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

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: 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.

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

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
4. cardiac failure

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

A pt recovering from surgery has an

indwelling urinary catheter. The nurse would
contact the pt's primary healthcare provider

Answer: 1
Rationale 1: A urine output of less than 30
mL per hour must be reported to the primary

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

with which of the following 24-hour urine

output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL

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

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

4. muscle relaxer

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 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.

The nurse is planning care for a pt with fluid

volume overload & hyponatremia. Which of
the following should be included in this pt's

Answer: 1
Rationale 1: The nursing care for a pt with
hyponatremia is dependent on the cause.

plan of care?
1. Restrict fluids.
2. Administer intravenous fluids.
3. Provide Kayexalate.
4. Administer intravenous normal saline with
furosemide.

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

Answer: 1

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.

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

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

2. dialysis
3. venous stasis ulcer
4. COPD

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

Answer: 3

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.

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?

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.

1.
2.
3.
4.

hypokalemia
hypernatremia
carbon dioxide
magnesium

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

Answer: 3
Rationale 1: Pulmonary edema is not
associated with dehydration.

source. Which of the following is this pt at

risk for developing?
1. pulmonary edema
2. atrial dysrhythmias
3. cerebral bleeding
4. stress fractures

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

Answer: 1
Rationale 1: Hypokalemia increases the risk

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.

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

Answer: 4
Rationale 1: Although this pt may be
prescribed digoxin this is not the primary
focus of this question.

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?"

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

Answer: 4
Rationale 1: If isotonic saline is not used, the

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

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

Answer: 1
Rationale 1: Elevations in magnesium levels

nurse realizes that which of the following

symptoms can indicate hypomagnesaemia?
1. hypotension, warmth, & sweating
2. nausea & vomiting
3. hyperreflexia
4. excessive urination

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

A pt is diagnosed with hyperphosphatemia.

The nurse realizes that this pt might also
have an imbalance of which of the following

Answer: 1
Rationale 1: Excessive serum phosphate
levels cause few specific symptoms. The

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.

electrolytes?
1. calcium
2. sodium
3. potassium
4. chloride

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

Answer: 1
Rationale 1: Acute respiratory acidosis
occurs due to a sudden failure of ventilation.
Overdoses of narcotic or sedative

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

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

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

4. encouraging milk intake

5. increasing vitamin D intake
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