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LeMone/Burke/Bauldoff, Medical-Surgical Nursing 5th Edition Test Bank Copyright 2011 by Pearson Education, Inc.

LeMone/Burke/Bauldoff, Medical-Surgical Nursing 5th Edition Test Bank Chapter 10 Question 1 Type: MCSA

What is the nurses primary concern regarding fluid and electrolytes when caring for an elderly patient who is intermittently confused?

1. risk of dehydration

2. risk of kidney damage

3. risk of stroke

4. risk of bleeding

Correct Answer: 1

Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a patient with an altered level of consciousness, there is an increased risk of dehydration and high serum osmolality.

Rationale 2: The risks for kidney damage are not specifically related to aging or fluid and electrolyte issues.

Rationale 3: The risk of stroke is not specifically related to aging or fluid and electrolyte issues.

Rationale 4: The risk of bleeding is not specifically related to aging or fluid and electrolyte issues.

Global Rationale: As an adult ages, the thirst mechanism declines. Adding this in a patient with an altered level of consciousness, there is an increased risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. Question 2 Type: MCSA

The nurse is planning care for a patient with severe burns. Which of the following is this patient at risk for developing?

1. intracellular fluid deficit


2. intracellular fluid overload

3. extracellular fluid deficit

4. interstitial fluid deficit

Correct Answer: 1

Rationale 1: Because this patient 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 and nucleus. Because this patient 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 patient 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 patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.

Global Rationale: Because this patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. The intracellular fluid is all fluids that exist within the cell cytoplasm and nucleus. The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. Question 3 Type: MCSA

A patient, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following?

1. the bodys natural compensatory mechanisms

2. pharmacological effects of a diuretic

3. effects of rapidly infused intravenous fluids

4. cardiac failure


Correct 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 and heart.

Rationale 2: A diuretic would cause further fluid loss, and 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 patient.

Global Rationale: 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 and heart. A diuretic would cause further fluid loss, and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. The manifestations reported are not indicative of cardiac failure in this patient. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. Question 4 Type: MCSA

A pregnant patient is admitted with excessive thirst, increased urination, and 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

Correct Answer: 1

Rationale 1: The patient with excessive thirst, increased urination and a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the patient&s excess volume loss that can increase the serum levels of sodium.

Rationale 2: Excess Fluid Volume is not an issue for patients 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.

Global Rationale: The patient with excessive thirst, increased urination and a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the patients excess volume loss that can increase the serum levels of sodium. Excess Fluid Volume is not an issue for patients with diabetes insipidus, especially during the early stages of treatment. Imbalanced Nutrition and Ineffective Tissue Perfusion do not apply. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. Question 5 Type: MCSA

A patient recovering from surgery has an indwelling urinary catheter. The nurse would contact the patients primary healthcare provider with which of the following 24-hour urine output volumes?

1. 600 milliliters

2. 750 milliliters

3. 1000 milliliters

4. 1200 milliliters

Correct Answer: 1

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

Rationale 2: A minimum of 720 milliliters over a 24-hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours).



Global Rationale: A urine output of less than 30 milliliters per hour must be reported to the primary healthcare provider. This indicates inadequate renal perfusion, placing the patient at increased risk for acute renal failure and


inadequate tissue perfusion. A minimum of 720 milliliters over a 24-hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours). Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 6 Type: MCSA

A patient 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

Correct Answer: 1

Rationale 1: Antidiuretic hormone and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system.

Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, and stress upon the heart and 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.

Global Rationale: Antidiuretic hormone and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system. Liver failure is not anticipated related to postoperative intravenous fluid administration. Seizure activity would more commonly be associated with electrolyte imbalances. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment


Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 7 Type: MCSA

A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need which of the following precautions implemented?

1. seizure

2. infection

3. neutropenic

4. high-risk fall

Correct Answer: 1

Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, and having an oral airway at the bedside would be included.

Rationale 2: Infection precautions not specifically indicated for a patient with hyponatremia.

Rationale 3: Neutropenic precautions not specifically indicated for a patient with hyponatremia.

Rationale 4: High-risk fall precautions not specifically indicated for a patient with hyponatremia.

Global Rationale: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, and having an oral airway at the bedside would be included. Infection or neutropenic precautions and high-risk fall precautions are not specifically indicated for a patient with hyponatremia. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 8 Type: MCSA

A patient is diagnosed with hypokalemia. After reviewing the patients current medications, which of the following might have contributed to the patients health problem?

1. corticosteroid


2. thiazide diuretic

3. narcotic

4. muscle relaxer

Correct Answer: 1

Rationale 1: Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting diuretics, amphotericin B, and 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.

Global Rationale: Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting diuretics, amphotericin B, and large doses of some antibiotics. Excessive sodium is lost with the use of thiazide diuretics. Narcotics and muscle relaxers do not typically affect electrolyte balance. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 9 Type: MCSA

A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which of the following?

1. hyperkalemia

2. hypokalemia

3. hypercalcemia

4. hypocalcemia

Correct 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 and ECG changes.

Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide.

Rationale 3: Hypercalcemia has been associated with thiazide diuretics.

Rationale 4: Hypocalcemia is seen in patients who have received many units of citrated blood and is not associated with diuretic use.

Global Rationale: 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 and ECG changes. Hypokalemia is seen in non-potassium diuretics such as furosemide. Hypercalcemia has been associated with thiazide diuretics. Hypocalcemia is seen in patients who have received many units of citrated blood and is not associated with diuretic use. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 10 Type: MCSA

The nurse is planning care for a patient with fluid volume overload and hyponatremia. Which of the following should be included in this patients plan of care?

1. Restrict fluids.

2. Administer intravenous fluids.

3. Provide Kayexalate.

4. Administer intravenous normal saline with furosemide.

Correct Answer: 1

Rationale 1: The nursing care for a patient with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase and 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 and hypernatremia.


Rationale 3: Kayexalate is used in patients with hyperkalemia.

Rationale 4: The administration of normal saline with furosemide is used to increase calcium secretion.

Global Rationale: The nursing care for a patient with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase and to prevent the sodium level from dropping further due to dilution. The administration of intravenous fluids would be indicated in fluid volume deficit and hypernatremia. Kayexalate is used in patients with hyperkalemia. The administration of normal saline with furosemide is used to increase calcium secretion. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 11 Type: MCSA

When caring for a patient diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the patient?

1. other electrolyte disturbances

2. hypertension

3. visual disturbances

4. drug toxicity

Correct Answer: 1

Rationale 1: The patient diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels.

Rationale 2: The patient with hypocalcemia may exhibit hypotension, and not hypertension.

Rationale 3: Visual disturbances do not occur with hypocalcemia.

Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.

Global Rationale: The patient diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels. The patient with hypocalcemia may exhibit hypotension, and not hypertension. Visual disturbances do not occur with hypocalcemia. Hypercalcemia is more commonly caused by drug toxicities. Cognitive Level: Analyzing


Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 12 Type: MCSA

A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this patients plan of care?

1. Request a dietitian consult for selecting foods high in phosphorous.

2. Provide aluminum hydroxide antacids as prescribed.

3. Instruct patient to avoid poultry, peanuts, and seeds.

4. Instruct to avoid the intake of sodium phosphate.

Correct Answer: 1

Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause and promoting a high phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans and peas, eggs, fish, organ meats, Brazil nuts and peanuts, poultry, seeds and whole grains.

Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided.

Rationale 3: Poultry, peanuts, and seeds are part of a high phosphate diet.

Rationale 4: Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate.

Global Rationale: Treatment of hypophosphatemia includes treating the underlying cause and promoting a high phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans and peas, eggs, fish, organ meats, Brazil nuts and peanuts, poultry, seeds and whole grains. Phosphate-binding antacids, such as aluminum hydroxide, should be avoided. Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 13 Type: MCSA


When analyzing an arterial blood gas report of a patient with COPD and 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.

Correct 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.

Global Rationale: The kidneys will compensate for a respiratory disorder by retaining bicarbonate. Excreting bicarbonate causes acidosis to develop. Retaining carbon dioxide causes respiratory acidosis. Excreting carbon dioxide causes respiratory alkalosis. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Describe the causes and effects of acid-base imbalances. Question 14 Type: MCSA

The nurse is caring for a patient diagnosed with renal failure. Which of the following does the nurse recognize as compensation for the acid-base disturbance found in patients with renal failure?

1. The patient breathes rapidly to eliminate carbon dioxide.

2. The patient will retain bicarbonate in excess of normal.

3. The pH will decrease from the present value.

4. The patients oxygen saturation level will improve.

Correct 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 and compensates for the acidosis.

Rationale 2: Because compensation must be performed by the system other than the affected system, the patient 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 patient with renal failure.

Global Rationale: In metabolic acidosis compensation is accomplished through increased ventilation or blowing off C02. This raises the pH by eliminating the volatile respiratory acid and compensates for the acidosis. Because compensation must be performed by the system other than the affected system, the patient cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal bicarbonate value. Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation. Oxygenation disturbance is not part of the acid-base status of the patient with renal failure. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the causes and effects of acid-base imbalances. Question 15 Type: MCSA

When caring for a group of patients, the nurse realizes that which of the following health problems increases the risk for metabolic alkalosis?

1. bulimia

2. dialysis

3. venous stasis ulcer

4. COPD

Correct Answer: 1

Rationale 1: Metabolic alkalosis is cause by vomiting, diuretic therapy or nasogastric suction, among others. A patient with bulimia may engage in vomiting or indiscriminate use of diuretics.

Rationale 2: A patient 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 patient diagnosed with COPD typically has hypercapnea and respiratory acidosis.

Global Rationale: Metabolic alkalosis is cause by vomiting, diuretic therapy or nasogastric suction, among others. A patient with bulimia may engage in vomiting or indiscriminate use of diuretics. A patient receiving dialysis has kidney failure, which causes metabolic acidosis. A venous stasis ulcer does not result in an acid-base disorder. The patient diagnosed with COPD typically has hypercapnea and respiratory acidosis. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the causes and effects of acid-base imbalances. Question 16 Type: MCSA

The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. The nurse would anticipate which initial intervention to correct this problem?

1. Encourage the patient to breathe in and out slowly into a paper bag.

2. Immediately administer oxygen via a mask and monitor oxygen saturation.

3. Prepare to start an intravenous fluid bolus using isotonic fluids.

4. Anticipate the administration of intravenous sodium bicarbonate.

Correct Answer: 1

Rationale 1: This patient is exhibiting signs of hyperventilation that is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the patient to retain carbon dioxide and lower oxygen levels to normal, correcting the cause of the problem.

Rationale 2: The oxygen levels are high, so oxygen is not indicated, and 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.

Global Rationale: This patient is exhibiting signs of hyperventilation that is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the patient to retain carbon dioxide and lower oxygen levels to normal, correcting the cause of the problem. The oxygen levels are high, so oxygen is not indicated, and would exacerbate the problem if given. Intravenous fluids would not be the initial intervention. Not enough


information is given to determine the need for intravenous fluids. Bicarbonate would be contraindicated as the pH is already high. Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe the causes and effects of acid-base imbalances. Question 17 Type: MCSA

A patient is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the patient 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.

Correct Answer: 2

Rationale 1: Potassium does not sustain respiratory function.

Rationale 2: Electrolytes have many functions. They assist in regulating water balance, help regulate and maintain acid-base balance, contribute to enzyme reactions, and 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.

Global Rationale: Electrolytes have many functions. They assist in regulating water balance, help regulate and maintain acid-base balance, contribute to enzyme reactions, and are essential for neuromuscular activity. Potassium does not sustain respiratory function. Intravenous fluids are used to keep venous access not potassium. Urinary output is impacted by fluid intake not potassium. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. Question 18


Type: MCSA

An elderly patient does not complain of thirst. What should the nurse do to assess that this patient 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.

Correct Answer: 3

Rationale 1: It is inappropriate to seek an IV at this stage.

Rationale 2: There is no indication the patient is experiencing pulmonary complications thus a cheat x-ray is no indicated.

Rationale 3: The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration and hyperosmolality. The nurse should check the patients urine for osmolality as a first step in determining hydration status before other detailed and invasive testing is done.

Rationale 4: There is no data to support the need for a brain scan.

Global Rationale: The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration and hyperosmolality. The nurse should check the patients urine for osmolality as a first step in determining hydration status before other detailed and invasive testing is done. It is inappropriate to seek an IV at this stage. There is no indication the patient is experiencing pulmonary complications thus a cheat x-ray is no indicated. There is no data to support the need for a brain scan. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. Question 19 Type: MCSA

An elderly patient who is being medicated for pain had an episode of incontinence. The nurse realizes that this patient 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, and 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.

Global Rationale: Functional changes of aging also affect fluid balance. Fear of incontinence can lead to self-limiting of fluid intake. 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, and laxatives), are at greatest risk for fluid volume imbalance. There is inadequate information to support the risk of over-hydration, fecal incontinence, or a stroke. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. Question 20 Type: FIB

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

Standard Text:

Correct Answer: 10

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

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub:


Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 21 Type: MCSA

A postoperative patient 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 patient?

1. Assist the patient to maintain a standing position for several minutes.

2. This patient should be on bed rest.

3. Assist the patient to move into different positions in stages.

4. Contact physical therapy to provide a walker.

Correct Answer: 3

Rationale 1: The patient should avoid prolonged standing.

Rationale 2: Bed rest can promote skin breakdown.

Rationale 3: The patient needs to be taught how to avoid orthostatic hypotension which would include assisting and teaching the patient how to move from one position to another in stages.

Rationale 4: A physician referral is needed for physical therapy intervention and is not indicated in this situation.

Global Rationale: The patient needs to be taught how to avoid orthostatic hypotension which would include assisting and teaching the patient how to move from one position to another in stages. The patient should avoid prolonged standing. Bed rest can promote skin breakdown. A physician referral is needed for physical therapy intervention and is not indicated in this situation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 22 Type: MCSA

A postoperative patient is diagnosed with fluid volume overload. Which of the following should the nurse assess in this patient?


1. poor skin turgor

2. decreased urine output

3. distended neck veins

4. concentrated hemoglobin and hematocrit levels

Correct 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 and 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 and blood urea nitrogen (BUN); and possible cerebral edema.

Rationale 4: Increased hemoglobin and hematocrit values are associated with fluid volume deficit.

Global Rationale: Circulatory overload causes manifestations such as a full, bounding pulse; distended neck and 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 and blood urea nitrogen (BUN); and possible cerebral edema. The other answers indicate a fluid volume deficit. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 23 Type: MCSA

An elderly patient is at home after being diagnosed with fluid volume overload. Which of the following should the home care nurse instruct this patient 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.


Correct Answer: 1

Rationale 1: The home care nurse should instruct this patient about ways to decrease dependent edema, which include wearing support hose, elevating feet when in a sitting position, and resting in a recliner or bed with extra pillows.

Rationale 2: The patient 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 patient to use extra pillows to keep the head up while sleeping.

Global Rationale: The home care nurse should instruct this patient about ways to decrease dependent edema, which include wearing support hose, elevating feet when in a sitting position, and resting in a recliner or bed with extra pillows. As long as the shoes are well fitting, there is not reason to avoid wearing them. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 24 Type: MCSA

A patient with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this patient could possibly have which of the following electrolyte imbalances?

1. hypokalemia

2. hypernatremia

3. carbon dioxide

4. magnesium

Correct 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 patient.


Rationale 4: Magnesium abnormalities are not normally seen in this type of patient.

Global Rationale: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia. The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations in potassium levels. Carbon dioxide and magnesium abnormalities are not anticipated for this patient. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 25 Type: MCSA

An elderly patient comes into the clinic with the complaint of watery diarrhea for several days with abdominal and muscle cramping. The nurse realizes that this patient is demonstrating which of the following?

1. hypernatremia

2. hyponatremia

3. fluid volume excess

4. hyperkalemia

Correct Answer: 2

Rationale 1: Hypernatremia is associated with fluid retention and overload. Fluid volume excess is associated with hypernatremia.

Rationale 2: This elderly patient has watery diarrhea, which contributes to the loss of sodium. The abdominal and muscle cramps are manifestations of a low serum sodium level.

Rationale 3: This patient is more likely to develop clinical manifestations associated with fluid volume deficit.

Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias.

Global Rationale: This elderly patient has watery diarrhea, which contributes to the loss of sodium. The abdominal and muscle cramps are manifestations of a low serum sodium level. Hypernatremia is associated with fluid retention and overload. Fluid volume excess is associated with hypernatremia. Hyperkalemia is associated with cardiac dysrhythmias. Cognitive Level: Analyzing Client Need: Physiological Integrity


Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 26 Type: MCSA

A patient is admitted with hypernatremia caused by being stranded on a boat in the Atlantic Ocean for five days without a fresh water source. Which of the following is this patient at risk for developing?

1. pulmonary edema

2. atrial dysrhythmias

3. cerebral bleeding

4. stress fractures

Correct Answer: 3

Rationale 1: Pulmonary edema is not associated with dehydration.

Rationale 2: Atrial dysrhythmias are not a factor for this patient.

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, and lead to cerebral vascular bleeding.

Rationale 4: There have been no activities to support the development or occurrence of stress fractures.

Global Rationale: 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, and lead to cerebral vascular bleeding. The patient in question would face dehydration. Pulmonary edema is not associated with dehydration. Atrial dysrhythmias are not a factor for this patient. There have been no activities to support the development or occurrence of stress fractures. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 27 Type: MCSA


The nurse is admitting a patient 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

Correct Answer: 4

Rationale 1: This patient will be less likely to develop a calcium imbalance.

Rationale 2: This patient will be less likely to develop a magnesium imbalance.

Rationale 3: This patient 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 can lead to potentially serious elevations of serum potassium levels.

Global Rationale: Because the kidneys are the principal organs involved in the elimination of potassium, renal failure can lead to potentially serious elevations of serum potassium levels. Imbalances in calcium, magnesium, and phosphorus are less likely. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 28 Type: MCSA

A patient who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following does the nurse realize might occur with this patient?

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.


Correct Answer: 1

Rationale 1: Hypokalemia increases the risk of digitalis toxicity in patients 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.

Global Rationale: Hypokalemia increases the risk of digitalis toxicity in patients who receive this drug for heart failure. More digoxin is not needed. A diuretic may cause further fluid loss. There is inadequate information to assess for concerns related to fluid volume deficits. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 29 Type: MCSA

A patient 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.

Correct 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 patients intravenous line.

Rationale 4: The nurse should administer diluted potassium into the patients intravenous line.

Global Rationale: The intravenous route is the recommended route for diluted potassium. Never administer undiluted potassium directly into a vein. It is not administered rectally. It is not given via IM injection.


Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 30 Type: MCSA

An elderly patient with a history of sodium retention arrives to the clinic with the complaints of heart skipping beats and leg tremors. Which of the following should the nurse ask this patient 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?

Correct Answer: 4

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

Rationale 2: The patients bowel habits are not of concern at this time.

Rationale 3: The cardiac and musculoskeletal discomforts being reported are not consistent with physical exertion.

Rationale 4: The patient has a history of sodium retention and might think that a salt substitute can be used. Advise patients who are taking a potassium supplement or potassium-sparing diuretic to avoid salt substitutes, which usually contain potassium.

Global Rationale: The patient has a history of sodium retention and might think that a salt substitute can be used. Advise patients who are taking a potassium supplement or potassium-sparing diuretic to avoid salt substitutes, which usually contain potassium. Although this patient may be prescribed digoxin this is not the primary focus of this question. The patients bowel habits are not of concern at this time. The cardiac and musculoskeletal discomforts being reported are not consistent with physical exertion. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance.


Question 31 Type: MCSA

A 35-year-old female patient comes into the clinic postoperative parathyroidectomy. Which of the following should the nurse instruct this patient?

1. Drink one glass of red wine per day.

2. Avoid the sun.

3. Milk and milk-based products will ensure an adequate calcium intake.

4. Red meat is the protein source of choice.

Correct Answer: 3

Rationale 1: This patient should avoid alcohol.

Rationale 2: This patient can benefit from sun exposure.

Rationale 3: This patient is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk and milk-based products.

Rationale 4: Protein monitoring is not indicated.

Global Rationale: This patient is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk and milk-based products, have adequate exposure to the sun, and avoid alcoholic beverages. The greatest dietary concern for this patient is the adequacy of calcium intake. Protein monitoring is not indicated. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 32 Type: MCSA

A patient is admitted for treatment of hypercalcemia. The nurse realizes that this patients intravenous fluids will most likely be which of the following?

1. dextrose 5% and water

2. dextrose 5% and ? normal saline


3. dextrose 5% and ? normal saline

4. normal saline

Correct Answer: 4

Rationale 1: If isotonic saline is not used, the patient 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.

Global Rationale: Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys. If isotonic saline is not used, the patient is at risk for hyponatremia in addition to the hypercalcemia. The remaining solutions are hypotonic and do not have adequate sodium content. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 33 Type: MCSA

A 28-year-old male patient is admitted with diabetic ketoacidosis. The nurse realizes that this patient will have a need for which of the following electrolytes?

1. sodium

2. potassium

3. calcium

4. magnesium

Correct Answer: 4

Rationale 1: The patient will not typically have an increased need for sodium.

Rationale 2: The patient will not typically have an increased need for potassium.


Rationale 3: The patient will not typically have an increased need for calcium.

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

Global Rationale: One risk factor for hypomagnesaemia is an endocrine disorder, including diabetic ketoacidosis. The patients levels of sodium, potassium, and calcium are not the primary needs of this patient. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 34 Type: MCSA

An elderly patient with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypomagnesaemia?

1. hypotension, warmth, and sweating

2. nausea and vomiting

3. hyperreflexia

4. excessive urination

Correct Answer: 1

Rationale 1: Elevations in magnesium levels are accompanied by hypotension, warmth, and sweating.

Rationale 2: Lower levels of magnesium are associated with nausea and vomiting.

Rationale 3: Lower levels of magnesium are associated and hyperreflexia.

Rationale 4: Urinary changes are not noted.

Global Rationale: Elevations in magnesium levels is accompanied by hypotension, warmth, and sweating. Lower levels are associated with nausea and vomiting, hypertension, and hyperreflexia. Urinary changes are not noted. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus.


Question 35 Type: MCSA

A patient is admitted with burns over 50% of his body. The nurse realizes that this patient is at risk for which of the following electrolyte imbalances?

1. hypercalcemia

2. hypophosphatemia

3. hypernatremia

4. hypermagnesemia

Correct Answer: 2

Rationale 1: Patients who experience burns are not at an increased risk for developing increased blood calcium levels.

Rationale 2: Causes of hypophosphatemia include stress responses and extensive burns.

Rationale 3: Patients who experience burns are not at an increased risk for developing increased blood sodium levels.

Rationale 4: Patients who experience burns are not at an increased risk for developing increased blood magnesium levels.

Global Rationale: Causes of hypophosphatemia include stress responses and extensive burns. Patients who experience burns are not at an increased risk for elevated levels of calcium, sodium, or magnesium. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 36 Type: MCSA

A patient is diagnosed with hyperphosphatemia. The nurse realizes that this patient might also have an imbalance of which of the following electrolytes?

1. calcium

2. sodium


3. potassium

4. chloride

Correct Answer: 1

Rationale 1: Excessive serum phosphate levels cause few specific symptoms. The effects of high serum phosphate levels on nerves and 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, and the ionized serum calcium level falls.

Rationale 2: There is no direct correlation between levels of phosphorus and that of sodium.

Rationale 3: There is no direct correlation between levels of phosphorus and that of potassium.

Rationale 4: There is no direct correlation between levels of phosphorus and that of chloride.

Global Rationale: Excessive serum phosphate levels cause few specific symptoms. The effects of high serum phosphate levels on nerves and 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, and the ionized serum calcium level falls. There is no direct correlation between levels of phosphorus and that of sodium, potassium, or chloride. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 37 Type: MCMA

The nurse is reviewing a patients blood pH level. Which of the systems in the body regulate blood pH?

Standard Text: Select all that apply.

1. renal

2. cardiac

3. buffers

4. respiratory

Correct Answer: 1,3


Rationale 1: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, and the renal system.

Rationale 2: The cardiac system is responsible for circulating blood to the body. It does not help maintain the bodys pH.



Global Rationale: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, and the renal system. The cardiac system is responsible for circulating blood to the body. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the causes and effects of acid-base imbalances. Question 38 Type: MCSA

The nurse observes a patients respirations and notes that the rate is 30 per minute and the respirations are very deep. The metabolic disorder this patient might be demonstrating is which of the following?

1. hypernatremia

2. increasing carbon dioxide in the blood

3. hypertension

4. pain

Correct Answer: 2

Rationale 1: Hypernatremia is associated with profuse sweating and 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 and depth of respiration increase. The increased rate and depth of lung ventilation eliminates carbon dioxide from the body, and carbonic acid levels fall, which brings the pH to a more normal range.

Rationale 3: The respiratory rate in a patient exhibiting hypertension is not altered.


Rationale 4: Pain may be manifested in rapid, shallow respirations.

Global Rationale: 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 and depth of respiration increase. The increased rate and depth of lung ventilation eliminates carbon dioxide from the body, and carbonic acid levels fall, which brings the pH to a more normal range. Hypernatremia is associated with profuse sweating and diarrhea. The respiratory rate in a patient exhibiting hypertension is not altered. Pain may be manifested in rapid, shallow respirations. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Describe the causes and effects of acid-base imbalances. Question 39 Type: MCSA

The blood gases of a patient with an acid-base disorder show a blood pH outside of normal limits. The nurse realizes that this patient is

1. fully compensated.

2. demonstrating anaerobic metabolism.

3. partially compensated.

4. in need of intravenous fluids.

Correct 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 bodys 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 patient may be in need of intravenous fluids, this is not the most correct or definitive answer.

Global Rationale: 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. Anaerobic metabolism results when the bodys cells become hypoxic. Although the patient may be in need of intravenous fluids, this is not the most correct or definitive answer. Cognitive Level: Analyzing


Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Describe the causes and effects of acid-base imbalances. Question 40 Type: MCSA

A patients blood gases show a pH greater of 7.53 and bicarbonate level of 36 mEq/L. The nurse realizes that the acid-base disorder this patient is demonstrating is which of the following?

1. respiratory acidosis

2. metabolic acidosis

3. respiratory alkalosis

4. metabolic alkalosis

Correct Answer: 4

Rationale 1: Respiratory acidosis and metabolic acidosis are both consistent with pH less than 7.35.

Rationale 2: Respiratory acidosis and metabolic acidosis are both consistent with pH less than 7.35.

Rationale 3: Respiratory alkalosis is associated with a pH greater than 7.45 and 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 and bicarbonate level greater than 26 mEq/L when the patient is in metabolic alkalosis.

Global Rationale: Arterial blood gases (ABGs) show a pH greater than 7.45 and bicarbonate level greater than 26 mEq/L when the patient is in metabolic alkalosis. Respiratory and metabolic acidosis are both consistent with pH less than 7.35. Respiratory alkalosis is associated with a pH greater than 7.45 and a PaCO2 of less than 35 mmHG. It is caused by respiratory related conditions. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Describe the causes and effects of acid-base imbalances. Question 41 Type: MCSA


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

1. respiratory acidosis

2. metabolic acidosis

3. respiratory alkalosis

4. metabolic alkalosis

Correct 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 patient 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 patient condition being described is respiratory not metabolic in nature.

Global Rationale: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition. The patient condition being described is respiratory not metabolic in nature. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Describe the causes and effects of acid-base imbalances. Question 42 Type: FIB

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

Standard Text:

Correct 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, and the remainder for the traditional night shift. In this case, 50% of 960 is 540 mL.

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 43 Type: MCHS

Place an X on the ECG tracing that is most likely to represent the electrical activity in the heart of a patient who has a serum potassium of 5.9.

Correct Answer:


Rationale : A serum potassium of 5.9 represents hyperkalemia. The ECG findings associated with hyperkalemia are prolongation of the PR interval, a wide QRS, ST segment depression, and a tall-tented T wave. Those findings are represented in the last of the ECG tracings. The first tracing is normal, the second tracing is representative of the changes noted in a patient with hypokalemia (ST segment depression, flattened T wave, and presence of a U wave).

Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Explain the pathophysiology and manifestations of imbalances of sodium, potassium, calcium, magnesium, and phosphorus. Question 44 Type: MCMA

The patient is receiving intravenous potassium (KCL). Which nursing actions are required?


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 and output.

Correct Answer: 2,4,5

Rationale 1: IV potassium can be a lethal drug. In most cases, KCL will be kept and mixed in the pharmacy and the nurse will not have access to undiluted KCL. KCL should be given via IV infusion, not IV push, and should not be added to the IV hanging. The nurse should monitor the injection site for redness, use an infusion controller for the IV infusion, and monitor patient fluid intake and output.

Rationale 2: The nurse should monitor the injection site for redness, use an infusion controller for the IV infusion, and monitor patient fluid intake and output.





Global Rationale: IV potassium can be a lethal drug. In most cases, KCL will be kept and mixed in the pharmacy and the nurse will not have access to undiluted KCL. KCL should be given via IV infusion, not IV push, and should not be added to the IV hanging. The nurse should monitor the injection site for redness, use an infusion controller for the IV infusion, and monitor patient fluid intake and output. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 45 Type: MCMA

Which patients are at risk for the development of hypercalcemia?


1. the patient with a malignancy

2. the patient taking lithium

3. the patient who uses sunscreen to excess

4. the patient with hyperparathyroidism

5. the patient who overuses antacids

Correct Answer: 1,2,4,5

Rationale 1: Patients 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 and 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 and retention of calcium by the kidneys.

Rationale 3: The patient 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 and retention of calcium by the kidneys.

Rationale 5: Lithium and overuse of antacids can result in hypercalcemia.

Global Rationale: Patients with malignancy are at risk for development of hypercalcemia due to destruction of bone or the production of hormone-like substances by the malignancy. Lithium and 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 and retention of calcium by the kidneys. The patient who uses sunscreen to excess is more likely to have a vitamin D deficiency which would result in hypocalcemia. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 46 Type: MCMA

The patient 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 patient?


1. bananas

2. seafood

3. white rice

4. lean red meat

5. chocolate



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

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

Rationale 3: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. White rice and lean red meat are not high in magnesium.

Rationale 4: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. White rice and lean red meat are not high in magnesium.

Rationale 5: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. Foods high in magnesium include green leafy vegetables, seafood, milk, bananas, citrus fruits, and chocolate.

Global Rationale: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. Foods high in magnesium include green leafy vegetables, seafood, milk, bananas, citrus fruits, and chocolate. White rice and lean red meat are not included. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 47 Type: MCMA

The patient has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse expect for this patient?


1. IV normal saline

2. calcium containing antacids

3. IV potassium phosphate

4. encouraging milk intake

5. increasing vitamin D intake


Correct Answer: 1,2

Rationale 1: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excrettion of phosphate.

Rationale 2: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Calcium containing antacids bind the phosphate for excretion through the GI tract.

Rationale 3: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV potassium phosphate is a treatment for low phosphate

Rationale 4: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Milk is a high phosphate food and should be discouraged.

Rationale 5: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Excess vitamin D increases phosphate absorption and can lead to hyperphosphatemia.

Global Rationale: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excrettion of phosphate. Calcium containing antacids bind the phosphate for excretion through the GI tract. IV potassium phosphate is a treatment for low phosphate. Milk is a high phosphate food and should be discouraged. Excess vitamin D increases phosphate absorption and can lead to hyperphosphatemia. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, effects, and care of the patient with fluid volume or electrolyte imbalance. Question 48 Type: MCMA

The patient, newly diagnosed with diabetes mellitus, is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. Which other assessment findings would the nurse anticipate in this patient?


1. tachycardia

2. weakness

3. dysrhythmias

4. Kussmauls respirations


5. cold, clammy skin


Rationale 1: Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, and Kussmauls respirations.

Rationale 2: These ABG results, coupled with the patients recent diagnosis of diabetes mellitus and 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, and Kussmauls respirations.



Rationale 5: Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, and Kussmauls respirations.

Global Rationale: These ABG results, coupled with the patients recent diagnosis of diabetes mellitus and 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, and Kussmauls respirations. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe the causes and effects of acid-base imbalance.

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