1. The nurse is caring for the child with hydronephrosis.

Which assessment
should the nurse perform to obtain the most accurate determination of fluid
balance?
A. Measuring the child’s intake and output
B. Weighing the child on the same scale
C. Assessing for the presence of edema
D. Evaluating serum electrolyte results

ANSWER: B

A. I & O provides data, but there is additional fluid lost through skin, lungs, and the GI tract that
cannot be measured.
B. Obtaining the child’s weight using the same scale is most accurate.
C. Edema is an indication of fluid retention but is not accurate.
D. Electrolyte levels are not measures of fluid balance, although some are affected by fluid excess
or deficit.

2. The nurse is calculating the client’s weight loss from vomiting and diarrhea.
The client’s weight prior to the illness was 135 lb, and current weight is 55 kg.
The nurse should calculate that the client lost how many pounds?

_______ lb (Record your answer as a whole number.)

ANSWER: 14
3. The nurse is caring for the client admitted with dehydration. Which factors
should the nurse explore as contributing to the client’s dehydration? Select all
that apply.
A. Diarrhea
B. Hemorrhage
C. Diabetic ketoacidosis
D. Hypoventilation
E. Decreased urination

ANSWER: A, B, C

A. Fluid volume deficit occurs with abnormal loss of body fluids, including diarrhea.
B. Hemorrhage can result in fluid volume deficit from a large loss of volume.
C. DKA is a risk factor or cause of dehydration because increased blood glucose levels
cause diuresis.
D. Hyperventilation and not hypoventilation is a risk factor or cause of dehydration.
E. Decreased urine output is a clinical manifestation of volume deficit, not a cause or
contributing factor.

4 . The child is prescribed oral rehydration therapy to treat dehydration from

vomiting and diarrhea. Which intervention should the nurse implement?
A. Give 50 to 100 rnL/kg of sterile water every 4 hours.
B. Give 40 to 50 mL/kg of rehydration solution every hour.
C. Give 40 to 50 mL/kg of rehydration solution over 4 hours.
D. Give 50 to 100 mL/kg of tap water every hour for 4 hours.

ANSWER: C

A. Water is not indicated as a fluid for rehydration because it lacks glucose, sodium,
potassium, and a base solution to equal an osmolality of 200 to 310 mOsm/L.
B. Giving 40 to 50 mL/kg of rehydration solution every hour could increase nausea and
vomiting from fullness.
C. The nurse should start with small sips of rehydration solution and increase it so the child
receives 40 to 50 mL/kg over 4 hours.
D. Tap water is not indicated as a fluid for rehydration because it lacks glucose, sodium,
potassium, and a base solution to equal an osmolality of 200 to 310 mOsm/L.

5. Fluid replacement is prescribed for the child hospitalized after an electrical

burn. Which indicators should the nurse use to determine adequacy of fluid
resuscitation? Select all that apply.
A. Capillary refill time
B. Sensorium
C. Urine output
 D. Blood pressure
E. Skin turgor

ANSWER: A, B, C, E

A. The capillary refill time is useful in evaluating peripheral tissue perfusion.

B. Changes in sensorium are useful in evaluating cerebral tissue perfusion.
C. Urine output is useful in evaluating perfusion to the kidneys.
D. The child’s BP um remain normotensive even with a state of hypovolemia.
E. Skin turgor is useful in «evaluating tissue hydration.

6 . After a tonsillectomy, the child has impaired swallowing related to

inflammation and pain. Which fluids should the nurse plan to administer?
A. Cool water or ice pops
B. Red or brown fluids
C. Colored citrus drinks
D. Ice cream or sorbet

ANSWER: A

A. Cold or frozen fluids can provide comfort while also providing fluid intake.
B. Red and brown fluids should be avoided to distinguish flesh and old blood.
C. Citrus should be avoided, as it can be irritating and is often not tolerated early
postoperative.
D. Milk products coat the throat and may require the child to attempt to clear the throat,
which could initiate bleeding.

7. The nurse is preparing an education session for high school students who
will be practicing for outdoor sports in temperatures averaging 100°F (38°C).
What information should the nurse include in the educational session? Select
all that apply.
A. Gradually increase the length of time and amount of activity.
B. On hot, humid days, limit sports activity to 15 -minute intervals.
C. Drink fluids before and during practice, even if not thirsty.
D. Wear full gear but remove some of it when taking breaks.
E. Playing while excessively fatigued will increase endurance.

ANSWER: A. B, C

A. Gradually increasing activity allows the body to adjust, especially when there is inactivity
prior to starting practices.
B. Limiting activity on hot, humid days allows time to replenish fluids and allows the body
to cool down.
C. Drinking fluids during these periods helps to decrease the risk of dehydration.
 D. Clothing should be limited to light layers, and sports gear should be gradually added into
the practice for short periods of time.
E. Excessive fatigue may be a sign of dehydration. The player should rest and be
encouraged to drink fluids and take measures to cool the body.

8. The adult client has a reddened sore throat with white patches that feels like “razor blades
when swallowing.” A rapid strep test is negative. Which statement should the nurse make
when instructing the client to gargle with saltwater?
A. “Saltwater will take away the pain.”
B. “Saltwater serves as a cleansing agent.”
C. “Saltwater reduces inflammation.”
D. “Saltwater helps distract from pain.”

ANSWER: C

A. The pain is relieved when inflammation is decreased.

B. Water alone is a cleansing agent, but this is not the purpose for this client.
C. The saltwater moves fluid out of the inflamed tissues by osmosis, thus reducing
inflammation.
D. Gargling may help distract from the pain, but this is not the purpose of gargling with
saltwater.

9. The client is to receive lactated Ringer’s 1000 mL IV to be delivered over 8 hours. At how
many milliliters per hour should the nurse should set the infusion rate?

_________ mL/hr (Record your answer as a whole number.)

ANSWER: 125

1000 mL divided by 8 hours equals 125 mL/hour.

10. The nurse is caring for the comatose client receiving IV fluids at the amount that equals
urine output. The client is losing weight. Which should be the nurse’s reasoning for the
client’s weight loss?
A. About 500 mL/day of fluid is lost through the GI tract.
B. Insensible fluid loss accounts for about 400 mL/day.
C. About 200 mL/day of fluid is lost through perspiration.
D. Total fluid loss other than urine can equal 1000 mL/day.

ANSWER: D

A. Fluid lost through the GI tract is 100 to 200 mL./day, not 500 mL.
B. Insensible fluid loss refers to the fluid lost through the lungs and skin and is 700' to 800
mL/day.
 C. Perspiration, under normal conditions, results in the loss of about 100 mL./day of fluid.
D. Besides urine, body fluid is lost through perspiration, the GI tract, skin, and lungs. This
can account for over 1000 mL/day, which is equal to approximately 1 kg, or 2.2 lb.

11. The client with ESRD has 2+ pitting edema, and a total serum protein is 5.8 g/dL. The
client is 6 feet tall and weighs 180 lb. The nurse concludes that this client’s edema likely
resulted from which physiological process?
A. Decreased capillary hydrostatic pressure
B. Decreased plasma oncotic pressure
C. Increased capillary permeability
D. Decreased serum electrolytes

ANSWER: B

A. Increased, not decreased, capillary hydrostatic pressure can result in edema.

B. The total serum protein of 5.8 g/dL is low (normal serum protein total is 6.0 to 8.0 g/dL).
ESRD clients often have low plasma protein from malnutrition and protein restriction.
These reduce plasma oncotic pressure and result in fluid remaining in the interstitial
space because pressure is not great enough to pull fluid into the capillaries.
C. Although edema can result from increased capillary permeability, the low serum protein
suggests decreased oncotic pressure is the most likely cause of the edema.
D. Because the client’s kidneys in ESRD are unable to excrete electrolytes, an increased
(not decreased) level of serum electrolytes is present.

12. The client is placed on strict 1&0. The nurse is instructing the NA on items on a food tray
that should be recorded as liquid intake. Place an X on the items on the food tray that should
be recorded as liquid intake.
Juice, ice cream, soup, and coffee are considered liquids and should be recorded as fluid intake.

13. The client with renal insufiiciency is prescribed to have a lSOO-mL fluid restriction and
strict monitoring of 1&0. Which interventions should the nurse include in the client’s plan of
care? Select all that apply.
A. Discuss the plan of care and fluid restriction with the client and family.
B. Document any pureed foods as part of the client’s liquid intake.
C. Record as intake the amount of water after subtracting for the ice chips.
D. Provide a collection device for measuring the client’s urine output.
E. Tell the family to record fluids they give on the facility intake record.
F. Encourage the family to bring the client’s favorite food items.

ANSWER: A, D

A. Informing the client and family of the plan of care helps to provide reinforcement for
the client and to ensure compliance with the fluid restriction and plan.
B. Pureed foods are not counted as liquid because they are considered solid in a different
form.
C. Ice chips are considered fluid; a 200-mL cup of ice is equal to 100 mL of water.
D. Measurement and collection devices are necessary when strict monitoring is required.
E. Only health care personnel should document on official agency records. The family
should be informed not to provide the client with additional liquid intake.
F. Bringing favorite food items from home should be discouraged to ensure that the client
follows the plan of care for fluid, protein, and electrolyte restrictions.
14. The client is placed on a 2000-mL fluid restriction. Which plan for fluid distribution over
24 hours should the nurse establish?

ANSWER: C

A. This plan is incorrect because fluids should be available during the night.
B. A large amount of fluid intake is planned from 3 to 11; this should be avoided because it
disrupts sleep if taken just before bedtime.
C. Generally, half of the total restriction is pro- vided during the day and the other half
between evening and nights. This plan helps to avoid thirst during the day and avoids
disrupting sleep with the need to urinate.
D. This total amount is 1500 mL, less than what was prescribed for a fluid restriction. The
client may become dehydrated.

15. The client being admitted to the ED reports feeling weak and having “almost passed out.”
The client was gardening in an outside temperature of 100°F (413°C). Assessment findings
reveal poor skin turgor, dry and dull mucous membranes, HR 120 bpm, and BP 92/54 mm
Hg. Which problem should the nurse identify as the priority?
A. Impaired mucous membranes
B. High risk for falls
C. Decreased cardiac output
D. Fluid volume deficit

ANSWER: D

A. Although the nurse should moisturize the client’s dry, dull mucous membranes, this is
not priority.
B. Falling is a concern, especially after feeling weak and faint, but the client is talking now.
Fluid volume deficit is the priority.
C. There are no symptoms of decreased cardiac out- put. The client’s MAP is 67, suggesting
adequate cardiac output for tissue perfusion ([systolic BP + 2 diastolic BP] + 3).
D. The priority problem is fluid volume deficit because signs of dehydration and
hypovolemia are evident (weakness, syncope, poor skin turgor, dry and dull mucous
membranes, hypotension).
16 . The daughter of the 82—year-old client with Alzheimer’s disease contacts a clinic
because her father has been unwilling to drink any fluids for over 24 hours. Which
statement by the nurse is most appropriate?
A. “Take your father to the hospital for intravenous fluid replacement.”
B. “Bring your father to the clinic to have blood drawn for electrolytes.”
C. “Tell me about other symptoms your father seems to be experiencing.”
D. “Offer popsicles and ice cream and call the clinic again tomorrow.”

ANSWER: C

A. There is insufficient information regarding hydration status to suggest hospital

admission for IV fluid replacement.
B. Laboratory tests, such as electrolytes, would not be indicated without first knowing the
client’s symptoms and hydration status.
C. The nurse should ask about signs and symptoms of dehydration (change in speech,
weakness, dry mucous membranes, decreased urine output). The treatments for
dehydration will depend on whether or not the client is symptomatic.
D. Popsicles and ice cream, though sources of fluids, would be insufficient to replace fluid
and electrolyte needs if the client is severely dehydrated.

17. The nurse determines that the client with heart failure is at risk for excess fluid volume.
Which physiological change resulting from heart failure supports the risk for excess fluid
volume?
A. Increased glomerular filtration rate (GFR)
B. Increased antidiuretic hormone (ADH) production
C. Increased sodium excretion
D. Increased cardiac output

ANSWER: B

A. A decrease in GFR (not increase) would put the client at risk for excess fluid volume.
B. ADH is produced in response to changes in intravascular volume. The result is increased
water reabsorption.
C. Increased sodium excretion usually results in increased fluid output and would not place
the client at risk for excess fluid volume.
D. Increased cardiac output usually increases perfusion to the kidney, resulting in increased
output, and does not place the client at risk for excess fluid volume.

18. A 1 -day-old infant exhibits jitteriness, apnea, cyanotic episodes, abdominal distention,
and a high- pitched cry. The mother is diabetic. Which electrolyte imbalance pertaining to
the infant should the nurse further explore?
A. Early-onset hypocalcemia
B. Late-onset hypocalcemia
C. Hyperglycemia
 D. Hypoglycemia

ANSWER: A

A. Early-onset hypocalcemia (first 34—48 hours) tends to accompany the hypoglycemia

that occurs shortly after birth in the infant of a diabetic mother.
B. Late-onset hypocalcemia occurs 3 to 4 days following birth in infants fed modified cow’s
milk.
C. Hyperglycemia in infants is usually asymptomatic; this infant has symptoms not
associated with hyperglycemia.
D. Hypoglycemia may occur with newborns of diabetic mothers, but signs would not
include abdominal distention or apnea with cyanosis.

19. The nurse obtains the response illustrated when assessing the client who has
hypocalcemia. How should the nurse document the client’s response to this assessment?

A. Positive Trousseau’s sign

B. Positive Homan’s sign
C. Positive Chvostek’s sign
D. Positive Weber test

ANSWER: A

A. Trousseau’s sign is an indicator of tetany associated with hypocalcemia. In

hypocalcemia, carpal spasms can be seen when a BP cuff is inflated on the client’s arm.
B. The Homan’s sign is a possible indicator of throm - bophlebitis; it is elicited by sharp
dorsiflexion of the foot and is not associated with the facial nerve in front of the ear.
C. Chvostek’s sign is an indicator of tetany associated with hypocalcemia. Chvostek’s sign is
a contraction of facial muscles in response to a tap over the facial nerve in front of the
ear.
 D. The Weber test is a screening test for hearing. A vibrating tuning fork is placed on the
midline of the head to ascertain in which car the sound isheard by bone conduction.

20. The nurse is assessing the 10-year-old client with ARF. Which electrolyte imbalance
should be the priority concern for the nurse?
A. Hypercalcemia
B. Hyperphosphatemia
C. Hyperkalemia
D. Hypematremia

ANSWER: C

A. Hypercalcemia may result in changes in the neuro- muscular system and bradycardia.
B. Hyperphosphatemia may result in the presence of hypocalcemia.
C. Hyperkalemia can lead to life-threatening cardiac arrhythmias and is priority. ARF in
children often results from acute glomerulonephritis with retention of potassium.
D. Hypernatremia may result in disorientation and lethargy.

21. The nurse is caring for the client with hypotension. Which electrolytes should be closely
monitored by the nurse?
A. Sodium, potassium, and chloride
B. Sodium, chloride, and calcium
C. Calcium, phosphate, and magnesium
D. Magnesium, potassium, and sodium

ANSWER: A

A. The nurse should closely monitor sodium, potassium, and chloride levels. Renin
secretion increases plasma levels of angiotensin 11, increases serum potassium, and
decreases serum sodium. Aldosterone is also released in response to renin. Aldosterone
increases sodium reabsorption and potassium excretion, resulting in an increase in
chloride.
B. Calcium balance is controlled by the parathyroid hormone, calcitonin, and vitamin D.
C. Calcium balance is controlled by the parathyroid hormone, calcitonin, and Vitamin D.
Phosphorus and magnesium are regulated by the kidneys and influenced by calcium
balance, and not regulated by the renin—angiotensin system.
D. Magnesium is regulated by the kidneys and influenced by calcium balance, and not
regulated by the renin-angiotensin system.

22. The client admitted to the ED has a serum potassium level of 3.0 mEq/L. The nurse
should assess for which finding?
A. Hypotension
B. Bounding pulses
C. Weak, irregular pulses
 D. Increased GI motility

ANSWER: C

A. Hypotension is a sign of hyperkalemia, not hypokalemia.

B. Bounding pulses are a sign of hyponatremia, not hypokalemia.
C. A serum potassium level of 3.0 mEq/L is low (hypokalemia). The nurse should assess for
a weak, irregular pulse.
D. With hypokalemia smooth muscle function is altered; this may cause a decrease in GI
motility, not an increase in GI motility, as well as a decrease in peristalsis.

23. The client admitted with fluid volume overload is being treated with a loop diuretic.
Serum potassium levels. are being monitored as illustrated. Which day is best for the nurse
to consult with the HCP regarding initiating potassium replacement?

ANSWER: C

A. The serum potassium of 5.6 mEq/L on day 1 is high and would not require replacement.
B. The serum potassium of 4.4 mEq/L on day 2 is in the midrange of normal.
C. The nurse should consult the HCP on day 3, when the client’s level is at the low end of
normal. The client’s serum potassium level is decreasing, and the client is taking a
diuretic. Supplementation is needed to prevent a reduction of serum potassium level
below normal.
D. The serum potassium of 3.1 mEq/L on day 4 is low; replacement should have started a
day earlier to prevent a reduction of the serum potassium level below normal.

24. The nurse is caring for the client who has an NG tube that is attached to intermittent
suction. The nurse should monitor for which most important electrolyte imbalances?
A. Hyponatrcmia and hypocalcemia
B. Hypokalemia and hypophosphatemia
C. Hypomagnesemia and hypochloremia
D. Hypokalemia and hyponatremia

ANSWER: D
 A. Although sodium is lost through NG fluids, calcium is not.
B. Although potassium is lost through NG fluids, phosphorus is not.
C. Magnesium and chloride may be lost with NG suctioning, but sodium and potassium are
the important electrolytes lost.
D. The nurse should monitor for hypokalemia and hyponatremia. NG losses contain both
sodium and potassium. These are most important because abnormalities can increase
the risk of life-threatening dysrhythmias.

25. The client is hyponatremic as a result of fluid volume overload. A fluid restriction of 800
mL/24 hours is prescribed. Which action by the nurse is most appropriate?
A. Provide ice chips and refill the client’s glass every 4 hours.
B. Have the client perform mouth care when feeling thirsty.
C. Offer sugary lozenges for the client to hold in the mouth.
D. Allow the client to salt foods to increase the sodium level.

ANSWER: B

A. Ice chips are considered fluid and should be included in the intake volume. A full glass of
ice chips is equivalent to 120 mL of fluid. If replaced every 2 hours, ice chips alone would
equal 1440 mL of fluid.
B. Frequent mouth care can help to reduce the sensation of thirst.
C. Lozenges, especially if high in sugar content, can produce the sensation of thirst.
D. Salt will increase fluid retention and may worsen the client’s condition.

26 . The nurse is caring for the client who is 1-day postthyroidectomy. Which assessment
findings should prompt the nurse to check the client’s serum calcium level?
A. Fatigue, decreased cardiac function, and tetany
B. Weakness, tachycardia, and disorientation
C. Muscle cramps, paresthesia, and Chvostek’s sign
D. Weakness, edema, and orthostatic hypotension

ANSWER: C

A. Fatigue is associated with sodium, potassium, and phosphorus imbalances.

B. Tachycardia is most often associated with abnormal serum magnesium levels.
C. Muscle cramps, paresthesia, and a positive Chvostek’s sign are common manifestations
of hypo- or hypercalcemia because of the irritation to the neuromuscular system.
D. Hypotension relates most often to volume changes rather than electrolyte imbalances.

27. The nurse reviews the serum laboratory results of four clients. Based on the findings,
which client should the nurse assess first?
A. The client with heart failure whose ionized serum calcium level is 3.8 mg/dL
B. The client admitted with nausea and vomiting whose sodium level is 145 mg/dL
C. The client admitted with SIADH whose potassium level is 3.5 mEq/L
 D. The client admitted with GI bleed whose phosphorus level is 2.4 mg/dL

ANSWER: A

A. The client’s ionized serum calcium level of 3.8 mg/dL is low (normal is 4.64—5.28
mg/dL). The nurse should assess this client first because calcium is essential to cardiac
function.
B. The client’s serum sodium level of 142 mg/dL is within the normal range of 135 to 145
mEq/L.
C. The client’s serum potassium level of 3.7 mEq/L is within the normal range of 3.5 to 5 .0
mEq/L.
D. The client’s serum phosphorus level of 2.4 mg/dL is slightly below the normal range of
2.5 to 4.5 mg/dL. Although it is important to assess this client, the client with the low
ionized serum calcium is priority.

28. The nurse is calculating the fluid balance for the client with DI. The client’s 1&0 for 8
hours is as follows: Intake: PO: 2000 mL water, 350 mL juice, 'A cup gelatin (110 mL), 360 mL
milk, and IV fluid of DSW at 125 mL/hour.

Output: 5000 mL

urine What amount should the nurse document for the 8-hour fluid balance? Negative (—) _
mL (Record your answer as a whole number.)

ANSWER: 1180

First determine the IV fluid intake. 125 X 8 = 1000

Next, add this total to the other fluid intake.

1000 + 2000 + 350 + 110 + 360 = 3820.

Next subtract the intake from the output:

5000 — 3820 = 1180.

29. The nurse is assessing the client who presented to the ED with a serum sodium level of
114 mEq/L. Which findings would the nurse relate to the serum sodium level? Select all that
apply.
A. Muscle weakness
B. Headache
C. Confusion
D. Warm, flushed skin
E. Abdominal cramping

ANSWER: A, B, C, E
 A. The serum sodium level is low. Hyponatremia results in weakness and muscle cramps
from cellular changes. In hyponatremia, sodium out- side cells decreases and water
moves into the cells, causing the cells to swell with water.
B. Water excess in hyponatremia lowers plasma osmolality, shifting fluid into brain cells
causing headache.
C. Water excess in hyponatremia lowers plasma osmolality, shifting fluid into brain cells
causing confusion.
D. Cold, clammy skin, not warm, flushed skin, is associated with hyponatremia.
E. Increased GI motility occurs in hyponatremia, resulting in abdominal cramping.

30. The nurse is evaluating assessment information gathered for four assigned clients. Based
on the information illustrated, which client requires priority interventions for excess fluid
volume?

A. Client A
B. Client B
C. Client C
D. Client D

ANSWER: D

A. Client A has edema, dyspnea, and a weight increased by 2 lb supporting fluid volume
excess, but these findings are not as extreme as those with Client D.
B. Client B has crackles, an intake that exceeds out- put, and an elevated BUN supporting
fluid volume excess, but these findings are not as extreme as those with Client D.
C. Client C has crackles, 1+ edema, and dyspnea. However, the output exceeds input, and
the client’s weight is down 3 lb. This client is not a priority.
D. Client D needs priority interventions for excess fluid volume because the client has a
greater degree of fluid volume excess than the other clients. Clients with excess fluid
 volume may have crackles and report dyspnea. Edema varies from trace to 4+ and can
be dependent to generalized edema. Excess fluid volume will most often result in an
increased weight and BUN and decreased Hct because of dilution.

31.The nurse is caring for the 90-year-old client with hypernatremia. Which assessment
findings should prompt the nurse to conclude that interventions have been ineffective?
A. Lethargy and paresthesias
B. Muscle cramps and spasms
C. Restlessness and agitation
D. Hypothermia and shivering

ANSWER: C

A. Paresthesias are associated with hyperkalemia and not hypematremia.

B. Muscle cramps and spasms are symptoms of hyponatremia, not hypematremia.
C. Hypernatremia (serum sodium greater than 145 mEq/L) results in water shifting out of
cells into the extracellular fluid with resultant dehydration and shrinkage of cells.
Dehydration of brain cells results in neurological manifestations such as restlessness,
agitation, lethargy, seizures, and even coma.
D. Increased body temperature can be a cause of the hypernatremia; a decrease might
suggest improvement, but the client should not be hypothermia.

32. The nurse is caring for the client with cardiac and renal disease. The client now has a
serum potassium level of 6.0 mEq/L. Which medications, if prescribed, should the nurse
administer? Select all that apply.
A. Sodium polystyrene 15 grams orally now
B. Regular insulin 4 units intravenously (IV) now
C. Dextrose 50% injection (50 mL) IV push now
D. Calcium gluconate 1.5 grams IV now
E. Potassium chloride 20 mEq orally now
F. Albuterol inhaler with spacer 2 puffs now

ANSWER: A, B, C, D, F

A. Sodium polystyrene (Kayexalate) is a cation exchange resin that exchanges sodium ions
for potassium ions in the intestine, helping to lower the serum potassium level.
B. Regular insulin temporarily shifts potassium into the cell; it is given with IV glucose to
prevent hypoglycemia.
C. Dextrose 50% injection is given with regular insulin IV to temporarily shift potassium
into the cells.
D. Calcium gluconate (Kalcinate) is administered to stabilize the cardiac cell membrane in
the presence of hyperkalemia.
E. Potassium supplements are contraindicated in clients with hyperkalemia since a further
increase in serum potassium concentration in hyperkalemia can produce cardiac arrest.
 F. Beta-2 adrenergic agonists, such as albuterol (Proventil), promote cellular reuptake of
potassium, possibly via the cyclic guanosine monophosphate (gAMP) receptor cascade.

33. The nurse is teaching the client with hypoparathyroidism. Which recommendation
should the nurse make knowing that the client is of the Orthodox Jewish faith?
A. Have milk or a dairy product with each meal
B. Avoid carbonated and caffeinated beverages
C. Ensure a calcium intake of 1 to 1.5 g daily
D. Eat foods high in iodine, such as shellfish

ANSWER: C

A. Dairy products are the primary source of calcium and should be increased in the
presence of hypoparathyroidism. However, persons of the Orthodox Jewish faith do not
eat meat and dairy products at the same meal. Two meals contain dairy products, and
one meal contains meat.
B. Carbonated beverages do not impact calcium, but caffeinated beverages inhibit calcium
absorption.
C. The client should be taught to ensure an adequate calcium intake, or supplements may
be required. In hypoparathyroidism, decreased function of the parathyroid glands leads
to decreased levels of parathyroid hormone (PTH). In the absence of adequate PTH
activity, the ionized calcium concentration in the extra- cellular fluid falls.
D. Those of the Orthodox Jewish faith do not eat shellfish or other fish without fins. Iodine
intake is unrelated to hypoparathyroidism. Iodine deficiency may result in an enlarged
thyroid gland.

34. The nurse is assessing the client who has a possible magnesium deficiency. Which
assessment should be the nurse’s priority?
ANSWER: A

A. The nurse’s priority should be to assess the heart. Hypomagnesemia can cause life-
threatening dysrhythmias, resulting in cardiovascular failure and arrest.
B. Hypomagneserrria causes neuromuscular irritability, but assessment of the reflexes is
not the nurse’s priority.
C. The nurse would stroke the cheek to assess for a Chvostek’s sign seen with
hypocalcemia, not hypomagnesemia.
D. It is important to assess for pitting edema with any condition, but it is not the priority
assessment in hypomagnesemia.

35. The hospitalized client has a serum magnesium level of 0.9 mg/dL. Which intervention is
the nurse’s priority?
A. Contact the HCP about stopping a prescribed loop diuretic.
B. Encourage the client to consume foods high in magnesium.
 C. Check for a protocol to give oral magnesium supplements.
D. Contact the HCP about giving a bolus IV dose of magnesium.

ANSWER: A

A. Some drugs cause increased renal losses of magnesium, including loop and thiazide
diuretics. Stopping these is priority.
B. Encouraging foods high in magnesium will take longer to increase the level of
magnesium than holding or discontinuing medications that promote magnesium loss.
C. The route of magnesium replacement is dependent on the severity of the condition.
Parenteral replacement is needed because the level is very low. Oral supplements will
take longer to be effective.
D. IV magnesium is not given as a bolus. It is important to use caution to prevent
hypermagnesemia.

36 . The emaciated client is admitted with a total serum protein level of 4 g/dL. When
assessing the client, the nurse should especially check for which alteration due to the low
serum protein level?
A. Confusion
B. Restlessness
C. Edema
D. Pallor

ANSWER: C

A. Confusion is not associated with low serum protein levels.

B. Restlessness is not associated with low serum protein levels.
C. Low serum protein causes a decrease in plasma oncotic pressure, allowing fluid to
remain in interstitial tissues. This causes edema.
D. Pallor is not associated with low serum protein levels.

37. The nurse assesses the client who presents to the ED with a panic attack. Which findings
should prompt the nurse to confer with the HCP about obtaining ABGs? Select all that apply.
A. Respirations 40 bpm
B. Tingling in the fingers
C. Muscle twitching
D. Salivation
E. Increased urination

ANSWER: A. B, C

A. Respiratory alkalosis may occur with a panic attack due to blowing off of carbon dioxide
with hyperventilation.
B. Tingling occurs in respiratory alkalosis due to the increase in neuromuscular excitability
associated with hyperventilation.
 C. Muscle twitching occurs from neuromuscular excitability associated with
hyperventilation.
D. Excess salivation is not associated with respiratory alkalosis that may result from a panic
attack.
E. Increased urination can occur from the stress response but is not associated with
respiratory alkalosis.

38. The child has an asthma attack and is treated with epinephrine while in the ED. Despite
receiving epinephrine, the child is still agitated, sweating profusely, and has an oxygen
saturation of 89% and a R of 30 bpm. Breath sounds are diminished, and wheezing is absent.
Based on this information, the nurse should anticipate interventions to treat which acid-
base imbalance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Metabolic acidosis

ANSWER: A

A. The nurse should anticipate interventions to treat respiratory acidosis. This child is most
likely in status asthmaticus with continued respiratory distress despite treatment. Even
though the child has a high respiratory rate, there is hypoventilation as a result of
bronchoconstriction. This results in carbon dioxide retention, increased Paco2 (greater
than 45 mm Hg), and a lowering of pH or an acidotic state.
B. Respiratory alkalosis would occur if excess carbon dioxide is blown off with
hyperventilation.
C. The client’s symptoms are associated with a respiratory and not a metabolic problem;
thus metabolic alkalosis is not correct.
D. The client’s symptoms are associated with a respiratory and not a metabolic problem;
thus metabolic acidosis is not correct.

39. The client is hospitalized with a history of chronic emesis from purging. Based on the
client’s history, the nurse should monitor for which complication?
A. Hyperkalemia
B. Hyperchloremia
C. Metabolic alkalosis
D. Metabolic acidosis

ANSWER: C

A. Hypokalerrria, not hyperkalemia, is caused by diarrhea and vomiting.

B. Hypochloremia, not hyperchlorernia, is associated with volume depletion due to
vomiting.
 C. The nurse should monitor for metabolic alkalosis, which occurs when there is a loss of
acid such as with prolonged vomiting.
D. Metabolic alkalosis, not metabolic acidosis, occurs with prolonged vomiting.

40. The client has arterial blood results of pH 7.50, Paco2 35 mm Hg, and HCO3 30 mmol/L.
Which musing interpretation of the client’s acid-base imbalance is correct?
A. Respiratory alkalosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Metabolic acidosis

ANSWER: B

A. Respiratory alkalosis would result in a Paco2 lower than the normal range of 35 to 45
mm Hg.
B. A pH of 7.50 indicates alkalosis. The HCO3 of 30 mmol/L is above the normal range of 20
to 24 mmol/L, indicating the primary acid-base imbalance is metabolic alkalosis.
C. Respiratory acidosis would result in a pH less than 7.35 and an increased Paco2.
D. Metabolic acidosis would result in a pH less than 7.35 and an increased HCO3.

41. The nurse is caring for the client with respiratory acidosis. Which ABG results should
indicate to the nurse that the client’s kidneys have compensated for the imbalance?

ANSWER: B

A. A normal pH with increased Paco2 and HCO3 indicates metabolic alkalosis with
respiratory compensation.
B. A normal pH with increased Paco2 and HCO3 indicates respiratory acidosis with
metabolic compensation. The increased Paco2, results in respiratory acidosis. The
kidneys respond slowly by retaining HCO3, which is a base. The normal HCO3 is 20 to 24
mmol/L. Full compensation occurs when the pH returns to the normal range of 7.35 to
7.45.
C. An increased pH, normal Paco2, and increased HCO3 indicate metabolic alkalosis.
D. A pH of 7.44, Pacoz of 45 mm Hg, and HCO3 of 24 mmth are normal blood gas findings.
42. The client with DKA has a blood sugar of 320 mg/dL, a respiratory rate of 32
breaths/min, and a deep, regular respiratory effort. The nurse should implement
interventions for which acid-base imbalance?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

ANSWER: C

A. DKA is a metabolic, not a respiratory, acid-base imbalance.

B. DKA is a metabolic, not a respiratory, acid—base imbalance.
C. The nurse should implement interventions for treating metabolic acidosis. In DKA, the
elevated blood sugar results in polyuria with a resultant decrease in the pH and HCO3
levels. Kussmaul respirations allow the body to “blow off” excess carbon dioxide to
compensate for the acidotic state and the decreased HCO3.
D. As DKA implies, it is an acidotic, not an alkalotic, imbalance.

43. The nurse is monitoring for complications when caring for the client with a pulmonary
embolism. Which ABG findings should indicate to the nurse that the client has respiratory
alkalosis?

ANSWER: A

A. In respiratory alkalosis the pH is greater than 7.45 (normal is 7.35 to 7.45). The Paco2 is
less than 35 mm Hg (the normal is 35 to 45 mm Hg). The HCO3 is normal (22—26
mEq/L). Because pulmonary emboli interfere with gas exchange, the respiratory center
is stimulated to meet oxygenation demands. The tachypnea produces respiratory
alkalosis.
B. The blood gas findings of pH 7.35, Paco2 35 mm Hg, and I-ICO3 22 mEq/L are all nomial.
C. The elevated pH of 7.50 and increased HCO3 of 28 mEq/L indicate metabolic alkalosis.
D. The decreased pH of 7.32 and increased Paco2 of 48 mm Hg indicate respiratory
acidosis.

44. The nurse assigned to care for multiple clients is reviewing the laboratory reports. Based
on the information provided, in which sequence should the nurse assess the clients?
Prioritize the order in which the nurse should plan to assess the clients.
a. The client with renal insufficiency whose serum potassium level is 5.2 mEq/L
b. The client with hyperemesis whose serum sodium level is 122 mEq/L
c. The client recovering following head trauma whose scrum osmolality is 290 mOsm/kg
 d. The client with DM whose ABG results are pH = 7.22, Paco2= 35 mm Hg, HCO3 = 15
mEq/L

ANSWER: D, B, A, C

D. The client with DM whose ABG results are pH = 7.22, Paco2 = 35 mm Hg, HCO3 = 15 mEq/L. The ABC
results indicate metabolic acidosis. A compensatory mechanism will include Kussmaul respirations to
eliminate excess acid. Airway assessment is priority, and further assessment is needed to determine the
underlying cause for the metabolic acidosis.

B. The client with hyperemesis whose serum sodium level is 122 mEq/L. This client is experiencing
severe hyponatremia with serum sodium below the normal range of 135 to 145 mEq/L and is at risk of
seizures. Safety is a major concern.

A. The client with renal insufficiency whose serum potassium level is 5.2 mEq/L. This client’s serum
potassium level is slightly above the normal of 3.5 to 5.0 mEq/L and should be assessed for signs of
hyperkalemia.

C. The client recovering following head trauma whose serum osmolality is 290 mOsm/kg. The serum
osmolality level is normal (normal is 285—295 mOsm/kg). This client is the most stable.

45. The nurse analyzed the ABG results for the newly admitted client with ethylene glycol
toxicity (sec exhibit). Which interventions should the nurse plan to implement? Select all
that apply.

A. Mechanical hyperventilation
B. Giving sodium bicarbonate
C. Initiating hemodialysis
D. Giving an intravenous (IV) colloid
E. Giving IV potassium replacement
F. Starting supplemental oxygen

ANSWER: B, C, E, F

A. Mechanical ventilation may be needed to support the client, but not with
hyperventilation. The Paco2 is below normal. This occurred because the client would
 initially hyperventilate as a compensatory mechanism to return the acid-base balance
back to normal by increasing the loss of Paco2 through the lungs. At this time,
mechanical hyperventilation will increase the loss of carbonic acid and further lower the
Paco2 level without correcting the problem.
B. The nurse should plan to give sodium bicarbonate. The ABGs reveal partially
compensated metabolic acidosis with the pH below the normal of 7.35 to 7.45, the
Pacoz below the normal of 35 to 45 mm Hg, and the HCO3 below the normal of 22 to 26
mEq/L. Ethylene glycol toxicity can produce metabolic acidosis. Half of the total
bicarbonate deficit should be replaced during the first few hours of therapy with sodium
bicarbonate.
C. Hemodialysis is an option for correcting a severe metabolic acidosis associated with
ethylene glycol toxicity.
D. Crystalloids, not colloids, would be used for fluid replacement.
E. The nurse should plan to give an IV potassium replacement. Initially, as a compensatory
mechanism in metabolic acidosis, potassium shifts out of the vascular compartment and
into the cell in exchange for hydrogen ion to reestablish acid-base balance. Until full
compensation occurs, potassium replacement is needed.
F. The Pao2 is low, so supplemental oxygen is needed.