IVT HERAPY Q AND A 2

7/27/2019 IVT HERAPY Q AND A 2

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What is the nurse's primary concern regarding

fluid & electrolytes when caring for an elderly

pt who is intermittently confused?

1. risk of dehydration

2. risk of kidney damage

3. risk of stroke

4. risk of bleeding

Answer: 1

Rationale 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.

The nurse is planning care for a pt with severe

burns. Which of the following is this pt at risk

for developing?

Answer: 1

Rationale 1: Because this pt was severely


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1. intracellular fluid deficit

2. intracellular fluid overload

3. extracellular fluid deficit

4. interstitial fluid deficit

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 fluidsthat 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.


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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?

1. the body's natural compensatory

mechanisms

2. pharmacological effects of a diuretic

3. effects of rapidly infused intravenous fluids4. cardiac failure

Answer: 1

Rationale 1: The internal vasoconstrictive

compensatory reactions within the body are

responsible for the symptoms exhibited. The

body naturally attempts to conserve fluid

internally specifically for the brain & 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.

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?

1. Risk for Imbalanced Fluid Volume

Answer: 1

Rationale 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


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2. Excess Fluid Volume

3. Imbalanced Nutrition

4. Ineffective Tissue Perfusion

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

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?

1. 600 mL

2. 750 mL

3. 1000 mL

4. 1200 mL

Answer: 1

Rationale 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).


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A pt is receiving intravenous fluids

postoperatively following cardiac surgery.

Nursing assessments should focus on which

postoperative complication?

1. fluid volume excess

2. fluid volume deficit

3. seizure activity

4. liver failure

Answer: 1

Rationale 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.


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A pt is diagnosed with severe hyponatremia.

The nurse realizes this pt will mostly likely

need which of the following precautions

implemented?

1. seizure

2. infection

3. neutropenic

4. high-risk fall

Answer: 1

Rationale 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 notspecifically indicated for a pt with

hyponatremia.

Rationale 4: High-risk fall precautions not

specifically indicated for a pt with

hyponatremia.

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?

1. corticosteroid

Answer: 1

Rationale 1: Excess potassium loss through

the kidneys is often caused by such meds as

corticosteroids, potassium-wasting diuretics,

amphotericin B, & large doses of some


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2. thiazide diuretic

3. narcotic

4. muscle relaxer

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.

A pt prescribed spironolactone isdemonstrating ECG changes & complaining of

muscle weakness. The nurse realizes this pt is

exhibiting signs of which of the following?

1. hyperkalemia

2. hypokalemia

3. hypercalcemia

4. 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


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have received many units of citrated blood & is

not associated with diuretic use.

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?

1. Restrict fluids.

2. Administer intravenous fluids.3. Provide Kayexalate.

4. Administer intravenous normal saline with

furosemide.

Answer: 1

Rationale 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 droppingfurther 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.


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When caring for a pt diagnosed with

hypocalcemia, which of the following should

the nurse additionally assess in the pt?

1. other electrolyte disturbances

2. hypertension

3. visual disturbances

4. drug toxicity

Answer: 1

Rationale 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 hypocalcemia.

Rationale 4: Hypercalcemia is more commonlycaused by drug toxicities.

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?

1. Request a dietitian consult for selecting

foods high in phosphorous.

2. Provide aluminum hydroxide antacids as

prescribed.

3. Instruct pt to avoid poultry, peanuts, &

Answer: 1

Rationale 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


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seeds.

4. Instruct to avoid the intake of sodium

phosphate.

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.

When analyzing an arterial blood gas report of

a pt with COPD & respiratory acidosis, thenurse anticipates that compensation will

develop through which of the following

mechanisms?

1. The kidneys retain bicarbonate.

2. The kidneys excrete bicarbonate.

3. The lungs will retain carbon dioxide.

4. The lungs will excrete carbon dioxide.

Answer: 1

Rationale 1: The kidneys will compensate for arespiratory 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

The nurse is caring for a pt diagnosed with

renal failure. Which of the following does the

Answer: 1

Rationale 1: In metabolic acidosis


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nurse recognize as compensation for the acid-

base disturbance found in pts with renal

failure?

1. The pt breathes rapidly to eliminate carbon

dioxide.

2. The pt will retain bicarbonate in excess of

normal.

3. The pH will decrease from the present

value.4. The pt's oxygen saturation level will

improve.

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 metabolicacidosis 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.

When caring for a group of pts, the nurse

realizes that which of the following health

Answer: 1

Rationale 1: Metabolic alkalosis is cause by


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problems increases the risk for metabolic

alkalosis?

1. bulimia

2. dialysis

3. venous stasis ulcer

4. COPD

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.

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?

1. Encourage the pt to breathe in & out slowly

into a paper bag.

Answer: 1

Rationale 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


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2. Immediately administer oxygen via a mask

& monitor oxygen saturation.

3. Prepare to start an intravenous fluid bolususing isotonic fluids.

4. Anticipate the administration of intravenous

sodium bicarbonate.

oxygen is not indicated, & would exacerbate

the problem if given. Intravenous fluids would

not be the initial intervention.Rationale 3: Not enough information is given

to determine the need for intravenous fluids.

Rationale 4: Bicarbonate would be

contraindicated as the pH is already high.

A pt is prescribed 20 mEq of potassiumchloride. The nurse realizes that the reason

the pt is receiving this replacement is

1. to sustain respiratory function.

2. to help regulate acid-base balance.

3. to keep a vein open.

4. to encourage urine output.

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.


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An elderly pt does not complain of thirst. What

should the nurse do to assess that this pt is

not dehydrated?1. Ask the physician for an order to begin

intravenous fluid replacement.

2. Ask the physician to order a chest x-ray.

3. Assess the urine for osmolality.

4. Ask the physician for an order for a brain

scan.

Answer: 3

Rationale 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.

An elderly pt who is being medicated for pain

had an episode of incontinence. The nurse

realizes that this pt is at risk for developing

1. dehydration.

Correct Answer: 1

Rationale 1: Functional changes of aging also

affect fluid balance. Older adults who have

self-care deficits, or who are confused,


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2. over-hydration.

3. fecal incontinence.

4. a stroke.

depressed, tube-fed, on bed rest, or taking

medications (such as sedatives, tranquilizers,

diuretics, & laxatives), are at greatest risk forfluid volume imbalance.

Rationale 2: There is inadequate evidence to

support the risk of over-hydration.


support the risk of fecal incontinence.


support the risk of a stroke.

The nurse assesses a pt's weight loss as being

22 lbs. How many liters of fluid did this pt

lose?

Correct Answer: 10

Rationale: Each liter of body fluid weighs 1 kg

or 2.2 lbs. This pt has lost 10 liters of fluid.

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?

Answer: 3

Rationale 1: The pt should avoid prolonged

standing.

Rationale 2: Bed rest can promote skin


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1. Assist the pt to maintain a standing position

for several minutes.

2. This pt should be on bed rest.3. Assist the pt to move into different

positions in stages.

4. Contact physical therapy to provide a

walker.

breakdown.

Rationale 3: The pt needs to be taught how to

avoid orthostatic hypotension which wouldinclude 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.

A postoperative pt is diagnosed with fluid

volume overload. Which of the following

should the nurse assess in this pt?

1. poor skin turgor

2. decreased urine output

3. distended neck veins

4. concentrated hemoglobin & hematocrit

levels

Answer: 3

Rationale 1: Poor skin turgor is associated with

fluid volume deficit.

Rationale 2: Decreased urine output is

associated with fluid volume deficit.

Rationale 3: Circulatory overload causes

manifestations such as a full, bounding pulse;

distended neck & peripheral veins; increased

central venous pressure; cough; dyspnea;

orthopnea; rales in the lungs; pulmonary

edema; polyuria; ascites; peripheral edema, or


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if severe, anasarca, in which dilution of plasma

by excess fluid causes a decreased hematocrit

& blood urea nitrogen (BUN); & possiblecerebral edema.

Rationale 4: Increased hemoglobin &

hematocrit values are associated with fluid

volume deficit.

An elderly pt is at home after being diagnosedwith fluid volume overload. Which of the

following should the home care nurse instruct

this pt to do?

1. Wear support hose.

2. Keep legs in a dependent position.

3. Avoid wearing shoes while in the home.

4. Try to sleep without extra pillows.

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


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extra pillows to keep the head up while

sleeping.

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?

1. hypokalemia

2. hypernatremia3. carbon dioxide

4. magnesium

Answer: 2

Rationale 1: The kidneys are the principal

organs involved in the elimination of

potassium. Renal failure is often associated

with elevations potassium levels.

Rationale 2: The kidney is the primaryregulator 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.

An elderly pt comes into the clinic with the

complaint of watery diarrhea for several days

with abdominal & muscle cramping. The nurse

Answer: 2

Rationale 1: Hypernatremia is associated with

fluid retention & overload. FVE is associated


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realizes that this pt is demonstrating which of

the following?

1. hypernatremia2. hyponatremia

3. fluid volume excess

4. hyperkalemia

with hypernatremia.

Rationale 2: This elderly pt has watery

diarrhea, which contributes to the loss ofsodium. 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.

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?

1. pulmonary edema

2. atrial dysrhythmias

3. cerebral bleeding

4. stress fractures

Answer: 3

Rationale 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.


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These vessels may tear, bleed, & lead to

cerebral vascular bleeding.

Rationale 4: There have been no activities tosupport the development or occurrence of

stress fractures.

The nurse is admitting a pt who was

diagnosed with acute renal failure. Which of

the following electrolytes will be most affectedwith this disorder?

1. calcium

2. magnesium

3. phosphorous

4. potassium

Answer: 4

Rationale 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

A pt who is taking digoxin (Lanoxin) is

admitted with possible hypokalemia. Which of

Answer: 1

Rationale 1: Hypokalemia increases the risk of


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the following does the nurse realize might

occur with this pt?

1. Digoxin toxicity may occur.2. A higher dose of digoxin (Lanoxin) may be

needed.

3. A diuretic may be needed.

4. Fluid volume deficit may occur.

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.

A pt is prescribed 40 mEq potassium as a

replacement. The nurse realizes that this

replacement should be administered

1. directly into the venous access line.

2. mixed in the prescribed intravenous fluid.

3. via a rectal suppository.

4. via intramuscular injection.

Answer: 2

Rationale 1: Never administer undiluted

potassium directly into a vein.

Rationale 2: The intravenous route is the

recommended route for diluted potassium.

Rationale 3: The nurse should administer

diluted potassium into the pt's intravenous

line.

Rationale 4: The nurse should administer

diluted potassium into the pt's intravenous

line.


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An elderly pt with a history of sodium

retention arrives to the clinic with the

complaints of "heart skipping beats" & legtremors. Which of the following should the

nurse ask this pt regarding these symptoms?

1. "Have you stopped taking your digoxin

medication?"

2. "When was the last time you had a bowel

movement?"

3. "Were you doing any unusual physical

activity?"

4. "Are you using a salt substitute?"

Answer: 4

Rationale 1: Although this pt may be

prescribed digoxin this is not the primaryfocus 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.

A 35-year-old female pt comes into the clinic

postoperative parathyroidectomy. Which of the

following should the nurse instruct this pt?

1. Drink one glass of red wine per day.

Answer: 3

Rationale 1: This pt should avoid alcohol.

Rationale 2: This pt can benefit from sun

exposure.


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2. Avoid the sun.

3. Milk & milk-based products will ensure an

adequate calcium intake.4. Red meat is the protein source of choice.

Rationale 3: This pt is at risk for developing

hypocalcemia. This risk can be avoided if

instructed to ingest milk & milk-basedproducts.

Rationale 4: Protein monitoring is not

indicated.

A pt is admitted for treatment of

hypercalcemia. The nurse realizes that thispt's intravenous fluids will most likely be

which of the following?

1. dextrose 5% & water

2. dextrose 5% & ? normal saline

3. dextrose 5% & ? normal saline

4. normal saline

Answer: 4

Rationale 1: If isotonic saline is not used, thept 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


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sodium excretion is accompanied by calcium

excretion through the kidneys.

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?

1. sodium

2. potassium3. calcium

4. magnesium

Answer: 4

Rationale 4: One risk factor for

hypomagnesaemia is an endocrine disorder,

including diabetic ketoacidosis.

An elderly pt with peripheral neuropathy has

been taking magnesium supplements. The

nurse realizes that which of the followingsymptoms can indicate hypomagnesaemia?

1. hypotension, warmth, & sweating

2. nausea & vomiting

3. hyperreflexia

Answer: 1

Rationale 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


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4. excessive urination associated & hyperreflexia.

Rationale 4: Urinary changes are not noted.

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?

1. hypercalcemia

2. hypophosphatemia3. hypernatremia

4. hypermagnesemia

Correct Answer: 2

Rationale 1: Pts who experience burns are not

at an increased risk for developing increased

blood calcium levels.

Rationale 2: Causes of hypophosphatemiainclude stress responses & extensive burns.



blood sodium levels.



blood magnesium levels.

A pt is diagnosed with hyperphosphatemia.

The nurse realizes that this pt might also have

Answer: 1

Rationale 1: Excessive serum phosphate levels


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an imbalance of which of the following

electrolytes?

1. calcium2. sodium

3. potassium

4. chloride

cause few specific symptoms. The effects of

high serum phosphate levels on nerves &

muscles are more likely the result ofhypocalcemia that develops secondary to an

elevated serum phosphorus level. The

phosphate in the serum combines with ionized

calcium, & the ionized serum calcium level

falls.

The nurse is reviewing a pt's blood pH level.

Which of the systems in the body regulate

blood pH? Select all that apply.

1. renal

2. cardiac

3. buffers

4. respiratory

Answer: 1,3

Rationale 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.


the body to maintain the pH despite

continuous acid production: buffers, the


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the body to maintain the pH despitecontinuous acid production: buffers, the


The nurse observes a pt's respirations & notes

that the rate is 30 per minute & the

respirations are very deep. The metabolicdisorder this pt might be demonstrating is

which of the following?

1. hypernatremia

2. increasing carbon dioxide in the blood

3. hypertension

4. pain

Answer: 2

Rationale 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.


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Rationale 4: Pain may be manifested in rapid,

shallow respirations.

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 is

1. fully compensated.

2. demonstrating anaerobic metabolism.

3. partially compensated.4. in need of intravenous fluids

Answer: 3

Rationale 1: If the pH is restored to within

normal limits, the disorder is said to be fully

compensated.

Rationale 2: Anaerobic metabolism resultswhen 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

intravenous fluids, this is not the most correct

or definitive answer.


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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 isdemonstrating is which of the following?

1. respiratory acidosis

2. metabolic acidosis

3. respiratory alkalosis

4. metabolic alkalosis

Answer: 4

Rationale 1& 2: Respiratory acidosis &

metabolic acidosis are both consistent with pHless 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.

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?

Answer: 1

Rationale 1: Acute respiratory acidosis occurs

due to a sudden failure of ventilation.

Overdoses of narcotic or sedative medications

can lead to this condition.

Rationale 2: The pt condition being described

is respiratory not metabolic in nature.


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1. respiratory acidosis

2. metabolic acidosis

3. respiratory alkalosis4. metabolic alkalosis



Overdoses of narcotic or sedative medicationscan lead to this condition.



Overdoses of narcotic or sedative medications

can lead to this condition. The pt condition

being described is respiratory not metabolic in

nature.

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?

Answer: 540

Rationale: Fluid allowed is calculated by

figuring the total daily IV intake (in this case

10 mL/hr 24 hours = 240 mL/day),

subtracting that total from the daily allowance

(in this case 1200mL - 240 mL = 960mL). The

amount calculated is then distributed as 50%

for the traditional day shift, 25%-35% for the

traditional evening shift, & the remainder for


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the traditional night shift. In this case, 50% of

960 is 540 mL.

The pt is receiving intravenous potassium

(KCL). Which nursing actions are required?

Select all that apply.

1. Administer the dose IV push over 3

minutes.

2. Monitor the injection site for redness.3. Add the ordered dose to the IV hanging.

4. Use an infusion controller for the IV.

5. Monitor fluid intake & output.

Answer: 2,4,5

Which pts are at risk for the development of

hypercalcemia? Select all that apply.1. the pt with a malignancy

2. the pt taking lithium

3. the pt who uses sunscreen to excess

4. the pt with hyperparathyroidism

Correct Answer: 1,2,4,5

Rationale 1: Pts with malignancy are at risk fordevelopment of hypercalcemia due to

destruction of bone or the production of

hormone-like substances by the malignancy.

Rationale 2: Lithium & overuse of antacids can


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5. the pt who overuses antacids result in hypercalcemia. Hypercalcemia can

result from hyperparathyroidism which causes

release of calcium from the bones, increasedcalcium 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.

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.

Answer: 1,2,5

Rationale: Serum magnesium level of 1.4

mg/dL suggests mild hypomagnesaemia, so

this pt should be counseled to eat foods high


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1. bananas

2. seafood

3. white rice4. lean red meat

5. chocolate

in magnesium. Foods high in magnesium

include green leafy vegetables, seafood, milk,

bananas, citrus fruits, & chocolate. White rice& lean red meat are not included.

The pt has a serum phosphate level of 4.7

mg/dL. Which interdisciplinary treatments

would the nurse expect for this pt? Select allthat apply.

1. IV normal saline

2. calcium containing antacids

3. IV potassium phosphate

4. encouraging milk intake

5. increasing vitamin D intake

Answer: 1,2

Rationale: Serum phosphate level of 4.7

mg/dL indicates hyperphosphatemia. IVnormal saline promotes renal excretion of

phosphate.

The pt, newly diagnosed with diabetes

mellitus, is admitted to the emergency

department with nausea, vomiting, &

Answer: 2,3,4

Rationale: Further assessment findings of this

condition are weakness, bradycardia,


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abdominal pain. ABG results reveal a pH of 7.2

& a bicarbonate level of 20 mEq/L. Which

other assessment findings would the nurseanticipate in this pt? Select all that apply.

1. tachycardia

2. weakness

3. dysrhythmias

4. Kussmaul's respirations

5. cold, clammy skin

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

IVT HERAPY Q AND A 2

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