FLUIDS AND ELECTROLYTES; ACID-BASE BALANCE100 ITEMS

1. What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt who is intermittently confused?A. risk of dehydrationB. risk of kidney damageC. risk of strokeD. risk of bleeding

Answer: 1Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an altered level of consciousness, there is an increased risk of dehydration & high serum osmolality.Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & electrolyte issues.Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues.Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues.

2. The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for developing?A. intracellular fluid deficitB. intracellular fluid overloadC. extracellular fluid deficitD. interstitial fluid deficit

Answer: 1Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this pt was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit.

3. A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale, cool skin, & decreased urine output. The nurse realizes these findings are most likely a direct result of which of the following?A. the body's natural compensatory mechanismsB. pharmacological effects of a diuretic

C. effects of rapidly infused intravenous fluidsD. cardiac failure

Answer: 1Rationale 1: The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain & heart.Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output.Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.

4. A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most appropriate?A. Risk for Imbalanced Fluid VolumeB. Excess Fluid VolumeC. Imbalanced NutritionD. Ineffective Tissue Perfusion

Answer: 1Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can increase the serum levels of sodium.Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially during the early stages of treatment. Rationale 3: Imbalanced Nutrition does not apply.Rationale 4: Ineffective Tissue Perfusion does not apply

5. A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the pt's primary healthcare provider with which of the following 24-hour urine output volumes?A. 600 mLB. 750 mLC. 1000 mLD. 1200 mL

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

6. A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assessments should focus on which postoperative complication?

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A. fluid volume excessB. fluid volume deficitC. seizure activityD. liver failure

Answer: 1Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following the stress response before, during, & immediately after surgery. This increase leads to sodium & water retention. Adding more fluids intravenously can cause a fluid volume excess & stress upon the heart & circulatory system.Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, & stress upon the heart & circulatory system.Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances.Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid administration.

7. A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need which of the following precautions implemented?A. seizureB. infectionC. neutropenicD. high-risk fall

Answer: 1Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, & having an oral airway at the bedside would be included.Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia.Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia.Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.

8. A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the following might have contributed to the pt's health problem?A. corticosteroidB. thiazide diureticC. narcoticD. muscle relaxer

Answer: 1Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.Rationale 2: Excessive sodium is lost with the use of thiazide diuretics.Rationale 3: Narcotics do not typically affect electrolyte balance.Rationale 4: Muscle relaxants do not typically affect electrolyte balance.

9. A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle weakness. The nurse

realizes this pt is exhibiting signs of which of the following?A. hyperkalemiaB. hypokalemiaC. hypercalcemiaD. Hypocalcemia

Answer: 1Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness & ECG changes.Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide.Rationale 3: Hypercalcemia has been associated with thiazide diuretics.Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is not associated with diuretic use.

10. The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the following should be included in this pt's plan of care?A. Restrict fluids.B. Administer intravenous fluids.C. Provide Kayexalate.D. Administer intravenous normal saline with furosemide.

Answer: 1Rationale 1: The nursing care for a pt with hyponatremia is dependent on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the sodium level from dropping further due to dilution.Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit & hypernatremia.Rationale 3: Kayexalate is used in pts with hyperkalemia.Rationale 4: The administration of normal saline with furosemide is used to increase calcium secretion.11. When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse additionally assess in the pt?A. other electrolyte disturbancesB. hypertensionC. visual disturbancesD. drug toxicity

Answer: 1Rationale 1: The pt diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels.Rationale 2: The pt with hypocalcemia may exhibit hypotension, & not hypertension.Rationale 3: Visual disturbances do not occur with

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hypocalcemia.Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.12. A pt with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the following interventions should the nurse include in this pt's plan of care?A. Request a dietitian consult for selecting foods high in phosphorous.B. Provide aluminum hydroxide antacids as prescribed.C. Instruct pt to avoid poultry, peanuts, & seeds.D. Instruct to avoid the intake of sodium phosphate.Answer: 1Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause & promoting a high phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried beans & peas, eggs, fish, organ meats, Brazil nuts & peanuts, poultry, seeds & whole grains.Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided.Rationale 3: Poultry, peanuts, & seeds are part of a high phosphate diet.Rationale 4: Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate.

13. When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse anticipates that compensation will develop through which of the following mechanisms?A. The kidneys retain bicarbonate.B. The kidneys excrete bicarbonate.C. The lungs will retain carbon dioxide.D. The lungs will excrete carbon dioxide.

Answer: 1Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate.Rationale 2: Excreting bicarbonate causes acidosis to develop.Rationale 3: Retaining carbon dioxide causes respiratory acidosis.Rationale 4: Excreting carbon dioxide causes respiratory alkalosis

14. The nurse is caring for a pt diagnosed with renal failure. Which of the following does the nurse recognize as compensation for the acid-base disturbance found in pts with renal failure?A. The pt breathes rapidly to eliminate carbon dioxide.B. The pt will retain bicarbonate in excess of normal.C. The pH will decrease from the present value.D. The pt's oxygen saturation level will improve.

Answer: 1Rationale 1: In metabolic acidosis compensation is accomplished through increased ventilation or "blowing

off" C02. This raises the pH by eliminating the volatile respiratory acid & compensates for the acidosis.Rationale 2: Because compensation must be performed by the system other than the affected system, the pt cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal bicarbonate value.Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation.Rationale 4: Oxygenation disturbance is not part of the acid-base status of the pt with renal failure.

15. When caring for a group of pts, the nurse realizes that which of the following health problems increases the risk for metabolic alkalosis?A. bulimiaB. dialysisC. venous stasis ulcerD. COPD

Answer: 1Rationale 1: Metabolic alkalosis is cause by vomiting, diuretic therapy or nasogastric suction, among others. A pt with bulimia may engage in vomiting or indiscriminate use of diuretics.Rationale 2: A pt receiving dialysis has kidney failure, which causes metabolic acidosis.Rationale 3: A venous stasis ulcer does not result in an acid-base disorder.Rationale 4: The pt diagnosed with COPD typically has hypercapnea & respiratory acidosis.

16. The nurse is caring for a pt who is anxious & dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, & HCO3 24. The nurse would anticipate which initial intervention to correct this problem?A. Encourage the pt to breathe in & out slowly into a paper bag.B. Immediately administer oxygen via a mask & monitor oxygen saturation.C. Prepare to start an intravenous fluid bolus using isotonic fluids.D. Anticipate the administration of intravenous sodium bicarbonate.

Answer: 1Rationale 1: This pt is exhibiting signs of hyperventilation that is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the pt to retain carbon dioxide & lower oxygen levels to normal, correcting the cause of the problem.Rationale 2: The oxygen levels are high, so oxygen is not indicated, & would exacerbate the problem if given. Intravenous fluids would not be the initial intervention.

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Rationale 3: Not enough information is given to determine the need for intravenous fluids.Rationale 4: Bicarbonate would be contraindicated as the pH is already high.17. A pt is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the pt is receiving this replacement isA. to sustain respiratory function.B. to help regulate acid-base balance.C. to keep a vein open.D. to encourage urine output.

Answer: 2Rationale 1: Potassium does not sustain respiratory function.Rationale 2: Electrolytes have many functions. They assist in regulating water balance, help regulate & maintain acid-base balance, contribute to enzyme reactions, & are essential for neuromuscular activity.Rationale 3: Intravenous fluids are used to keep venous access not potassium.Rationale 4: Urinary output is impacted by fluid intake not potassium.

18. An elderly pt does not complain of thirst. What should the nurse do to assess that this pt is not dehydrated?A. Ask the physician for an order to begin intravenous fluid replacement.B. Ask the physician to order a chest x-ray.C. Assess the urine for osmolality.D. Ask the physician for an order for a brain scan.

Answer: 3Rationale 1: It is inappropriate to seek an IV at this stage.Rationale 2: There is no indication the pt is experiencing pulmonary complications thus a cheat x-ray is not indicated.Rationale 3: The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration & hyperosmolality. The nurse should check the pt's urine for osmolality as a 1st step in determining hydration status before other detailed & invasive testing is done.Rationale 4: There is no data to support the need for a brain scan.

19. An elderly pt who is being medicated for pain had an episode of incontinence. The nurse realizes that this pt is at risk for developingA. dehydration.B. over-hydration.C. fecal incontinence.D. a stroke.

Correct Answer: 1Rationale 1: Functional changes of aging also affect fluid balance. Older adults who have self-care deficits, or who are confused, depressed, tube-fed, on bed rest, or

taking medications (such as sedatives, tranquilizers, diuretics, & laxatives), are at greatest risk for fluid volume imbalance.Rationale 2: There is inadequate evidence to support the risk of over-hydration.Rationale 3: There is inadequate evidence to support the risk of fecal incontinence.Rationale 4: There is inadequate evidence to support the risk of a stroke.

20. The nurse assesses a pt's weight loss as being 22 lbs. How many liters of fluid did this pt lose?A. 10B. 15C. 20D. 5

Correct Answer: ARationale: Each liter of body fluid weighs 1 kg or 2.2 lbs. This pt has lost 10 liters of fluid.

21. A postoperative pt with a fluid volume deficit is prescribed progressive ambulation yet is weak from an inadequate fluid status. What can the nurse do to help this pt?A. Assist the pt to maintain a standing position for several minutes.B. This pt should be on bed rest.C. Assist the pt to move into different positions in stages.D. Contact physical therapy to provide a walker.Answer: 3

Rationale 1: The pt should avoid prolonged standing.Rationale 2: Bed rest can promote skin breakdown.Rationale 3: The pt needs to be taught how to avoid orthostatic hypotension which would include assisting & teaching the pt how to move from one position to another in stages.Rationale 4: A physician referral is needed for physical therapy intervention & is not indicated in this situation.

22. A postoperative pt is diagnosed with fluid volume overload. Which of the following should the nurse assess in this pt?A. poor skin turgorB. decreased urine outputC. distended neck veinsD. concentrated hemoglobin & hematocrit levels

Answer: 3Rationale 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 &

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peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit & blood urea nitrogen (BUN); & possible cerebral edema.Rationale 4: Increased hemoglobin & hematocrit values are associated with fluid volume deficit.

23. An elderly pt is at home after being diagnosed with fluid volume overload. Which of the following should the home care nurse instruct this pt to do?A. Wear support hose.B. Keep legs in a dependent position.C. Avoid wearing shoes while in the home.D. Try to sleep without extra pillows.

Answer: 1Rationale 1: The home care nurse should instruct this pt about ways to decrease dependent edema, which include wearing support hose, elevating feet when in a sitting position, & resting in a recliner or bed with extra pillows.Rationale 2: The pt should elevate the legs.Rationale 3: As long as the shoes are well fitting, there is not reason to avoid wearing them.Rationale 4: It is appropriate for the pt to use extra pillows to keep the head up while sleeping.

24. A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this pt could possibly have which of the following electrolyte imbalances?A. hypokalemiaB. hypernatremiaC. carbon dioxideD. Magnesium

Answer: 2Rationale 1: The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations potassium levels.Rationale 2: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia.Rationale 3: Carbon dioxide abnormalities are not normally seen in this type of pt.Rationale 4: Magnesium abnormalities are not normally seen in this type of pt.

25. An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the following?A. hypernatremiaB. hyponatremia

C. fluid volume excessD. Hyperkalemia

Answer: 2Rationale 1: Hypernatremia is associated with fluid retention & overload. FVE is associated with hypernatremia.Rationale 2: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The abdominal & muscle cramps are manifestations of a low serum sodium level.Rationale 3: This pt is more likely to develop clinical manifestations associated with fluid volume deficit.Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias.

26. A pt is admitted with hypernatremia caused by being str&ed on a boat in the Atlantic Ocean for five days without a fresh water source. Which of the following is this pt at risk for developing?A. pulmonary edemaB. atrial dysrhythmiasC. cerebral bleedingD. stress fractures

Answer: 3Rationale 1: Pulmonary edema is not associated with dehydration.Rationale 2: Atrial dysrhythmias are not a factor for this pt.Rationale 3: The brain experiences the most serious effects of cellular dehydration. As brain cells contract, the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, & lead to cerebral vascular bleeding.Rationale 4: There have been no activities to support the development or occurrence of stress fractures.

27. The nurse is admitting a pt who was diagnosed with acute renal failure. Which of the following electrolytes will be most affected with this disorder?A. calciumB. magnesiumC. phosphorousD. Potassium

Answer: 4Rationale 1: This pt will be less likely to develop a calcium imbalance.Rationale 2: This pt will be less likely to develop a magnesium imbalance.Rationale 3: This pt will be less likely to develop a phosphorous imbalance.Rationale 4: Because the kidneys are the principal organs involved in the elimination of potassium, renal failure

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28. A pt who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the following does the nurse realize might occur with this pt?A. Digoxin toxicity may occur.B. A higher dose of digoxin (Lanoxin) may be needed.C. A diuretic may be needed.D. Fluid volume deficit may occur.

Answer: 1Rationale 1: Hypokalemia increases the risk of digitalis toxicity in pts who receive this drug for heart failure.Rationale 2: More digoxin is not needed.Rationale 3: A diuretic may cause further fluid loss.Rationale 4: There is inadequate information to assess for concerns related to fluid volume deficits.

29. A pt is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement should be administeredA. directly into the venous access line.B. mixed in the prescribed intravenous fluid.C. via a rectal suppository.D. via intramuscular injection.

Answer: 2Rationale 1: Never administer undiluted potassium directly into a vein.Rationale 2: The intravenous route is the recommended route for diluted potassium.Rationale 3: The nurse should administer diluted potassium into the pt's intravenous line.Rationale 4: The nurse should administer diluted potassium into the pt's intravenous line.

30. An elderly pt with a history of sodium retention arrives to the clinic with the complaints of "heart skipping beats" & leg tremors. Which of the following should the nurse ask this pt regarding these symptoms?

A. "Have you stopped taking your digoxin medication?"B. "When was the last time you had a bowel movement?"C. "Were you doing any unusual physical activity?"D. "Are you using a salt substitute?"Answer: 4Rationale 1: Although this pt may be prescribed digoxin this is not the primary focus of this question.Rationale 2: The pt's bowel habits are not of concern at this time.Rationale 3: The cardiac & musculoskeletal discomforts being reported are not consistent with physical exertion.Rationale 4: The pt has a history of sodium retention & might think that a salt substitute can be used. Advise pts who are taking a potassium supplement or potassium-sparing diuretic to avoid salt substitutes, which usually contain potassium.

31. A 35-year-old female pt comes into the clinic postoperative parathyroidectomy. Which of the following should the nurse instruct this pt?A. Drink one glass of red wine per day.B. Avoid the sun.C. Milk & milk-based products will ensure an adequate calcium intake.D. Red meat is the protein source of choice.

Answer: 3Rationale 1: This pt should avoid alcohol.Rationale 2: This pt can benefit from sun exposure.Rationale 3: This pt is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk & milk-based products.Rationale 4: Protein monitoring is not indicated.

32. A pt is admitted for treatment of hypercalcemia. The nurse realizes that this pt's intravenous fluids will most likely be which of the following?A. dextrose 5% & waterB. dextrose 5% & ? normal salineC. dextrose 5% & ? normal salineD. normal saline

Answer: 4Rationale 1: If isotonic saline is not used, the pt is at risk for hyponatremia in addition to the hypercalcemia.Rationale 2: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.Rationale 3: This solution is hypotonic. Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.Rationale 4: Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys.

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

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

34. An elderly pt with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which of the following symptoms can indicate hypomagnesaemia?A. hypotension, warmth, & sweatingB. nausea & vomiting

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C. hyperreflexiaD. excessive urination

Answer: 1Rationale 1: Elevations in magnesium levels are accompanied by hypotension, warmth, & sweating.Rationale 2: Lower levels of magnesium are associated with nausea & vomiting.Rationale 3: Lower levels of magnesium are associated & hyperreflexia.Rationale 4: Urinary changes are not noted.

35. A pt is admitted with burns over 50% of his body. The nurse realizes that this pt is at risk for which of the following electrolyte imbalances?A. hypercalcemiaB. hypophosphatemiaC. hypernatremiaD. Hypermagnesemia

Correct Answer: 2Rationale 1: Pts who experience burns are not at an increased risk for developing increased blood calcium levels.Rationale 2: Causes of hypophosphatemia include stress responses & extensive burns.Rationale 3: Pts who experience burns are not at an increased risk for developing increased blood sodium levels.Rationale 4: Pts who experience burns are not at an increased risk for developing increased blood magnesium levels.

36. A pt is diagnosed with hyperphosphatemia. The nurse realizes that this pt might also have an imbalance of which of the following electrolytes?A. calciumB. sodiumC. potassiumD. Chloride

Answer: 1Rationale 1: Excessive serum phosphate levels cause few specific symptoms. The effects of high serum phosphate levels on nerves & muscles are more likely the result of hypocalcemia that develops secondary to an elevated serum phosphorus level. The phosphate in the serum combines with ionized calcium, & the ionized serum calcium level falls.

37. The nurse is reviewing a pt's blood pH level. Which of the systems in the body regulate blood pH? Select all that apply.A. renalB. cardiacC. buffersD. Respiratory

Answer: 1,3Rationale 1: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, & the renal system.Rationale 2: The cardiac system is responsible for circulating blood to the body. It does not help maintain the body's pH.Rationale 3: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, & the renal system.Rationale 4: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, & the renal system.

38. The nurse observes a pt's respirations & notes that the rate is 30 per minute & the respirations are very deep. The metabolic disorder this pt might be demonstrating is which of the following?A. hypernatremiaB. increasing carbon dioxide in the bloodC. hypertensionD. Pain

Answer: 2Rationale 1: Hypernatremia is associated with profuse sweating & diarrhea.Rationale 2: Acute increases in either carbon dioxide or hydrogen ions in the blood stimulate the respiratory center in the brain. As a result, both the rate & depth of respiration increase. The increased rate & depth of lung ventilation eliminates carbon dioxide from the body, & carbonic acid levels fall, which brings the pH to a more normal range.Rationale 3: The respiratory rate in a pt exhibiting hypertension is not altered.Rationale 4: Pain may be manifested in rapid, shallow respirations.

39. The blood gases of a pt with an acid-base disorder show a blood pH outside of normal limits. The nurse realizes that this pt isA. fully compensated.B. demonstrating anaerobic metabolism.C. partially compensated.D. in need of intravenous fluids

Answer: 3Rationale 1: If the pH is restored to within normal limits, the disorder is said to be fully compensated.Rationale 2: Anaerobic metabolism results when the body's cells become hypoxic.Rationale 3: If the pH is restored to within normal limits, the disorder is said to be fully compensated. When these changes are reflected in arterial blood gas (ABG) values but the pH remains outside normal limits, the disorder is said to be partially compensated.Rationale 4: Although the pt may be in need of

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intravenous fluids, this is not the most correct or definitive answer.

40. A pt's blood gases show a pH greater of 7.53 & bicarbonate level of 36 mEq/L. The nurse realizes that the acid-base disorder this pt is demonstrating is which of the following?A. respiratory acidosisB. metabolic acidosisC. respiratory alkalosisD. metabolic alkalosis

Answer: 4Rationale 1& 2: Respiratory acidosis & metabolic acidosis are both consistent with pH less than 7.35.Rationale 3: Respiratory alkalosis is associated with a pH greater than 7.45 & a PaCO2 of less than 35 mmHG. It is caused by respiratory related conditions.Rationale 4: Arterial blood gases (ABGs) show a pH greater than 7.45 & bicarbonate level greater than 26 mEq/L when the pt is in metabolic alkalosis.

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

Answer: 1Rationale 1: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition.Rationale 2: The pt condition being described is respiratory not metabolic in nature.Rationale 3: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition.Rationale 4: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition. The pt condition being described is respiratory not metabolic in nature.

42. The pt has been placed on a 1200 mL daily fluid restriction. The pt's IV is infusing at a keep open rate of 10 mL/hr. The pt has no additional IV medications. How much fluid should the pt be allowed from 0700 until 1500 daily?A. 540 mlB. 300 mlC. 600 mlD. 590 ml

Answer: 540Rationale: Fluid allowed is calculated by figuring the total daily IV intake (in this case 10 mL/hr × 24 hours = 240 mL/day), subtracting that total from the daily allowance (in this case 1200mL - 240 mL = 960mL). The amount calculated is then distributed as 50% for the traditional day shift, 25%-35% for the traditional evening shift, & the remainder for the traditional night shift. In this case, 50% of 960 is 540 mL.

43. The pt is receiving intravenous potassium (KCL). Which nursing actions are required? Select all that apply.A. Administer the dose IV push over 3 minutes.B. Monitor the injection site for redness.C. Add the ordered dose to the IV hanging.D. Use an infusion controller for the IV.E. Monitor fluid intake & output.

Answer: 2,4,5

44. Which pts are at risk for the development of hypercalcemia? Select all that apply.A. the pt with a malignancyB. the pt taking lithiumC. the pt who uses sunscreen to excessD. the pt with hyperparathyroidismE. the pt who overuses antacids

Correct Answer: 1,2,4,5Rationale 1: Pts with malignancy are at risk for development of hypercalcemia due to destruction of bone or the production of hormone-like substances by the malignancy.Rationale 2: Lithium & overuse of antacids can result in hypercalcemia. Hypercalcemia can result from hyperparathyroidism which causes release of calcium from the bones, increased calcium absorption in the intestines & retention of calcium by the kidneys.Rationale 3: The pt who uses sunscreen to excess is more likely to have a vitamin D deficiency which would result in hypocalcemia.Rationale 4: Hypercalcemia can result from hyperparathyroidism which causes release of calcium from the bones, increased calcium absorption in the intestines & retention of calcium by the kidneys.Rationale 5: Lithium & overuse of antacids can result in hypercalcemia.45. The pt who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this pt? Select all that apply.A. bananasB. seafoodC. white riceD. lean red meatE. Chocolate

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Answer: 1,2,5Rationale: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this pt should be counseled to eat foods high in magnesium. Foods high in magnesium include green leafy vegetables, seafood, milk, bananas, citrus fruits, & chocolate. White rice & lean red meat are not included.

46. The pt has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse expect for this pt? Select all that apply.A. IV normal salineB. calcium containing antacidsC. IV potassium phosphateD. encouraging milk intakeE. increasing vitamin D intake

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

47. The pt, newly diagnosed with diabetes mellitus, is admitted to the emergency department with nausea, vomiting, & abdominal pain. ABG results reveal a pH of 7.2 & a bicarbonate level of 20 mEq/L. Which other assessment findings would the nurse anticipate in this pt? Select all that apply.A. tachycardiaB. weaknessC. dysrhythmiasD. Kussmaul's respirationsE. cold, clammy skin

Answer: 2,3,4Rationale: Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, & Kussmaul's respirations.

Rationale: These ABG results, coupled with the pt's recent diagnosis of diabetes mellitus & history of vomiting would lead the nurse to suspect metabolic acidosis. Further assessment findings of this condition are weakness, bradycardia, dysrhythmias, general malaise, decreased level of consciousness, warm flushed skin, & Kussmaul's respirations.

48. A client’s nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to the fluid management should be delegated to a nursing assistant? a. Administer IV fluids as prescribed by the physician. b. Provide straws and offer fluids between meals. c. Develop plan for added fluid intake over 24 hours d. Teach family members to assist client with fluid intake

1. ANSWER B – The nursing assistant can reinforce additional fluild intake once it is part of the

care plan. Administering IV fluids, developing plans, and teaching families require additional education and skills that are within the scope of practice for the RN.

49. The client also has the nursing diagnosis Decreased Cardiac Output related to decrease plasma volume. Which finding on assessment supports this nursing diagnosis? a. Flattened neck veins when client is in supine position

b. Full and bounding pedal and post-tibial pulses c. Pitting edema located in feet, ankles, and calves d. Shallow respirations with crackles on auscultation 2. ANSWER A – Normally, neck veins are distended when the client is in the supine position. The veins flatten as the client moves to a sitting position. The other three responses are characteristic of Excess Fluid Volume.

50. The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for the LPN/LVN being supervised by the nurse? (Choose all that apply.) a. Remind client to avoid commercial mouthwashes. b. Encourage mouth rinsing with warm saline. c. Assess lips, tongue, and mucous membranes d. Provide mouth care every 2 hours while client is awake e. Seek dietary consult to increase fluids on meal trays. 3. ANSWER A, B, C, D - The LPN/LVN’s scope of practice and educational preparation includes oral care and routine observation. State practice acts vary as to whether LPN/LVNs are permitted to perform assessment. The client should be reminded to avoid most commercial mouthwashes that contain alcohol, a drying agent. Initiating a dietary consult is within the purview of the RN or physician.

51. The physician has written the following orders for the client with Excess Fluid volume. The client’s morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time? a. Weight client every morning. b. Maintain accurate intake and output. c. Restrict fluid to 1500 mL per day d. Administer furosemide (Lasix) 40 mg IV push

4. ANSWER D – Bilateral moist crackles indicate fluid-filled alveoli, which interferes with gas exchange. Furosemide is a potent loop diuretic that will help mobilize the fluid in the lungs. The other orders are important but not urgent.

52. You have been pulled to the telemetry unit for the day. The monitor informs you that the client has developed prominent U waves. Which laboratory value should you check immediately? a. Sodium b. Potassium

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c. Magnesium d. Calcium

5. ANSWER B – Suspect hypokalemia and check the client’s potassium level. Common ECG changes with hypokalemia include ST depression, inverted T waves, and prominent U waves. Client with hypokalemia may also develop heart block.

53. The client’s potassium level is 6.7 mEq/L. Which intervention should you delegate to the student nurse under your supervision? a. Administer Kayexalate 15 g orally b. Administer spironolactone 25 mg orally c. Assess WCG strip for tall T waves d. Administer potassium 10 mEq orally

6. ANSWER A – The client’s potassium level is high (normal range 3.5-5.0). Kayexalate removes potassium from the body through the gastrointestinal system. Spironolactone is a potassium-sparing diuretic that may cause the client’s potassium level to go even higher. The nursing student may not have the skill to assess ECG strips and this should be done by the RN.

54. A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality will you be sure to monitor? a. Hypokalemia b. Hyperkalemia c. Hyponatremia d. Hypernatremia

7. ANSWER C - SIADH causes a relative sodium deficit due to excessive retention of water.

55. The charge nurse assigned in the care for a client with acute renal failure and hypernatremia to you, a newly graduated RN. Which actions can you delegate to the nursing assistant? a. Provide oral care every 3-4 hours b. Monitor for indications of dehydration c. Administer 0.45% saline by IV line d. Assess daily weights for trends 8. ANSWER A – Providing oral care is within the scope of practice for the nursing assistant. Monitoring and assessing clients, as well as administering IV fluids, require the additional education and skill of the RN. 56. The experienced LPN/LVN reports that a client’s blood pressure and heart rate have decreased and that when the face is assessed, one side twitches. What action should you take at this time? a. Reassess the client’s blood pressure and heart rate b. Review the client’s morning calcium level c. Request a neurologic consult today d. Check the client’s papillary reaction to light 9. ANSWER B – A positive Chvostek’s sign (facial twitching of one side of the mouth, nose, and cheek in response to tapping the face just below and in front of the ear) is a neurologic manifestation of hypocalcemia. The LPN/LVN is experienced and possesses the skills to take accurate vital signs. 57.You are preparing to discharge a client whose

calcium level was low but is now just slightly within the normal range (9-10.5 mg/dL). Which statement by the client indicates the need for additional teaching? a. “I will call my doctor if I experience muscle twitching or seizures.” b. “I will make sure to take my vitamin D with my calcium each day.” c. “I will take my calcium pill every morning before breakfast.” d. “I will avoid dairy products, broccoli, and spinach when I eat.” 10. ANSWER D – Clients with low calcium levels should be encouraged to consume dairy products, seafood, nuts, broccoli, and spinach. Which are all good sources of dietary calcium.

58.A nursing assistant asks why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response? a. “The client’s low phosphorus is probably due to malnutrition.” b. “The client is just worn out form not getting enough rest.” c. “The client’s skeletal muscles are weak because of the low phosphorus.” d. “The client will do more for herself when her phosphorus is normal” 11. ANSWER C – A musculoskeletal manifestation of low phosphorous is generalized muscle weakness that may lead to acute muscle breakdown (rhabdomyolysis). Even though the other statements are true, they do not answer the nursing assistant’s question.

59.You are reviewing a client’s morning laboratory results. Which of these results is of most concern? a. Serum potassium 5.2 mEq/L b. Serum sodium 134 mEq/L c. Serum calcium 10.6 mg/dL d. Serum magnesium 0.8 mEq/L 59. ANSWER D – While all of these laboratory values are outside of the normal range, the magnesium is most outside of normal. With a magnesium level this low, the client is at risk for ECG changes and life-threatening ventricular dysrhythmias.

60. You are the charge nurse. Which client is most appropriate to assign to the step-down unit nurse pulled to the intensive care unit for the day? a. A 68-year-old client on ventilator with acute respiratory failure and respiratory acidosis b. A 72-year-old client with COPD and normal arterial blood gases (ABGs) who is ventilator-dependent c. A 56-year-old new admission client with diabetic ketoacidosis (DKA) on a n insulin drip d. A 38-year-old client on a ventilator with narcotic overdose and respiratory alkalosis

13. ANSWER B – The client with COPD, although ventilator dependent, is the most stable of this group. Clients with acid-base imbalances often require frequent laboratory assessment and changes in therapy

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to correct their disorders. In addition, the client with DKA is a new admission and will require an in-depth admission assessment. All three of these clients need care from an experienced critical care nurse.

61.A client with respiratory failure is receiving mechanical ventilation and continues to produce ABG results indicating respiratory acidosis. Which action should you expect to correct this problem? a. Increase the ventilator rate from 6 to 10 per minute b. Decrease the ventilator rate from 10 to 6 per minute c. Increase the oxygen concentration for 30% to 40% d. Decrease the oxygen concentration for 40% to 30% 14. ANSWER A – the blood gas component responsible for respiratory acidosis is CO2 (Carbon dioxide). Increasing the ventilator rate will blow off more CO2 and decrease the acidosis. Changes in the oxygen setting may improve oxygenation but will not affect respiratory acidosis.

62.Which action should you delegate to the nursing assistant for the client with diabetic ketoacidosis? (Choose all that apply.) a. Check fingerstick glucose every hour. b. Record intake and output every hour. c. Check vital signs every 15 minutes. d. Assess for indicators of fluid imbalance. 15. ANSWER B, C – The nursing assistant’s training and education include how to take vital signs and record intake and output. The need to take vital signs this frequently indicates that the client maybe unstable. The nurse should give the nursing assistant reporting parameters when delegating this action, should also check the vital signs for indications in instability. Performing fingerstick glucose checks and assessing clients require additional education and skill that are appropriate to licensed nurses. Some facilities may train experienced nursing assistants to perform fingerstick glucose checks and change their role descriptions to designate their new skills, but this is beyond the normal scope of practice for a nursing assistant.

63.You are admitting an elderly client to the medical unit. Which factor indicates that this client has a risk for acid-base imbalances? a. Myocardial infarction 1 year ago b. Occasional use of antacids c. Shortness of breath with extreme exertion d. Chronic renal insufficiency

16. ANSWER D – Risk factors for acid-base imbalances in the older adult include chronic renal disease and pulmonary disease. Occasional antacid use will not cause imbalances, although antacid abuse is a risk factor for metabolic alkalosis. 64.A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding should you instruct the student to report immediately? a. Respiratory rate of 8 to 10 per minute b. Pain level decreased from 6/10 to 2/10

c. Client requests room door be closed. d. Heart rate 90-100 per minute

17. ANSWER A – A decreased respiratory rate indicates respiratory depression which also puts the client at risk for respiratory acidosis, All of the other findings are important and should be reported to the RN, but the respiratory rate is urgent.

65.The nursing assistant reports to you that a client seems very anxious and that vital signs included a respiratory rate of 38 per minute. Which acid-base imbalance should you suspect? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis 18. ANSWER B – The client is most likely hyperventilating and blowing off CO2. This decrease in CO2 will lead to an increase in pH, causing respiratory alkalosis. Respiratory acidosis results from respiratory depression and retained CO2. Metabolic acidosis and alkalosis result from problems related to renal acid-base control.

66.A client is admitted to the unit for chemotherapy. To prevent an acid-base problem, which of the following would you instruct the nursing assistant to report? a. Repeated episodes of nausea and vomiting b. Complaints of pain associated with exertion c. Failure to eat all food on breakfast tray d. Client hair loss during morning bath 19. ANSWER A – Prolonged nausea and vomiting can result in acid deficit that can lead to metabolic alkalosis. The other findings are important and need to be assessed but are not related to acid-base imbalances.

67.A client has a nasogastric tube connected to intermittent wall suction. The student nurse asks why the client’s respiratory rate has increased. What your best response? a. “It’s common for clients with uncomfortable procedures such as nasogastric tubes to have a higher rate to breathing.” b. “The client may have a metabolic alkalosis due to the NG suctioning and the increased respiratory rate is a compensatory mechanism.” c. “Whenever a client develops a respiratory acid-base problem, increasing the respiratory rate helps correct the problem.” d. “The client is hyperventilating because of anxiety and we will have to stay alert for development of a respiratory acidosis.”

20. ANSWER B – Nasogastric suctioning can result in a decrease in acid components and metabolic alkalosis. The client’s increase in rate and depth of ventilation is an attempt to compensate by blowing off CO2. the first response maybe true but does not address all the components of the question. The third and fourth answers are inaccurate.

68. pH 7.51, pCO2 40, HCO3- 31:

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a. Normal b. Uncompensated metabolic alkalosis c. compensated respiratory acidosis d. Uncompensated respiratory alkalosis

69. pH 7.33, pCO2 29, HCO3- 16: a. Uncompensated respiratory alkalosis b. Uncompensated metabolic acidosis c. Compensated respiratory acidosis d. Uncompensated metabolic acidosis 70. pH 7.40, pCO2 40, HCO3- 24: a. Normal b. Uncompensated metabolic acidosis c. Compensated respiratory acidosis d. Compensated metabolic acidosis

71. pH 7.12, pCO2 60, HCO3- 29: a. Uncompensated metabolic acidosis b. Uncompensated respiratory acidosis c. Compensated respiratory acidosis d. Compensated metabolic acidosis

72. pH 7.48, pCO2 30, HCO3- 23: a. Uncompensated metabolic alkalosis b. Uncompensated respiratory alkalosis c. Compensated respiratory alkalosis d. Compensated metabolic alkalosis

73. pH 7.62, pCO2 47, HCO3- 30: a. Uncompensated metabolic alkalosis b. Uncompensated respiratory alkalosis c. compensated respiratory alkalosis d. compensated metabolic alkalosis

74. A mist tent contains a nebulizer that creates a cool, moist environment for a child with an upper respiratory tract infection. The cool humidity helps the child breathe by: A. decreasing respiratory tract edema.B. preventing anxiety.C. drying secretions.D. increasing fluid intake.

65. 1The mist tent decreases respiratory tract edema, which causes croup. However, the child needs to be prepared because the confinement can cause high anxiety. The tent liquefies secretions, rather than drying them, and it doesn't increase the child's fluid intake. (SR 4055)

75. A bone mineral analysis reveals that a patient who is postmenopausal has severe osteoporosis. Which of the following instructions should the nurse give to the patient's family to ensure a safe environment for the patient? A. "Disinfect the bathroom weekly."B. "Carpet floor surfaces."C. "Install handrails on stairways."D. "Keep the lights dim."

66. 3(3) Osteoporosis of the hip increases the risk of

hip fractures. Decreased bone mass density puts one at high risk for hip fractures. Installing handrails on stairways will improve mobility and prevent falls. (1) Disinfecting the bathroom does not prevent falls and hip fractures in the patient with osteoporosis. (2) Carpeting floor surfaces often makes ambulation more difficult. (4) Poor lighting increases the risk for falling. Areas should be well lit. (SR 5456)

76. Based on multiple referrals, the nurse determines that childhood injuries are increasing in the community in which she practices. The first step the nurse would take in developing an educational program is: A. assessing for a decrease in referrals following a

pediatric safety class.B. assessing the strengths and needs of the

community while identifying barriers to learning.

C. choosing a health promotion or health belief model as a framework.

D. developing and implementing a specific plan to decrease childhood injuries.68. 2Following the identification of a learning need, the first step is to assess the strengths and needs of the community while identifying barriers to learning. (SR 3856)

77. Which of the following activities would the nurse likely choose to implement in response to a nursing diagnosis of Activity Intolerance related to lack of energy conservation? A. Encourage the client to perform all tasks early

in the day.B. Encourage the client to alternate periods of rest

and activity throughout the day.C. Administer narcotics to promote pain relief and

rest.D. Instruct the client to not perform daily hygienic

care until activity tolerance improves.69. 22: The client with rheumatoid arthritis should be encouraged to alternate periods of activity and rest throughout the day. 1: Encouraging the client to perform all activities of daily living at once will worsen fatigue and stress her ability to recover. 3: Narcotics are not typically administered to control arthritic pain. 4: Encouraging the client to cease all participation in daily activities will decrease activity tolerance and make fatigue more pronounced. (SR 3222)

78. A client has a diagnosis of borderline personality disorder. She has attached herself to one nurse and refuses to speak with other staff members. She tells the nurse that the other nurses are mean, withhold her medication, and mistreat her. The staff is discussing this problem at their weekly conference. Which intervention would be most appropriate for the nursing staff to implement?

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A. Provide an unstructured environment for the client.

B. Rotate the nurses who are assigned to the client.

C. Ignore the client's behaviors.D. Bend unit rules to meet the client's needs.

70. 2Rotating staff members who work with a client with a borderline personality disorder keeps the client from becoming dependent on any one nurse and reduces the use of splitting and her fear of abandonment. Firm rules and consistency among staff members will help control the client's behavior. Ignoring splitting behaviors can cause the client to increase the behavior by trying to get a response from the staff. Unit rules must be consistently enforced and followed by each nurse to help the client control behavior. (SR 4297)

79. A client's chest tube accidentally disconnects from the drainage tube when she turns onto her side. Which of the following actions should the nurse take first? A. Notify the physician.B. Clamp the chest tube.C. Raise the level of the drainage system.D. Reconnect the tube.

71. 22: When a chest tube becomes disconnected, the nurse should take immediate steps to prevent air from entering the chest cavity which may cause the lung to collapse. Therefore, when a chest tube is accidentally disconnected from the drainage tube, the nurse should either double-clamp the chest tube as close to the client as possible or place the open end of the tube in a container of sterile water or saline solution. Then the physician should be notified. 1: First priority must be given to clamping the chest tube. 3: To prevent backward flow of drainage, the drainage system should never be raised above chest level. 4: To prevent backward flow of drainage, the drainage system should never be raised above chest level. (SR 3072)

80. For a client with COPD who has trouble raising respiratory secretions, which of the following nursing measures would help reduce the tenacity of secretions? A. Ensuring that the client's diet is low in salt.B. Ensuring that the client's oxygen therapy is

continuous.C. Helping the client maintain a high fluid intake.D. Keeping the client in a semi-sitting position as

much as possible.72. 33: A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions. 1: A low-salt diet does not help reduce the viscosity of mucus. 2: Continuous oxygen therapy does

not help reduce the viscosity of mucus. 4: Maintaining a semi-sitting position does not help reduce the viscosity of mucus. (SR 3057)

81. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action? A. Make an appointment because the client needs

to be evaluated.B. Explain that these are expected problems for

the latter stages of pregnancy.C. Arrange for the client to be admitted to the

birth center for delivery.D. Tell the client to go to the hospital; she may be

experiencing signs of heart failure from a 45% to 50% increase in blood volume.74. 2The nurse must distinguish between normal physiologic complaints of the latter stages of pregnancy and those that need referral to the health care provider. In this case, the client indicates normal physiologic changes due to the growing uterus and pressure on the diaphragm. The client doesn't need to be seen or admitted for delivery. The client's signs aren't indicative of heart failure. (SR 4385)

82. A nurse works on a medical-surgical unit where nurses work on 12-client pods. Each pod is staffed by two registered nurses. When one of the nurses leaves the unit, the remaining nurse cares for all 12 clients. If she needs help, she can call the agency's in-house resource nurse. One evening when a coworker left the unit, the remaining nurse, who was making rounds on the departed nurse's clients, found medications left at bedsides and a client with a blood-draw tourniquet remaining on his arm. In addressing the problems, the nurse should: A. inform the nurse-supervisor right away.B. correct the problems and submit a written

report.C. speak to the coworker when she returns to the

unit.D. ask for a meeting with the coworker and a

manager.75. 3When a nurse discovers substandard practice by another nurse, it's always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse-supervisor first doesn't promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issues can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed by only those directly involved. (SR 3840)

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83. The nurse is caring for a client with a history of falls. The first priority when caring for a client at risk for falls is: A. placing the call light for easy access.B. keeping the bed at the lowest position possible.C. instructing the client not to get out of bed

without assistance.D. keeping the bedpan available so that the client

doesn't have to get out of bed.76. 2Keeping the bed at the lowest possible position is the first priority for clients at risk for falling. Keeping the call light easily accessible is important but isn't a top priority. Instructing the client not to get out of bed may not effectively prevent falls. (SR 3974)

84. Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting? A. Administering pain medication.B. Completing the admission history.C. Maintaining hydration.D. Teaching about planned diagnostic tests.

77. 11: Administering pain medication would have the highest priority during the first hour after the client's admission. 2: Completing the admission history can be done after the client's pain is controlled. 3: Maintaining hydration is important but will be accomplished over time. In the first hour after admission, the highest priority is pain relief. 4: It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable. (SR 3095)

85. pH = 7.30 CO2 = 75 HCO3 = 22 A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

86. Is this Compensated, Uncompensated or Partially Compensated? A. CompensatedB. UncompensatedC. Partially Compensated

87. pH = 7.36 CO2 = 32 HCO3 = 20 A. Respiratory AcidosisB. Respiratory AlkalosisC. Metabolic AlkalosisD. Metabolic Acidosis

88. Is this Compensated, Uncompensated or Partially Compensated? A. CompensatedB. Uncompensated

C. Partially Compensated

89. pH = 7.48 CO2 = 46 HCO3 = 28A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

90. Is this Compensated, Uncompensated or Partially Compensated? A. CompensatedB. UncompensatedC. Partially Compensated

91. pH = 7.38 CO2 = 50 HCO3 = 27 A. Respiratory Alkalosis B. Metabolic AcidosisC. Metabolic AlkalosisD. Respiratory Acidosis

92. Is this Compensated, Uncompensated or Partially Compensated? A. CompensatedB. UncompensatedC. Partially Compensated

93. pH = 7.50 CO2 = 35 HCO3 = 32 A. Respiratory AcidosisB. Respiratory AlkalosisC. Metabolic Acidosis D. Metabolic Alkalosis

94. Is this Compensated, Uncompensated or Partially Compensated? A. CompensatedB. UncompensatedC. Partially Compensated

95. pH = 7.48 CO2 = 36 HCO3 = 33 A. Respiratory AcidosisB. Respiratory AlkalosisC. Metabolic Acidosis D. Metabolic Alkalosis

96. Is this Compensated, Uncompensated or Partially Compensated? A. CompensatedB. UncompensatedC. Partially Compensated

97. pH = 7.2 CO2 = 48 HCO3 = 26 A. Respiratory AcidosisB. Respiratory AlkalosisC. Metabolic Acidosis D. Metabolic Alkalosis

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98. Is this Compensated, Uncompensated or Partially Compensated? A. CompensatedB. UncompensatedC. Partially Compensated

99. pH = 7.2 CO2 = 52 HCO3 = 24 A. Respiratory AcidosisB. Respiratory AlkalosisC. Metabolic Acidosis D. Metabolic Alkalosis

100. Is this Compensated, Uncompensated or Partially Compensated? A. CompensatedB. UncompensatedC. Partially Compensated

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