2. A homeless client is brought into the emergency department with indications of extremely poor nutrition.

Arterial blood gas levels are assessed, and the nurse anticipates that this client will demonstrate which of the following results? 1. pH 7.3, PaCO2 38 mm Hg, HCO3 19 mEq/L 2. pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L 3. pH 7.35, PaCO2 35 mm Hg, HCO3 24 mEq/L 4. pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L ANS: 1 Metabolic acidosis may be found in cases of starvation. The clients pH is below the normal of 7.35 (at 7.3), the PaCO2 is in the normal range of 35 to 45 mm Hg (at 38 mm Hg), and the HCO3 is below the normal of 22 mEq/L (at 19 mEq/L). These findings demonstrate metabolic acidosis. Values of pH 7.5, PaCO2 34 mm Hg, HCO3 20 mEq/L are consistent with respiratory alkalosis, compensated, which would not be typical of malnutrition. Values of pH 7.52, PaCO2 48 mm Hg, HCO3 28 mEq/L are consistent with metabolic alkalosis, compensated, which would not be an expected finding with extremely poor nutrition.

3. When a clients serum sodium level is 120 mEq/L, the priority nursing assessment is to monitor the status of which body system? 1. Neurological 2. Gastrointestinal 3. Pulmonary 4. Hepatic ANS: 1 Because sodium is necessary for nerve impulse transmission, the priority nursing assessment with hyponatremia is the neurological system.

4. An 8-year-old is admitted to the pediatric unit with pneumonia. On assessment the nurse notes that the child is warm and flushed, is lethargic, has difficulty breathing, and has moist rales. The nurse determines that the child is suffering from: 1. Metabolic acidosis 2. Respiratory acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis ANS: 2 These assessment findings (i.e., warm and flushed skin, lethargy, and medical diagnosis of pneumonia) are indicative of respiratory acidosis. Lethargy and flushed skin may be seen with metabolic acidosis, but this child has a respiratory problem with difficulty breathing, which is consistent with respiratory acidosis.

5. Arterial blood gas levels are obtained for the client. If the clients results are pH 7.48, CO2 42 mm Hg, and HCO3 32 mEq/L, the client is exhibiting which one of the following acid-base imbalances? 1. Metabolic acidosis 2. Respiratory acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis ANS: 4 The clients pH is elevated at 7.48 (normal 7.35 to 7.45), the CO2 is normal at 42 mm Hg (normal 35 to 45 mm Hg), and the bicarbonate is elevated at 32 mEq/L (normal 22 to 26 mEq/L). The client is experiencing metabolic alkalosis. In metabolic acidosis the clients pH would be below 7.35, and the bicarbonate would be below 22 mEq/L. In respiratory acidosis the clients pH would be below 7.35, and the CO2 would be elevated above 45 mm Hg. In respiratory alkalosis the clients pH would be above 7.45, and the CO2 would be below 35 mm Hg.

6. The nurse is aware that the compensating mechanism that is most likely to occur in the presence of respiratory acidosis is: 1. Hyperventilation to decrease the CO2 levels 2. Hypoventilation to increase the CO2 levels 3. Retention of HCO3 by the kidneys to increase the pH level 4. Excretion of HCO3 by the kidneys to decrease the pH level ANS: 3 The compensating mechanism in the presence of respiratory acidosis is retention of bicarbonate by the kidneys to increase the pH level. Hyperventilation would be the compensating mechanism in metabolic acidosis to decrease CO2 levels. Hypoventilation would be the compensating mechanism in metabolic alkalosis to increase CO2 levels. The compensating mechanism in the presence of metabolic alkalosis is excretion of bicarbonate to decrease the pH level 7. Of all of the following clients, the nurse recognizes that the individual who is most at risk for a fluid volume deficit is: 1. A 6-month-old learning to drink from a cup 2. A 12-year-old who is moderately active in 80 F weather 3. A 42-year-old with severe diarrhea 4. A 90-year-old with frequent headaches ANS: 3

14. For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the following signs and symptoms? 1. Weak, thready pulse 2. Hypertension 3. Dry mucous membranes 4. Flushed skin ANS: 2 Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and flushed skin are both symptomatic of fluid volume deficit, not excess 17. For a child who has ingested the remaining contents of an aspirin bottle, the nurse suspects signs and symptoms consistent with: 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis ANS: 4 A salicylate overdose may cause respiratory alkalosis because of hyperventilation. Aspirin overdose is not associated with metabolic acidosis, metabolic alkalosis or respiratory acidosis.

18. The single best indicator of fluid status is the nurses assessment of the clients: 1. Skin turgor 2. Intake and output 3. Serum electrolyte levels 4. Daily weight ANS: 4 Daily weights are the single most important indicator of fluid status. Skin turgor is a measure of hydration, as are intake and output. Serum electrolyte levels help monitor fluid status; however, daily weights are the single best indicator of a clients fluid status. 22. The nurse anticipates that the client with a fluid volume excess will manifest a(n): 1. Increased urine specific gravity 2. Decreased body weight 3. Increased blood pressure 4. Decreased pulse strength

ANS: 3 Hypertension is manifested with fluid volume excess. The urine specific gravity would be decreased with fluid volume excess. The nurse would anticipate an increased urine specific gravity with fluid volume deficit, as well as an increase in body weight and an increase in pulse strength. 28. The nurse recognizes which of the following clients is at the greatest risk for dehydration? 1. A 35-year-old client diagnosed with Crohns disease 2. A 15-year-old client who is following a low-carbohydrate diet 3. A 2-year-old client diagnosed with an allergy to milk proteins 4. A 79-year-old client who has been diagnosed with advanced Alzheimers disease ANS: 4 Infants, clients with neurological or psychological problems, and some older adults who are unable to perceive or respond to the thirst mechanism are at risk for dehydration. 2. A client experiencing respiratory alkalosis as a result of asthma is likely to present with which of the following clinical signs? (Select all that apply.) 1. A respiratory rate of 36 breaths per minute 2. Complaints of numbness in fingers and toes 3. Dizziness when attempting to sit upright 4. Difficulty holding a cup because of tremors 5. An irregular heartbeat on an electrocardiogram (ECG) 6. Warm, flushed skin ANS: 1, 2, 3, 4 Physical examination of a client experiencing respiratory alkalosis may reveal dizziness, confusion, dysrhythmias, tachypnea, numbness and tingling of extremities, convulsions, and coma. 3. A client experiencing respiratory acidosis as a result of pneumonitis is likely to present with which of the following clinical signs? (Select all that apply.) 1. Tingling fingers 2. Difficult to arouse 3. Warm, flushed skin 4. Tremors in the hands 5. Reporting a terrible headache 6. Repeatedly asking Where am I? ANS: 2, 3, 4, 5, 6

4. A client experiencing diabetic ketoacidosis is likely to present with which of the following clinical signs? (Select all that apply.) 1. Red, flushed skin 2. Verbally aggressive 3. Complaints of dry mouth 4. Crackles in both lung fields 5. Oral temperature of 102.8 F 6. Requiring frequent linen changes ANS: 1, 2, 3, 5, 6 Physical examination of a client experiencing diabetic ketoacidosis may reveal dry and sticky mucous membranes, flushed and dry skin, thirst, elevated body temperature, irritability, convulsions, and coma. The remaining option is not reflective of diabetic ketoacidosis. 6. Which of the following clients is at risk for fluid, electrolyte, and acid-base imbalances? (Select all that apply.) 1. 50-year-old with hypertension 2. 36-year-old with schizophrenia 3. 40-year-old with a fractured femur 4. 15-month-old with diarrhea for 2 days 5. 76-year-old with advanced Alzheimers disease 6. 25-year-old with partial-thickness burns over 40% of the body ANS: 1, 3, 4, 5, 6 When there is a loss of body fluids because of burns, illnesses, or trauma, the client is also at risk for electrolyte imbalance. In addition, electrolyte imbalance may occur from vomiting, diarrhea, or a clients inability to communicate fluid needs, resulting in acidbase disturbances. Trauma, disease, and medications (e.g., diuretics) all contribute to alterations in fluid, electrolyte, and acid-base balance. Schizophrenia itself is not a risk for fluid, electrolyte, or acid-base imbalance