242-257 f&e

252 251

FLUIDS AND ELECTROLYTE IMBALANCES

1. Mama Alats latest electrolyte level reveals acute sodium depletion and remaining 110 mEq/L sodium level. The medical regimen ordered is to infuse Mama Alat with highly hypertonic sodium solution of 5% NaCl. The nurse understands that this regimen is essential to

a. promote aldosterone release to reabsorb sodium and water

b. allow sodium ions to enter the cells

c. correct the acute sodium depletion

d. relieve the acute manifestations of cerebral edema

2. A client is diagnosed with severe anemia after many episodes of syncope and extreme fatigability. Blood transfusion is ordered. Prior to the administration of the blood, the serum potassium level of the client and the storage time of the blood are determined. The scientific rationale for this is:

a. aged blood has high serum potassium concentration that can lead to hyperkalemia

b. prolonged blood storage causes cellular lysis that can lead to hypokalemia

c. blood components have high potassium level causing hyperkalemia

d. blood administration and potassium level is indirectly proportional

3. A nurse is conducting a review class to nursing students about the functions of the different cations and anions in the body. Chloride, the major anion of the extracellular fluid, primarily maintains central nervous system function. Which is accurately stated?

a. Chloride, together with sodium, attracts water to form the liquid portion of the CSF.

b. Chloride, making up the composition of the intravascular fluid, assists in determining osmotic pressure in the brain.

c. Chloride is affected by aldosterone release, which also affects sodium level for neural functioning.

d. Chloride shift aids in hydrogen ions depression, which releases oxygen from hemoglobin for cerebral perfusion.

4. Prior to administering the physicians order of intravenous infusion that contains potassium, it is of utmost importance for the nurse to

a. get baseline blood pressure

b. check input and output table

c. assess the skin turgor of the abdomen

d. determine presence of edema

5. The nurse is developing a plan of care for a client with heart failure, who is at risk for excess fluid volume. Which physiological change ensuing from heart failure corroborations this nursing diagnosis?

a. rapid sodium excretionb. Improved cardiac outputc. elevated antidiuretic hormone productiond. increased glomerular filtration rate6. The nurse is preparing to start the IV of Mr. Flow, a 70-year-old client, with order of 125 ml per hour of continuous fluid replacement. What are the equipments the nurse should prepare at the bedside before IV insertion?

a. 1-inch cannula, gauge 18 lumen, to be inserted in the left arm, antecubital region

b. 1-inch cannula, gauge 22 lumen, to be inserted in the top vein of the left handc. 3-inch cannula, gauge 18 lumen, to be inserted in the left hand

d. 3-inch cannula, gauge 22 lumen, to be inserted in the right arm, antecubital region

7. A client with liver problem developed ascites. Because of continuous increase in abdominal girth, paracentesis will be done to the client. After the first fluid aspiration, total of 1800 ml of fluid is removed. Following the procedure, the immediate action of the nurse is to watch out for

a. Symptoms of decreased peristalsis.

b. Complaints of respiratory difficulty and congestion.

c. Fever and chills.

d. Signs of vascular collapse.

8. Upon auscultation of the lungs, crackles was noted on the base of both lungs of a client with cirrhosis. The client was also observed with dyspnea. The nurse suspects fluid volume excess. The nurse will also anticipate which of the following signs that the client may elicit?

a. blood pressure of 150/90

b. urine output of 100 for the passed 3 hours

c. pulse of grade 1+

d. negative jugular vein distention

9. Nurse Dylan is monitoring a client who is hypotensive. The nurse is aware that the body will compensate when this condition persists by activating the renin-angiotensin mechanism. The nurse will expect which of the following electrolytes will be affected in this mechanism?

a. Potassium, sodium, and magnesiumb. Chloride, calcium and sodiumc. Calcium, magnesium and phosphated. Sodium, chloride, and potassium10. Fluid volume deficit is suspected on a client who has been taking diuretics on a long-term basis. The nurse assigned on the client should monitor for what diagnostic abnormality related to the clients condition?

a. hematocrit of 30%

b. potassium level of 3.6 mEq/L

c. urine specific gravity of 1.035

d. central venous pressure 11 cm H20

11. Among the body functions below, osmosis can accomplish

a. Ventilation and perfusion

b. Urine production

c. Sweat production

d. Blood coagulation

12. A patient who has a history of chronic alcoholism goes to the hospital with his latest laboratory result of decreased magnesium level. When performing the initial assessment, the nurse should give emphasis on assessing the

a. Musculoskeletal systemb. Renal systemc. Respiratory systemd. Cardiovascular system13. As a knowledgeable nurse, you are aware that calcium level of 8.5 mg/dl is related to which of the following conditions?

a. Hyperparathyroidism that elevates the level of parathormone to attract calcium back to the circulation

b. Multiple myeloma that increases bone breakdown leading to the exit of calcium from the bone to the blood

c. Comatose state will signal osteoclastic activity and bone resorption

d. Chronic renal failure leading to inability to metabolize Vitamin D that promotes calcium absorption

14. Sodium polystyrene sulfonate (Kayexalate) enema will be administered by Nurse Azin to a client with a potassium level of 6.0 mEq/L. Nurse Azin is correct when she instructs the client to do what activity and expect which of the following side effects?

a. retain the enema for 30 minutes to allow for glucose exchange; afterward, the client should have diarrhea

b. retain the enema for 60 minutes to allow for glucose exchange; diarrhea is not necessary to reduce the potassium level

c. retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea.

d. retain the enema for 60 minutes to allow for sodium exchange; diarrhea is not necessary to reduce the potassium level.

15. After 1 week of hospitalization, the patient develops hypokalemia. Which of the following are significant symptoms of his disorder?

1. Muscle weakness

2. Leg cramps

3. Hypertension and tachycardia

4. Decreased bowel motility

5. U wave on ECG

6. Inverted T wave on ECG

7. Muscle irritability

a. all except 4 and 5

b. all except 3 and 7

c. 1, 2, 3, 5

d. 1, 2, 4, 5

16. Nurse Electra is reviewing the health care providers orders for a client who was transferred from surgery following aortic aneurysm repair. The orders are maintain client on NPO, keep nasogastric tube in place, vital signs q 1 hour, and an order that the nurse thinks he should clarify with the physician. The order that is pertained in the situation that needs physicians clarification is

a. 50 ml D5W with Cefoxitin (Mefoxin) 1gm IV over 30 minutes.b. 40 mEq potassium diluted in 1L D5W over 8 hoursc. 25 mEq potassium IV push.d. 10 mEq in 250 ml D5W to run over 3 hours17. A client developed hypermagnesemia due to untreated diabetic ketoacidosis. The nurse assigned to the client most likely expect all of the manifestation except

a. facial flushing, drowsiness, and dysarthria

b. muscle weakness, shallow breathing, and hypotension

c. urine output of 20 cc/hour, nausea and vomiting

d. absent patellar reflex, muscle rigidity and spasm

18. A client is now transferred back to the surgical floor after abdominal surgery. His IV is ordered to run at 125 ml per hour. The client is also on an NPO status while a nasogastric tube is placed for decompression. The nurse in the surgical floor will most likely expect the administration of

a. 0.9% sodium chlorideb. Dextrose 10% in waterc. Dextrose 5% in waterd. Lactated Ringers solution19. An IV running at 180 mL/hr via an IV pump is given to the patient following exploratory laparotomy. A nasogastric tube is also place to decompress the abdomen. While assessing the client, the nurse should notify the physician if which is observed?

a. Rales in all lung fields are noted upon auscultation

b. Increasing level of consciousness and negative pedal edema

c. Pump alarming that means a high pressure has been reachedd. Nasogastric tube output is 550 mL, urine output of 900 mL, and intake of 1800 mL

20. Nurse Rose is performing a dressing change on Mr. Pipin with an abdominal wound inserted with a Penrose drain. Nurse Rose should give focus in documenting the

a. Character of drainage, clients tolerance of procedure, type of dressing used.b. Type of dressing used, description of the wound, presence of drains with character of drainage.c. Description of the wound, presence and character of drainage, time and date of dressing change.d. Status of wound healing, amount of drainage, how client tolerated the procedure.21. The client had a colon resection this morning. In the post-operative period, the client is given with 0.9% NaCI at 125 ml per hour, inserted with a nasogastric tube under low-pressure suction and was created with ileostomy. The nurse noted that the client is progressively becoming restless. Upon reviewing the clients laboratory studies post-operatively, the nurse should be alerted with

a. Sodium level 152 mEq/L. b. H and H count 14.2 and 39%. c. Blood urea nitrogen 29 mg/dl.d. Capillary blood glucose 175 mg/dl. 22. The latest potassium level of a client with acute renal failure is 6.0 mEq/L. The priority action of the nurse is to

a. Increase fluid intake to dilute the electrolyte concentration.b. Request laboratory check for sodium level.

c. Add more fiber in the diet.d. Place the client on a cardiac monitor.23. Due to 2 days of constant fever with unknown origin, the client is for monitoring in the hospital. Physical assessment of Nurse Chiyo reveals sticky mucous membranes and profuse diaphoresis. Weakness and disorientation were also noted while Nurse Chiyo is interviewing the client. The neurologic assessment shows a decreasing level of consciousness. With these manifestations, Nurse Chiyo suspects the presence of

a. Hypermagnesemia.b. Hypernatremia.c. Hyperkalemia.d. Hypercalcemia.24. Mr. Azukal is started on low-dose intravenous insulin therapy. The nurse assigned to Mr. Azukal is aware of the important nursing assessments in accordance to the possible complications of this therapy, except frequent

a. evaluation of blood glucose levels, because glucose levels should decline as insulin levels increaseb. elevation of serum ketones to monitor the course of ketosis.c. blood pressure measurements to monitor the degree of hypotension.d. estimates of serum potassium, because increased blood glucose levels are correlated with elevated potassium levels.25. A nurse is assigned to clients with fluid imbalances. The nurse is knowledgeable to conclude that the kidneys control the output of fluids and the input of fluid is being controlled by

a. Antidiuretic hormone

b. Thirst sensation

c. Aldosterone release

d. Renin-angiotensin mechanism

ACID-BASE IMBALANCES

26. Mr. Allen was rushed in the emergency room after overdosing with sedatives. His arterial blood gas result reveals respiratory acidosis. He is placed on a cardiac monitor for possible ventricullar fibrillation. The nurse is aware that this cardiac complication is related to

a. Stimulation of the medulla oblongata.

b. Depression of the SA node.

c. Sedative effect to myocardium.

d. Hyperkalemia.

27. In case Mr. Allen developed ventricullar fibrillation, what should the nurse get from the crash cart as a preliminary emergency drug?

a. Epinephrine IM

b. Lidocaine IV push

c. Sodium bicarbonate IV

d. Potassium chloride side drip

28. A client is for monitoring in the emergency floor while waiting for the result of his arterial blood gas. As a knowledgeable nurse, you should know what breathing pattern is most appropriate in any of the blood gas result. Which of the following is suitably stated?

a. Pursed lip breathing is most appropriate to compensate for respiratory alkalosis

b. Purse lip breathing is most effective for respiratory acidosis

c. Ventilation with brown paper bag is suitable for respiratory acidosis

d. Ventilation with brown paper bag is least functional for respiratory alkalosis.

29. Mr. Guillermo was diagnosed of Guillain-Barr syndrome and recently develops respiratory acidosis as a result of reduced alveolar ventilation. As the nurse caring for Mr. Guillermo, you know that the kidneys play a major role in the compensatory mechanism of respiratory acidosis by

a. increased GFR of acid and stimulation of serum bicarbonate secretion

b. decreased GFR of acid and suppression of serum bicarbonate secretion

c. hyperventilation and suppression of serum bicarbonate secretion

d. hyperventilation and decreased GFR of acid

30. Due to pulmonary embolism confirmed on chest x-ray, the patient is starting to manifest symptoms of respiratory alkalosis. Other than the arterial blood gas analysis, the nurse should also monitor for which laboratory studies?

a. hyperkalemia, hypercalcemia, hypophosphatemia

b. hypokalemia, hypocalcemia, hyperphosphatemia

c. hyperkalemia, hypercalcemia, hyperphosphatemia

d. hypokalemia, hypocalcemia, hypophosphatemia

31. Radial arterial blood gas analysis is ordered to be performed on a client with chronic lung infection. Before drawing the sample, the nurse performs the Allens test correctly by

1. Open the hand in a relaxed, slightly flexed position

2. Release the pressure on the ulnar artery

3. Manually occlude the ulnar artery

4. Flushing of hands in about 3 to 5 seconds

5. Asking the patient to make a fist

6. Observing for pallor of the palms

a. 5, 3, 1, 6, 2, 4

b. 1, 6, 3, 4, 5, 2

c. 3, 5, 6, 1, 2, 4

d. 6, 1, 3, 5, 4, 2

32. Severe diarrhea can lead to metabolic acidosis due to excessive loss of bicarbonate. The nurse must therapeutically adhere to the collaborative management for this case. Which should the nurse anticipate to be prescribed for metabolic acidosis?

a. Fluid replacement

b. Administration of bronchodilators

c. Breath into a brown paper bag

d. Perform postural drainage

33. The physician ordered acetazolamide (Diamox) administration for a client with metabolic alkalosis after 24 hours of intermittent projectile vomiting. The main action of this drug in relation to acid-base imbalance is

a. it inhibits the combination of hydrogen ions and carbonate.

b. it increases excretion of bicarbonate by the kidneys.

c. it hastens the peristalsis to excrete bicarbonate in the feces.

d. it increases carbonic acid retention in the lungs.

34. Respiratory and metabolic acidosis may result to systemic manifestation. The nurse should monitor for

1. cerebral vasoconstriction

2. increased blood pressure

3. CNS depression

4. hypokalemia

5. coma

6. peripheral vasodilation

7. increased intracranial pressure

a. 1, 2, 3, 4

b. 2, 3, 5, 7

c. 1, 3, 5, 6

d. 2, 4, 6, 7

35. Hypovolemic shock has the tendency to cause acidosis. What is the physiologic basis of this acid-base imbalance?

a. Decreased blood volume compensates with enhancing the rate and depth of ventilation and increased sensitivity of the central chemoreceptors.b. Decreased blood volume is associated with hydrogen ion excess, poor respiratory and skeletal muscle weakness.c. Decreased blood volume is associated with decreased blood supply, oxygenation and increased anaerobic metabolism.d. Decreased blood volume is associated with failure of the kidneys to excrete hydrogen ions and reabsorb bicarbonate ions.36. A client with diabetes mellitus type I diagnosed 10 years ago advances to a complication called Diabetic ketoacidosis. The nurse notices this client to be breathing deeply and rapidly. The nurse correctly documented this as Kussmauls respirations. The scientific rationale for this kind of breathing pattern is

a. The shallow and slow respirations will increase the HCO3 in the serum.b. The kidneys produce excess urine and the lungs try to compensate.c. The respirations increase the amount of carbon dioxide in the bloodstream.d. The lungs speed up to release carbon dioxide and increase the pH.37. Nurse Vent is assigned to a 65-year-old patient, who is being weaned from a ventilator. Prior to extubation, the latest arterial blood gases are analyzed from the following results: pH of 7.33, PaO2 of 74mmHg, PaCO2 of 51mmHg and HCO3 of 25 mEq/L. Immediate physician notifications is necessary because the client is in a state of

a. Respiratory alkalosis

b. Respiratory acidosis

c. Metabolic alkalosis

d. Metabolic acidosis

38. A male clients findings on arterial blood gas analysis are pH 7.31, PaCO2 39 mm Hg, and HCO3 19 mEq/L. The nurse is aware that the effectivity of the medical regimen will be reflected if the next result will reveal

a. pH 7.40 and PaCO2 31 mm Hgb. pH 7.47 and PaCO2 50 mm Hgc. pH 7.42 and PaCO2 47 mm Hgd. pH 7.33 and PaCO2 29 mm Hg39. Upon interview for the clients medical history, the nurse is alerted that chronic lung disease belongs to the past diagnosis of the client. The nurse is aware that the client has an increased risk of developing respiratory acidosis and should watch out for which manifestations?

a. Restlessness, lethargy, inability to focus

b. Paresthesia, confusion, and bradypnea

c. Shallow and slowed breathing

d. Hyperactivity and bradycardia

40. One of the morning shift nurse is assigned to four patients in the ward. Which of the following patients handled by the nurse will most likely progress to metabolic alkalosis?a. A 12-year old boy receiving isotonic sodium chloride IV solution

b. A 61-year old with who is unable to access water freely

c. A 36-year old post surgical patient who has continuous nasogastric suction

d. A 58-year-old who just experienced a stroke

ANSWERS AND CONCEPT ILLUMINATIONSFLUIDS AND ELECTROLYTE IMBALANCES1. ANSWER: D.

CONCEPT ILLUMINATIONAcute hyponatremia could yield complications like cerebral edema. As the intravascular sodium level decreases, the intravascular fluid becomes diluted while the intracellular fluid is concentrated. This promotes osmosis or the move of fluid from the intravascular that is diluted, to the intracellular which is concentrated. This mechanism will develop cerebral edema as evidenced by altered mental status, obtunded state that may progress to coma. Highly hypertonic sodium solutions like 3% NaCl and 5% NaCl are used to relieve the manifestations of cerebral edema, not to correct the acute sodium depletion. These solutions does not affect the aldosterone release by the adrenal cortex and definitely not allow sodium ions to enter the cell, because sodium is normal retained extracellularly.

2. ANSWER: A.

CONCEPT ILLUMINATION

The potassium level and duration of blood storage are directly proportional, meaning as the storage time of the blood increases, known as aged blood, the potassium concentration also increases. Potassium concentration is related to the deterioration of red blood cell when the blood is stored for a longer time prior to its use. When the potassium level of the client is already elevated, extreme precaution should be done when the client is for blood transfusion.

3. ANSWER: A.

CONCEPT ILLUMINATIONThe choroid plexus, where the cerebrospinal fluid or CSF is formed, depends on chloride combined with sodium to attract water to form the fluid portion of the CSF. Cerebrospinal fluid functions to cushion the brain and prevent friction from the skull, provides nourishment to brain cells, removes metabolites and regulates intracranial pressure. Option B is incorrect because chloride is present in the extracellular fluid particularly in the interstitial space and lymphatic compartments than in blood or intravascularly. Option C is not related to chloride function since aldosterone release affects sodium and water, while chloride only follows sodium. Option D is also incorrect because chloride aids in hydrogen ions formation, not depression, which releases oxygen from hemoglobin for cerebral perfusion.4. ANSWER: B.CONCEPT ILLUMINATION

Potassium administration is very dangerous to clients with impaired renal function because of the change of decreased ability to excrete potassium. Serum potassium has a narrow therapeutic window, which is only from 3.5 to 5.0 mEq/L. When potassium can accumulate in the body and exceed the therapeutic level of 5.0 mEq/L, it can cause cardiac dysrhythmias and arrest. Regarding the vital signs, the complication of potassium excess is reflected by the apical pulse rate, instead of the blood pressure making option A not the priority. Assessment of skin turgor is more related for clients who are at risk for dehydration and not directly related to IV fluids containing potassium, thus option C is also unnecessary. Edema monitoring is for clients who are at risk for fluid volume excess in dependent position.

5. ANSWER: C.


In response to changes in fluid level in the body, the posterior pituitary gland will secrete antidiuretic hormone. This hormone binds to membrane bound receptors and increases water reabsorption by kidney tubules. This mechanism will result in less water loss as urine. When less fluid is loss in the urine, more fluid remains in the intravascular space, which will return to the heart. When the heart is not that effective in pumping out blood to the circulation, this will result to congestion and fluid volume excess. Rapid sodium excretion will be followed by increased fluid output and would not place the client at risk for excess fluid volume. Improved cardiac output will allow more renal perfusion, resulting in increased urine output and does not place the client at risk for excess fluid volume. An increase in GFR would not also put the client at risk for excess fluid volume. 6. ANSWER: B.

CONCEPT ILLUMINATIONA small gauge or lumen catheter is preferred for continuous fluid replacement. Gauge 22 is a small gauge catheter used to prevent sudden fluid overload. On the other hand, gauge 18 is the standard gauge for clients who will undergo blood transfusion. This gauge has larger lumen diameter to prevent blood coagulation. In terms of the insertion site, IV catheter insertion should be started in the most distal part of the extremity, using the lowest vein possible and progress upward. The antecubital area is not a preferred area.

7. ANSWER: D.


Paracentesis is done to remove the fluid situated in the peritoneal cavity. The nurse should make sure that the client listens attentively to instructions such as remaining still during the procedure so as not to puncture proximal organs. After paracentesis, since large amount of fluid is aspirated, the body could develop into vascular collapse or sudden and rapid decreased of fluid volume. The nurse should monitor the vital signs for signs of hypovolemic shock as evidenced by hypotension, tachycardia, and tachypnea. The temperature is not usually altered after paracentesis, unless there is the development of infection. Peristalsis will be affected prior to paracentesis because the enlarging abdomen compresses the colon. Respiratory difficulty and congestion are common also before the procedure because the diaphragm has limited expansion.

8. ANSWER: A.


When there is elevated blood volume in the body, the pressure of the blood will also increase. For clients with liver cirrhosis, the liver is not functioning normally and cannot adequately produce the most abundant protein, which is albumin. Albumin maintains the colloid osmotic pressure in the intravascular space. Hypoalbuminemia or decreased albumin level will lead to inadequate pulling of blood back to the blood vessels. One of the risks of this condition is pulmonary congestion as evidenced by dyspnea and crackles auscultated due to presence of fluid.

9. ANSWER: D.


In response to decreased blood volume and perfusion to the kidneys, the juxtaglomerular apparatus will release the enzyme called renin into the circulation. Renin acts on the protein angiotensinogen, which will be converted to angiotensin I. As blood flows with angiotensin I and goes to the lungs, the angiotensin-converting-enzyme will convert angiotensin I to angiotensin II. This last enzyme is a potent vasoconstrictor and will also act on the adrenal cortex to produce more aldosterone. Aldosterone increases sodium reabsorption and will be followed by fluid that will now elevate the blood volume. Aldosterone also leads to potassium excretion, resulting in an increase in chloride. Sodium, potassium, and chloride are the main electrolytes affected on this mechanism. Calcium level is related to the action of the parathyroid gland, thyrocalcitonin, and vitamin D produced by the kidneys. On the other hand, calcium balance influences phosphorus and magnesium regulation by the kidneys. 10. ANSWER: C.


Long-term intake of diuretics may lead to dehydration and fluid volume deficit. When the body has less blood volume, the compensatory mechanism is decreased glomerular filtration to decrease urine output. If the body is conserving the remaining fluid, the urine specific gravity will be elevated. Urine specific gravity is the measure of the concentration of the particles or solutes in the urine. A high specific gravity indicates concentrated urine. Normal urine specific gravity is 1.010 to 1.030. The hematocrit level in option A is decreased, which means hemodilution due to excessive fluid volume not deficit. The normal hematocrit level is 37% to 47%. Potassium level in option B is normal, indicating that there is no problem with regards to the effect of most diuretics which is hypokalemia. Central venous pressure is the pressure of the right side of the heart and the normal level is 0 to 14 cm H2O, therefore option D means that there is no problem in the fluid level of the body.

11. ANSWER: B.


Osmosis is the passage or movement of solvent from a less concentrated to a more concentrated solution through a semi-permeable membrane. This tends to equalize the concentrations of the two solutions. Urine production is achieved through osmosis. The mechanism starts with filtration to form a filtrate, a less concentrated area, in the Bowmans capsule. Then the reabsorption phase takes place when solutes move from a more concentrated area to a less concentrated area, which is the filtrate. On the other hand, water is reabsorbed across the wall of the nephrons by osmosis. Ventilation and perfusion work best using diffusion, or the movement of solute, that is the oxygen, from an area of more oxygen to an area of less oxygen. Example is the movement of oxygen from alveoli to the blood and then perfusion when oxygen moves from the blood to the cells. Sweat production is more on excretion of sodium ions. Blood coagulation is aided by platelets and clotting factors, not by osmosis.

12. ANSWER: D.

CONCEPT ILLUMINATIONMagnesium primarily aids in bone formation and for the maintenance of nerve and muscle functions. Magnesium naturally works as a sedative of the muscles. When there is magnesium toxicity, the body becomes weak and the reflexes become hypoactive. In case of magnesium deficiency, since sedative effect is lessened, the body will become irritable causing arrthythmias, vasodilation, and hyperactive reflexes of the nervous system. Normal magnesium level is 1.5 to 2.5 mEq/L. Cardiovascular function should be monitored closely because hypomagnesemia can cause life-threatening arrhythmias, resulting in cardiovascular failure and arrest. The musculoskeletal system may also be affected in magnesium deficiency but this is not the priority of the nurse, as well as the renal system. The respiratory system could become hyperactive in case of magnesium deficiency; therefore, this system will only be the priority if there is risk of respiratory failure, which commonly happens in hypermagnesemia.

13. ANSWER: D.


The calcium level in the situation indicates hypocalcemia. The normal level of calcium is 4.5 to 5.5 mEq/L or 9 to 11 mg/dl. The kidneys are responsible in metabolizing Vitamin D, which main function is to promote calcium absorption in the intestines. When the kidneys fail, the vitamin D level will be insufficient for calcium absorption leading to hypocalcemia. Hyperparathyroidism causes hypercalcemia because of the increased level of parathormone that promotes bone tissue breakdown leading to the movement of calcium back to the circulation. Multiple myeloma is abnormal proliferation of plasma cells in the bone. Since the bone structures are saturated with the plasma cells, the bone will break down leading to the exit of calcium from the bone going to the blood that again causes hypercalcemia. Comatose clients have prolonged bed rest and due to immobility or non-usage of the bones, osteoclastic activity will be trigger leading to bone resorption and demineralization.

14. ANSWER: C.


Potassium and sodium in the body is inversely proportional due to the sodium-potassium pump. In case of hyperkalemia, kayexalate is given since it is a sodium exchange resin. This composition of enema will allow the body to gain sodium, as potassium is lost in the bowel. For the exchange to occur, Kayexalate must be in contact with the bowel for at least 30 minutes, therefore the nurse should instruct the client to retain the solution in the area. Sorbitol in the Kayexalate enema causes diarrhea, which increases potassium loss and decreases the potential for Kayexalate retention.

15. ANSWER: D.

CONCEPT ILLUMINATIONPotassium is the major intracellular electrolyte. The influence of potassium is direct to cardiac and skeletal muscles. Under the mechanism of the sodium-potassium pump, potassium goes in and out of the cell. In cases of hypokalemia, direct irritability to the cardiac and skeletal muscles will be decreased causing muscle weakness, leg cramps, decreased bowel motility, anorexia, nausea, vomiting, paresthesias and dysrhythmias like presence of U wave, short T wave, and depressed ST segment. Hypertension, tachycardia, and muscle irritability are more related to hyperkalemia. Inverted T wave will be seen on clients with myocardial infarction due to ischemic regions in the myocardium.

16. ANSWER: C.

CONCEPT ILLUMINATIONLethal effects will happen if potassium is given IV push. This route allows rapid accumulation of potassium that can lead to cardiac arrest. It is also extremely irritating and painful at the catheter site. The therapeutic way of giving potassium is to dilute it in an IV solution and run over the time of the total infusion. Examples of therapeutic potassium administration are 40 mEq potassium diluted in 1L D5W over 8 hours or potassium 10 mEq in 250 ml D5W to run over 3 hours. The other orders listed are all within acceptable limits for a postoperative client.

17. ANSWER: B.


Hypermagnesemia is a complication of untreated diabetic ketoacidosis when catabolism releases cellular magnesium that cannot be excreted due to decreased GFR in an attempt to alleviate fluid volume depletion. Magnesium acts like a sedative, that when the level of it in the body is increased, body neuromuscular functions are depressed. Manifestations include muscle weakness that can lead to paralysis, nausea and vomiting, facial flushing, drowsiness and difficulty speaking or dysarthria, respiratory depression leading to shallow slowed breathing, hypotension, decreased urinary reflex leading to oliguria and hypoactive to absent deep tendon reflexes. Option D is incorrect in terms of muscle rigidity and spasm because both of these symptoms can be seen in hypomagnesemia, where the sedative effects are decreased leading to hyperactivity of muscles.

18. ANSWER: D.


Lactated Ringers solution is an isotonic solution that contains multiple electrolytes with closely the same concentration with plasma. It is used for clients with risk of fluid and electrolyte imbalance after abdominal surgery, burns, fluid lost as bile or diarrhea, or for acute blood loss replacement.

19. ANSWER: A.


One of the complications of intravenous fluid replacement is pulmonary congestion as evidenced by rales or crackles auscultated in all lung fields. This should be brought to the HCPs attention. Increasing level of consciousness indicates that oxygenation in the lungs and cerebral perfusion is normal. Negative pedal edema conveys not fluid retention.

20. ANSWER: C.


The status of the wound, characteristics of the drainage, and time and date of dressing change are the most critical data to record. How well the client tolerated the procedure may be charted if the client had untoward response, but other information is more critical. Type of dressing used is not necessary.

21. ANSWER: A.


The client is placed on suction plus ileostomy excretes fluid output. Both of these means that the client is losing fluids, but the only replacement fluid used is 0.9% NaCl, which only contains sodium and not enough to compensate with the losing electrolytes. The laboratory value of sodium level 152 mEq/L indicates that the client has hypernatremia. Sodium is followed by water in the kidneys, therefore there will be increased venous return and cardiac workload. The hemoglobin and hematocrit values are within the normal range. The blood urea nitrogen (BUN) level is elevated, and this needs to be investigated and correlated with the serum creatinine level. It is not alarmingly high and could be indication of decreased fluids, but it is not the priority concern. The glucose level is expected to be elevated due to the stress brought by the surgical procedure.22. ANSWER: D.


The complication of hyperkalemia is increased stimulation of the heart which may cause cardiac dysrhythmias that can lead to cardiac arrest. Because of this, the client should be placed on a cardiac monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the serum potassium level significantly. The nurse also may assess the sodium level because sodium is another electrolyte commonly measured with the potassium level. However, this is not a priority action of the nurse. Vegetables are a natural source of potassium in the diet, and their use would not be increased.

23. ANSWER: B.CONCEPT ILLUMINATIONDue to water loss in profuse diaphoresis, sodium is retained in high concentration in the body known as hypernatremia. Manifestations of hypernatremia are sticky mucous membranes, musculoskeletal affectation evidenced by weakness, and neurologic involvement as a sign of disorientation and decreased level of consciousness. Only weakness and decreasing level of consciousness are affected by hypermagnesemia, hyperkalemia, and hypercalcemia. The other manifestations are uncommon to these 3 options.

24. ANSWER: D.


It is true that when the blood glucose level increases, potassium level will most likely increase because potassium ions are attached to glucose. However, the situation pertains to the assessment that the nurse should not do frequently. When a client is receiving insulin, regular glucose monitoring is necessary, but not potassium level unless the client has other associated disorders that potassium could aggravate. The nurse should include only the monitoring of glucose for possible hypoglycemia due to the insulin therapy. In addition is the monitoring for serum ketones since insulin is given to diabetes mellitus Type I which is also related to the development of ketosis. Clients receiving insulin are also at risk for hypotension because of diluted blood with less glucose.

25. ANSWER: B.


Intake and output mechanism should work collaboratively to maintain the fluid status of the body on equilibrium. The kidneys play a major role in the excretion or output of body fluids. On the other hand, thirst sensation acts as the major control of fluid intake or input. Unless the body is triggered by the oral cavity for the presence of dryness and thirst, fluid input will not be achieved. Antidiuretic hormone controls also the output like the kidneys, since it prevents diuresis. Aldosterone is another hormone that reabsorbs water and sodium, therefore it acts mainly on output control. Renin-angiotensin mechanism is under the kidney control on fluid status.

ACID-BASE IMBALANCES

26. ANSWER: D.

CONCEPT ILLUMINATIONSedative depresses the respiratory function, slowing respiration, and retaining carbon dioxide causing respiratory acidosis. Hyperkalemia may result as the hydrogen concentration overwhelms the compensatory mechanisms and hydrogen ions moves into cells, causing a shift of potassium out of the cell into the blood. Potassium has a direct effect to the myocardial contraction, therefore hyperkalemia will rapidly and excessive stimulate the ventricular contraction causing ventricullar fibrillation. The medulla oblongata is not directly stimulated by potassium. Depression of SA node and sedation of the myocardium both slows down the conduction and contractility of the heart, therefore ventricullar fibrillation is not possible in this two conditions.

27. ANSWER: C.


The cause of ventricullar fibrillation is hyperkalemia secondary to respiratory acidosis. The body effectively compensates with respiratory acidosis by increasing the bicarbonate level yielding to metabolic alkalosis. The preliminary emergency drug in this situation is sodium bicarbonate basing on the origin of the attack. Epinephrine and lidocaine are next to be given to stabilize the conduction. Potassium chloride will only aggravate the fibrillation since it will further increase potassium level. 28. ANSWER: B.

CONCEPT ILLUMINATIONBreathing techniques aid in either carbon dioxide elimination or retention. In respiratory acidosis, the goal is to eliminate carbon dioxide level because it is elevated in the circulation. The best way to eliminate carbon dioxide is to perform pursed lip breathing because this prolongs the exhalation phase and excretes more carbon dioxide compared to normal exhalation. On the other hand, respiratory alkalosis goal is to retain carbon dioxide because it is insufficient in the circulation. Carbon dioxide is best retained when the client is taught to breathe using a paper bag. This traps the carbon dioxide inside the bag, and when the client inhales again, more carbon dioxide will likely enter back the pulmonary area. Option A is incorrect because pursed lip is for respiratory acidosis, not alkalosis. Option C is incorrect as well, because ventilation with paper bag is more suitable for respiratory alkalosis. Option D should be states as ventilation with brown paper bag is more functional for respiratory alkalosis.

29. ANSWER: A.

CONCEPT ILLUMINATIONThe kidneys also maintain the equilibrium of acids and bases in the body. In case of respiratory acidosis, the function of the kidneys is to eliminate the acid. This is done by increasing the glomerular filtration rate (GFR) of acid while stimulating bicarbonate secretion. When bicarbonate is elevated in the blood, the body will interpret this as metabolic alkalosis in response to respiratory acidosis. Hyperventilation also aids in respiratory acidosis, however this is effective if with stimulation of serum bicarbonate secretion.

30. ANSWER: D.


Respiratory alkalosis should be monitored for electrolyte imbalance specifically hypokalemia, hypocalcemia, hypophosphatemia. Hypokalemia results from hydrogen ions pulled out of the cell in exchange for potassium. There will be potassium entrance into the cell leading to deficient potassium level in the blood. On the other hand, severe alkalosis leads to inhibited ionization of calcium causing hypocalcemia. Hypophosphatemia is from the reuptake of phosphate by the cells, thereby losing phosphate in the blood.

31. ANSWER: A.


Allens test is performed prior to radial arterial blood gas analysis. The purpose of this test is to assess and confirm for the presence of collateral circulation using the ulnar artery. The blood sample may be taken from the radial artery safely if collateral circulation is adequate. The correct method in performing Allens test is by:

1. Asking the patient to make a fist

2. Manually occlude the ulnar artery

3. Open the hand in a relaxed, slightly flexed position

4. Observing for pallor of the palms

5. Release the pressure on the ulnar artery

6. Flushing of hands in about 3 to 5 seconds

32. ANSWER: A.


The body will have the tendency to increase the rate and depth of respirator to promote respiratory alkalosis to compensate with metabolic acidosis. This is known as hyperventilation to eliminate carbon dioxide so as not to aggravate the acidity of the blood. Hyperventilation will lead to rapid insensible water loss. Fluid replacement will be ordered by the physician. Bronchodilators are therapeutic for clients with respiratory acidosis, not metabolic acidosis. Breathing into a brown paper bag is related to respiratory alkalosis to reinhale carbon dioxide and this is not what the body wanted in the treatment of metabolic acidosis. Postural drainage is more related to trapping of carbon dioxide in respiratory acidosis.

33. ANSWER: B.

CONCEPT ILLUMINATIONMetabolic alkalosis is due to bicarbonate excess. The goal of acetazolamide (Diamox), which is a carbonic anhydrase inhibitor, is to increase the excretion of bicarbonate by the kidneys. The renal system is the main organ that retains and excretes bicarbonate. Therefore, to control the bicarbonate level, the renal excretion of bicarbonate should be triggered. The other options are not related to the action of acetazolamide.

34. ANSWER: B.


Respiratory and metabolic acidosis has direct effect to the cerebral and peripheral blood vessels. Here are the manifestations that the nurse should watch out:

1. Cerebral vasodilation is associated with acidosis. Cerebral vasoconstriction is related to alkalosis.

2. Increased blood pressure secondary to peripheral vasoconstriction.

3. CNS depression secondary to cerebral vasodilation, therefore watched out for coma.

4. Hyperkalemia due to hydrogen ions moving into cell while potassium will go out of the cell into the serum. Hypokalemia results from alkalosis.

5. Coma secondary to cerebral vasodilation and CNS depression.

6. Peripheral vasoconstriction is associated with acidosis. Peripheral vasodilation will be seen in alkalosis.

7. Increased intracranial pressure can be seen both in acidosis and alkalosis. If acidosis is the cause, it is because of the vasodilatory effect. If alkalosis is the cause, it is due to vasoconstriction but increased firing effect.

35. ANSWER: C.


Hypovolemic shock leads to decreased oxygen supply and perfusion. The metabolism of the cell will then be achieved through anaerobic respiration that will result to synthesis of lactic acid. Lactic acid will produce more hydrogen ions that are acidic causing metabolic acidosis. 36. ANSWER: D.


Diabetic acidosis is one of the causes of metabolic acidosis. The main goal of the body with this specific imbalance is to promote respiratory alkalosis. To achieve respiratory alkalosis, Kussmauls respiration is done to decrease carbonic acid level, which is a type of acid that aggravates metabolic acidosis. When the client breaths deeply and rapidly, carbon dioxide is largely eliminated, then stimulation for high pH or alkalosis will be attained.

37. ANSWER: B.


The first step in interpretation is to determine if pH is alkalosis or acidosis. Then evaluate PaCo2 as the respiratory component and HCO3 as the metabolic component. The clients pH is 45 mmHg indicate a state of respiratory acidosis and indicates that the patient is not tolerating the weaning process.

38. ANSWER: A.

CONCEPT ILLUMINATIONThe interpretation of the arterial blood gas in the situation is uncompensated metabolic acidosis. It is said to be uncompensated because the partial pressure of carbon dioxide in the situation remained to be normal, even with the presence of acidic pH and metabolic acidosis. The treatment regimen is said to be effective if the pH will become normal and the partial pressure of carbon dioxide will become alkalosis in response to the metabolic acidosis. A pH level of 7.40 means full compensation and PaCO2 of 31 mm Hg means respiratory alkalosis.

39. ANSWER: A.


Chronic lung disease can lead to respiratory acidosis because of decreased oxygenation and elevated carbon dioxide level. The effect of acidosis to the nervous system is that this condition causes cerebral vasodilation, which can lead to increased intracranial pressure and central nervous system depression. The manifestations of such complication are manifested by restlessness, lethargy, and inability of the client to focus. Contrary to acidosis is alkalosis, which may cause cerebral vasoconstriction and central nervous system stimulation as evidenced by seizure and hyperactivity. In terms of the bodys compensatory mechanism, when there is respiratory acidosis, the body will tend to increase and make the respiration deep to expel carbon dioxide and accommodate oxygen. The choices that contain bradypnea, shallow and slowed breathing, plus bradycardia are all not forms of the bodys compensatory mechanism. Paresthesia is more related to deficient perfusion to extremities. Hyperactivity is applicable for respiratory alkalosis due to central nervous system stimulation.

40. ANSWER: C.


The physiologic disturbance of patients with metabolic alkalosis is high pH and elevated plasma bicarbonate concentration. Patients who are vomiting, with intestinal obstruction, and are undergoing gastric lavage are likely to progress to metabolic alkalosis with loss of hydrogen and chloride ions.

242-257 f&e

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