twitches. What action
should you take at this time?
a. Reassess the clients blood pressure and
heart rate
b. Review the clients morning calcium level
c. Request a neurologic consult today
d. Check the clients papillary reaction to
light
9. ANSWER B A positive Chvosteks
sign (facial twitching of one side of the
mouth, nose, and cheek in response to
tapping the face just below and in front of
the ear) is a neurologic manifestation of

hypocalcemia. The LPN/LVN is experienced


and possesses the skills to take accurate
vital signs.
57.You are preparing to discharge a client
whose calcium level was low but is now just
slightly within the normal range (9-10.5
mg/dL). Which statement by the client
indicates the need for additional teaching?
a. I will call my doctor if I experience muscle
twitching or seizures.
b. I will make sure to take my vitamin D with
my calcium each day.
c. I will take my calcium pill every morning
before breakfast.
d. I will avoid dairy products, broccoli, and
spinach when I eat.
10. ANSWER D Clients with low
calcium levels should be encouraged to
consume dairy products, seafood, nuts,
broccoli, and spinach. Which are all good
sources of dietary calcium.
58.A nursing assistant asks why the client
with a chronically low phosphorus level
needs so much assistance with activities of
daily living. What is your best response?
a. The clients low phosphorus is probably
due to malnutrition.
b. The client is just worn out form not
getting enough rest.
c. The clients skeletal muscles are weak
because of the low phosphorus.
d. The client will do more for herself when
her phosphorus is normal
11. ANSWER C A musculoskeletal
manifestation of low phosphorous is
generalized muscle weakness that may lead
to acute muscle breakdown
(rhabdomyolysis). Even though the other
statements are true, they do not answer the
nursing assistants question.
59.You are reviewing a clients morning
laboratory results. Which of these results is
of most concern?
a. Serum potassium 5.2 mEq/L
b. Serum sodium 134 mEq/L
c. Serum calcium 10.6 mg/dL
d. Serum magnesium 0.8 mEq/L
59. ANSWER D While all of these
laboratory values are outside of the normal
range, the magnesium is most outside of
normal. With a magnesium level this low, the
client is at risk for
ECG changes and life-threatening ventricular
dysrhythmias.
60. You are the charge nurse. Which client is
most appropriate to assign to the step-down
unit nurse pulled to the intensive care unit
for the day?
a. A 68-year-old client on ventilator with
acute respiratory failure and respiratory
acidosis
b. A 72-year-old client with COPD and normal
arterial blood gases (ABGs) who is ventilator11

dependent
c. A 56-year-old new admission client with
diabetic ketoacidosis (DKA) on a n insulin
drip
d. A 38-year-old client on a ventilator with
narcotic overdose and respiratory alkalosis
13. ANSWER B The client with COPD,
although ventilator dependent, is the most
stable of this group. Clients with acid-base
imbalances often require frequent laboratory
assessment and changes in therapy to
correct their disorders. In addition, the client
with DKA is a new admission and will require
an in-depth admission assessment. All three
of these clients need care from an
experienced critical care nurse.
61.A client with respiratory failure is
receiving mechanical ventilation and
continues to produce ABG results indicating
respiratory acidosis. Which action should you
expect to correct this problem?
a. Increase the ventilator rate from 6 to 10
per minute
b. Decrease the ventilator rate from 10 to 6
per minute
c. Increase the oxygen concentration for 30%
to 40%
d. Decrease the oxygen concentration for
40% to 30%
14. ANSWER A the blood gas
component responsible for respiratory
acidosis is CO2 (Carbon dioxide). Increasing
the ventilator rate will blow off more CO2
and decrease the acidosis. Changes in the
oxygen setting may improve oxygenation but
will not affect respiratory acidosis.
62.Which action should you delegate to the
nursing assistant for the client with diabetic
ketoacidosis? (Choose all that apply.)
a. Check fingerstick glucose every hour.
b. Record intake and output every hour.
c. Check vital signs every 15 minutes.
d. Assess for indicators of fluid imbalance.
15. ANSWER B, C The nursing
assistants training and education include
how to take vital signs and record intake and
output. The need to take vital signs this
frequently indicates that the client maybe
unstable. The nurse should give the nursing
assistant reporting parameters when
delegating this action, should also check the
vital signs for indications in instability.
Performing fingerstick glucose checks and
assessing clients require additional education
and skill that are appropriate to licensed
nurses. Some facilities may train
experienced nursing assistants to perform
fingerstick glucose checks and change their
role descriptions to designate their new
skills, but this is beyond the normal scope of
practice for a nursing assistant.
63.You are admitting an elderly client to the
medical unit. Which factor indicates that this
client has a risk for acid-base imbalances?

a. Myocardial infarction 1 year ago


b. Occasional use of antacids
c. Shortness of breath with extreme exertion
d. Chronic renal insufficiency
16. ANSWER D Risk factors for acidbase imbalances in the older adult include
chronic renal disease and pulmonary
disease. Occasional antacid use will not
cause imbalances, although antacid abuse is
a risk factor for metabolic alkalosis.
64.A client with lung cancer has received
oxycodone 10 mg orally for pain. When the
student nurse assesses the client, which
finding should you instruct the student to
report immediately?
a. Respiratory rate of 8 to 10 per minute
b. Pain level decreased from 6/10 to 2/10
c. Client requests room door be closed.
d. Heart rate 90-100 per minute
17. ANSWER A A decreased
respiratory rate indicates respiratory
depression which also puts the client at risk
for respiratory acidosis, All of the other
findings are important and should be
reported to the RN, but the respiratory rate is
urgent.
65.The nursing assistant reports to you that
a client seems very anxious and that vital
signs included a respiratory rate of 38 per
minute. Which acid-base imbalance should
you suspect?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
18. ANSWER B The client is most
likely hyperventilating and blowing off CO2.
This decrease in CO2 will lead to an increase
in pH, causing respiratory alkalosis.
Respiratory acidosis results from respiratory
depression and retained CO2. Metabolic
acidosis and alkalosis result from problems
related to renal acid-base control.
66.A client is admitted to the unit for
chemotherapy. To prevent an acid-base
problem, which of the following would you
instruct the nursing assistant to report?
a. Repeated episodes of nausea and
vomiting
b. Complaints of pain associated with
exertion
c. Failure to eat all food on breakfast tray
d. Client hair loss during morning bath
19. ANSWER A Prolonged nausea and
vomiting can result in acid deficit that can
lead to metabolic alkalosis. The other
findings are important and need to be
assessed but are not related to acid-base
imbalances.
67.A client has a nasogastric tube connected
to intermittent wall suction. The student
12

nurse asks why the clients respiratory rate


has increased. What your best response?
a. Its common for clients with
uncomfortable procedures such as
nasogastric tubes to have a higher rate to
breathing.
b. The client may have a metabolic alkalosis
due to the NG suctioning and the increased
respiratory rate is a compensatory
mechanism.
c. Whenever a client develops a respiratory
acid-base problem, increasing the respiratory
rate helps correct the problem.
d. The client is hyperventilating because of
anxiety and we will have to stay alert for
development of a respiratory acidosis.
20. ANSWER B Nasogastric
suctioning can result in a decrease in acid
components and metabolic alkalosis. The
clients increase in rate and depth of
ventilation is an attempt to compensate by
blowing off CO2. the first response maybe
true but does not address all the components
of the question. The third and fourth answers
are inaccurate.
68. pH 7.51, pCO2 40, HCO3- 31:
a.
Normal
b.
Uncompensated metabolic
alkalosis
c.
compensated respiratory
acidosis
d.
Uncompensated respiratory
alkalosis
69. pH 7.33, pCO2 29, HCO3- 16:
a.
Uncompensated respiratory
alkalosis
b.
Uncompensated metabolic
acidosis
c.
Compensated respiratory
acidosis
d.
Uncompensated metabolic
acidosis
70. pH 7.40, pCO2 40, HCO3- 24:
a.
Normal
b.
Uncompensated metabolic
acidosis
c.
Compensated respiratory
acidosis
d.
Compensated metabolic
acidosis
71. pH 7.12, pCO2 60, HCO3- 29:
a.
Uncompensated metabolic
acidosis
b.
Uncompensated respiratory
acidosis
c.
Compensated respiratory
acidosis
d.
Compensated metabolic
acidosis
72. pH 7.48, pCO2 30, HCO3- 23:

a.
alkalosis
b.
alkalosis
c.
alkalosis
d.
alkalosis

Uncompensated metabolic
Uncompensated respiratory
Compensated respiratory
Compensated metabolic

73. pH 7.62, pCO2 47, HCO3- 30:


a. Uncompensated metabolic
alkalosis
b. Uncompensated respiratory
alkalosis
c. compensated respiratory alkalosis
d. compensated metabolic alkalosis
74.A mist tent contains a nebulizer that
creates a cool, moist environment for a
child with an upper respiratory tract
infection. The cool humidity helps the
child breathe by:
A. decreasing respiratory tract edema.
B. preventing anxiety.
C. drying secretions.
D. increasing fluid intake.
65. 1
The mist tent decreases respiratory
tract edema, which causes croup.
However, the child needs to be
prepared because the confinement
can cause high anxiety. The tent
liquefies secretions, rather than drying
them, and it doesn't increase the
child's fluid intake. (SR 4055)
75.A bone mineral analysis reveals that a
patient who is postmenopausal has
severe osteoporosis. Which of the
following instructions should the nurse
give to the patient's family to ensure a
safe environment for the patient?
A. "Disinfect the bathroom weekly."
B. "Carpet floor surfaces."
C. "Install handrails on stairways."
D. "Keep the lights dim."
66. 3
(3) Osteoporosis of the hip increases
the risk of hip fractures. Decreased
bone mass density puts one at high
risk for hip fractures. Installing
handrails on stairways will improve
mobility and prevent falls. (1)
Disinfecting the bathroom does not
prevent falls and hip fractures in the
patient with osteoporosis. (2)
Carpeting floor surfaces often makes
ambulation more difficult. (4) Poor
lighting increases the risk for falling.
Areas should be well lit. (SR 5456)
76.Based on multiple referrals, the nurse
determines that childhood injuries are
increasing in the community in which she
practices. The first step the nurse would
take in developing an educational
program is:
13

A. assessing for a decrease in referrals


following a pediatric safety class.
B. assessing the strengths and needs of
the community while identifying
barriers to learning.
C. choosing a health promotion or health
belief model as a framework.
D. developing and implementing a
specific plan to decrease childhood
injuries.
68. 2
Following the identification of a
learning need, the first step is to
assess the strengths and needs of the
community while identifying barriers
to learning. (SR 3856)
77.Which of the following activities would the
nurse likely choose to implement in
response to a nursing diagnosis of Activity
Intolerance related to lack of energy
conservation?
A. Encourage the client to perform all
tasks early in the day.
B. Encourage the client to alternate
periods of rest and activity throughout
the day.
C. Administer narcotics to promote pain
relief and rest.
D. Instruct the client to not perform daily
hygienic care until activity tolerance
improves.
69. 2
2: The client with rheumatoid arthritis
should be encouraged to alternate
periods of activity and rest throughout
the day. 1: Encouraging the client to
perform all activities of daily living at
once will worsen fatigue and stress her
ability to recover. 3: Narcotics are not
typically administered to control
arthritic pain. 4: Encouraging the
client to cease all participation in daily
activities will decrease activity
tolerance and make fatigue more
pronounced. (SR 3222)
78.A client has a diagnosis of borderline
personality disorder. She has attached
herself to one nurse and refuses to speak
with other staff members. She tells the
nurse that the other nurses are mean,
withhold her medication, and mistreat
her. The staff is discussing this problem at
their weekly conference. Which
intervention would be most appropriate
for the nursing staff to implement?
A. Provide an unstructured environment
for the client.
B. Rotate the nurses who are assigned to
the client.
C. Ignore the client's behaviors.
D. Bend unit rules to meet the client's
needs.
70. 2
Rotating staff members who work with
a client with a borderline personality

disorder keeps the client from


becoming dependent on any one
nurse and reduces the use of splitting
and her fear of abandonment. Firm
rules and consistency among staff
members will help control the client's
behavior. Ignoring splitting behaviors
can cause the client to increase the
behavior by trying to get a response
from the staff. Unit rules must be
consistently enforced and followed by
each nurse to help the client control
behavior. (SR 4297)
79.A client's chest tube accidentally
disconnects from the drainage tube when
she turns onto her side. Which of the
following actions should the nurse take
first?
A. Notify the physician.
B. Clamp the chest tube.
C. Raise the level of the drainage system.
D. Reconnect the tube.
71. 2
2: When a chest tube becomes
disconnected, the nurse should take
immediate steps to prevent air from
entering the chest cavity which may
cause the lung to collapse. Therefore,
when a chest tube is accidentally
disconnected from the drainage tube,
the nurse should either double-clamp
the chest tube as close to the client as
possible or place the open end of the
tube in a container of sterile water or
saline solution. Then the physician
should be notified. 1: First priority
must be given to clamping the chest
tube. 3: To prevent backward flow of
drainage, the drainage system should
never be raised above chest level. 4:
To prevent backward flow of drainage,
the drainage system should never be
raised above chest level. (SR 3072)
80.For a client with COPD who has trouble
raising respiratory secretions, which of
the following nursing measures would
help reduce the tenacity of secretions?
A. Ensuring that the client's diet is low in
salt.
B. Ensuring that the client's oxygen
therapy is continuous.
C. Helping the client maintain a high fluid
intake.
D. Keeping the client in a semi-sitting
position as much as possible.
72. 3
3: A fluid intake of 2 to 3 L/day,
providing that the client does not have
cardiovascular or renal disease, helps
liquefy bronchial secretions. 1: A lowsalt diet does not help reduce the
viscosity of mucus. 2: Continuous
oxygen therapy does not help reduce
the viscosity of mucus. 4: Maintaining
a semi-sitting position does not help
14

reduce the viscosity of mucus. (SR


3057)
81.A client, now 37 weeks pregnant, calls the
clinic because she's concerned about
being short of breath and is unable to
sleep unless she places three pillows
under her head. After listening to her
concerns, the nurse should take which
action?
A. Make an appointment because the
client needs to be evaluated.
B. Explain that these are expected
problems for the latter stages of
pregnancy.
C. Arrange for the client to be admitted
to the birth center for delivery.
D. Tell the client to go to the hospital; she
may be experiencing signs of heart
failure from a 45% to 50% increase in
blood volume.
74. 2
The nurse must distinguish between
normal physiologic complaints of the
latter stages of pregnancy and those
that need referral to the health care
provider. In this case, the client
indicates normal physiologic changes
due to the growing uterus and
pressure on the diaphragm. The client
doesn't need to be seen or admitted
for delivery. The client's signs aren't
indicative of heart failure. (SR 4385)
82.A nurse works on a medical-surgical unit
where nurses work on 12-client pods.
Each pod is staffed by two registered
nurses. When one of the nurses leaves
the unit, the remaining nurse cares for all
12 clients. If she needs help, she can call
the agency's in-house resource nurse.
One evening when a coworker left the
unit, the remaining nurse, who was
making rounds on the departed nurse's
clients, found medications left at bedsides
and a client with a blood-draw tourniquet
remaining on his arm. In addressing the
problems, the nurse should:
A. inform the nurse-supervisor right
away.
B. correct the problems and submit a
written report.
C. speak to the coworker when she
returns to the unit.
D. ask for a meeting with the coworker
and a manager.
75. 3
When a nurse discovers substandard
practice by another nurse, it's always
appropriate to address the situation
before conveying the information to a
manager or supervisor. Informing the
nurse-supervisor first doesn't promote
goodwill between nurses and can
affect nursing care. It may be
necessary to correct the problem
before the nurse returns, but a written
report may not be necessary if the

issues can be remedied informally. If


the problem persists, it may be
necessary to meet jointly with a
manager, but initially the problem
should be addressed by only those
directly involved. (SR 3840)
83.The nurse is caring for a client with a
history of falls. The first priority when
caring for a client at risk for falls is:
A. placing the call light for easy access.
B. keeping the bed at the lowest position
possible.
C. instructing the client not to get out of
bed without assistance.
D. keeping the bedpan available so that
the client doesn't have to get out of
bed.
76. 2
Keeping the bed at the lowest possible
position is the first priority for clients
at risk for falling. Keeping the call light
easily accessible is important but isn't
a top priority. Instructing the client not
to get out of bed may not effectively
prevent falls. (SR 3974)
84.Which of the following nursing
interventions should have the highest
priority during the first hour after the
admission of a client with cholecystitis
who is experiencing pain, nausea, and
vomiting?
A. Administering pain medication.
B. Completing the admission history.
C. Maintaining hydration.
D. Teaching about planned diagnostic
tests.
77. 1
1: Administering pain medication
would have the highest priority during
the first hour after the client's
admission. 2: Completing the
admission history can be done after
the client's pain is controlled. 3:
Maintaining hydration is important but
will be accomplished over time. In the
first hour after admission, the highest
priority is pain relief. 4: It is not
appropriate to try to teach while a
client is in pain. Teaching about
planned diagnostic tests can occur
after the client is comfortable. (SR
3095)
85.

pH = 7.30 CO2 = 75 HCO3 = 22


A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis

86.
or

Is this Compensated, Uncompensated


Partially Compensated?
A. Compensated
B. Uncompensated
15

C. Partially Compensated
87.

pH = 7.36 CO2 = 32 HCO3 = 20


A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Alkalosis
D. Metabolic Acidosis

88.
or

Is this Compensated, Uncompensated


Partially Compensated?
A. Compensated
B. Uncompensated
C. Partially Compensated

89.

90.
or

91.

92.
or

93.

pH = 7.48 CO2 = 46 HCO3 = 28


A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Is this Compensated, Uncompensated
Partially Compensated?
A. Compensated
B. Uncompensated
C. Partially Compensated
pH = 7.38 CO2 = 50 HCO3 = 27
A. Respiratory Alkalosis
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Respiratory Acidosis
Is this Compensated, Uncompensated
Partially Compensated?
A. Compensated
B. Uncompensated
C. Partially Compensated
pH = 7.50 CO2 = 35 HCO3 = 32
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis

94.
or

Is this Compensated, Uncompensated


Partially Compensated?
A. Compensated
B. Uncompensated
C. Partially Compensated

95.

pH = 7.48 CO2 = 36 HCO3 = 33


A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis

96.
or

Is this Compensated, Uncompensated


Partially Compensated?
A. Compensated
B. Uncompensated
C. Partially Compensated

97.

pH = 7.2 CO2 = 48 HCO3 = 26


A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Is this Compensated, Uncompensated
Partially Compensated?
A. Compensated
B. Uncompensated
C. Partially Compensated

98.
or

99.

pH = 7.2 CO2 = 52 HCO3 = 24


A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis

100.
or

Is this Compensated, Uncompensated


Partially Compensated?
A. Compensated
B. Uncompensated
C. Partially Compensated

16