Ramont2e Rev TIF Ch26

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 26Question 1

Type: MCSA

The nurse is teaching peers about fluids and electrolytes, and explains that when movement of substances betwee

intracellular and extracellular spaces requires the use of energy, it is considered which of the following?

1. iffusion

2. !smosis

. Active transport

!. "assive transport

Corre"t #ns$er: #

Rationa%e 1$ Active transport is defined as the movement of substances with the use of energy to help them move

between compartments% iffusion, osmosis, and passive transport do not require the use of energy, and substance

move in an effort to equali&e concentrations of solutes%

Rationa%e 2$ Active transport is defined as the movement of substances with the use of energy to help them move between compartments% iffusion, osmosis, and passive transport do not require the use of energy, and substance


Rationa%e $ Active transport is defined as the movement of substances with the use of energy to help them move

between compartments% iffusion, osmosis, and passive transport do not require the use of energy, and substancemove in an effort to equali&e concentrations of solutes%

Rationa%e !$ Active transport is defined as the movement of substances with the use of energy to help them move

between compartments% iffusion, osmosis, and passive transport do not require the use of energy, and substance


&%o'a% Rationa%e:

Cogniti(e )e(e%: 'nderstandingC%ient Need: "hysiological (ntegrity

C%ient Need *u':

Nursing+ntegrated Con"epts: )ursing "rocess$ Assessment

)earning -ut"ome: iscuss the definitions, composition, and distribution of fluids in the body%

Question 2

Type: MCSA

*amont, )iedringhous, Comprehensive Nursing Care +nd dition 'pdate Test -an.

Copyright +/0+ by "earson ducation, (nc%



The nurse is caring for a client with an elevated serum potassium level% The physician orders administration of

glucose and insulin to drive potassium into the cell% Another nurse as.s, 1levating intracellular potassium is

dangerous too, isn2t it?1 The nurse2s best response would be which of the following?

1. 13es, but not as dangerous as when the level is high in the serum%1

2. 1"otassium level is higher in the cell, and serum potassium is more dangerous%1

. 1"otassium isn2t normally found in the cell, so it can be more easily excreted in the cell%1

!. 1)o, potassium has no effect in the cell%1

Corre"t #ns$er: +

Rationa%e 1$ (ntracellular potassium is normally high, and can be accommodated more easily in the cell than in

the serum% levated serum potassium can cause cellular excitation, of particular danger with cardiac cells%

Rationa%e 2$ (ntracellular potassium is normally high, and can be accommodated more easily in the cell than inthe serum% levated serum potassium can cause cellular excitation, of particular danger with cardiac cells%

Rationa%e $ (ntracellular potassium is normally high, and can be accommodated more easily in the cell than in


Rationa%e !$ (ntracellular potassium is normally high, and can be accommodated more easily in the cell than in


&%o'a% Rationa%e:

Cogniti(e )e(e%: ApplyingC%ient Need: "hysiological (ntegrity

C%ient Need *u':

Nursing+ntegrated Con"epts: )ursing "rocess$ "lanning

)earning -ut"ome: iscuss the definitions, composition, and distribution of fluids in the body%

Question

Type: MCSA

4hen caring for the client with edema secondary to congestive heart failure, the nurse monitors which of the

following as an indication of the client2s ability to excrete excess fluid volume through the .idney?

1. Creatinine

2. Albumin

. Sodium

!. Chloride





Corre"t #ns$er: 0

Rationa%e 1$ Serum creatinine levels indicate the .idney2s ability to function in order to excrete excess fluidvolumes% levated creatinine levels indicate .idney damage% 5owered serum albumin levels might explain edema

in clients with normally functioning .idneys, because albumin helps to hold fluid in the intravascular space%

levated sodium levels would cause less fluid to be excreted, but would not indicate the ability of the .idneys toexcrete excess fluid% Chloride does not impact .idney excretion of fluid%

Rationa%e 2$ Serum creatinine levels indicate the .idney2s ability to function in order to excrete excess fluid

volumes% levated creatinine levels indicate .idney damage% 5owered serum albumin levels might explain edema

in clients with normally functioning .idneys, because albumin helps to hold fluid in the intravascular space%levated sodium levels would cause less fluid to be excreted, but would not indicate the ability of the .idneys to

excrete excess fluid% Chloride does not impact .idney excretion of fluid%

Rationa%e $ Serum creatinine levels indicate the .idney2s ability to function in order to excrete excess fluid

volumes% levated creatinine levels indicate .idney damage% 5owered serum albumin levels might explain edemain clients with normally functioning .idneys, because albumin helps to hold fluid in the intravascular space%

levated sodium levels would cause less fluid to be excreted, but would not indicate the ability of the .idneys to

excrete excess fluid% Chloride does not impact .idney excretion of fluid%

Rationa%e !$ Serum creatinine levels indicate the .idney2s ability to function in order to excrete excess fluidvolumes% levated creatinine levels indicate .idney damage% 5owered serum albumin levels might explain edema

in clients with normally functioning .idneys, because albumin helps to hold fluid in the intravascular space%

levated sodium levels would cause less fluid to be excreted, but would not indicate the ability of the .idneys toexcrete excess fluid% Chloride does not impact .idney excretion of fluid%

&%o'a% Rationa%e:

Cogniti(e )e(e%: Analy&ing

C%ient Need: "hysiological (ntegrityC%ient Need *u':


)earning -ut"ome: (dentify mechanisms for regulation of body fluids and electrolytes%

Question !

Type: MCSA

The nurse is caring for a client with bilateral rales audible in the bases of the lung, 6ugular vein distention, and a

low hematocrit% The nurse attributes these symptoms to which of the following?

1. 7luid volume deficit

2. 7luid volume balance

. 7luid volume excess

!. levated serum calcium and magnesium levels





Corre"t #ns$er: #

Rationa%e 1$ These symptoms are classic manifestations of fluid volume overload or excess causing fluid to shiftinto the lungs and causing dilution of cells in the hematocrit%

Rationa%e 2$ These symptoms are classic manifestations of fluid volume overload or excess causing fluid to shift

into the lungs and causing dilution of cells in the hematocrit%

Rationa%e $ These symptoms are classic manifestations of fluid volume overload or excess causing fluid to shiftinto the lungs and causing dilution of cells in the hematocrit%

Rationa%e !$ These symptoms are classic manifestations of fluid volume overload or excess causing fluid to shift

into the lungs and causing dilution of cells in the hematocrit%

&%o'a% Rationa%e:


C%ient Need: "hysiological (ntegrity

C%ient Need *u':


)earning -ut"ome: (dentify mechanisms for regulation of body fluids and electrolytes%

Question

Type: MCSA

The nurse reviews the client2s arterial blood gas and finds the p8 is 9%#0, pC! + is :/, and 8C!# is +#% The nurse

attributes these results to which of the following?

1. (nadequate .idney function

2. (nadequate respiratory function

. xcessive inta.e of al.aline foods

!. iarrhea and vomiting

Corre"t #ns$er: +

Rationa%e 1$ The acidic level of the p8 in combination with an elevated carbon dioxide level indicates that the

client2s breathing is inadequate to meet gas exchange needs of the body% (nadequate .idney function would havean impact on bicarbonate levels% -icarbonate levels would be increased if excessive inta.e of al.aline foods were

to blame, and diarrhea and vomiting would cause a metabolic, not a respiratory, picture%

Rationa%e 2$ The acidic level of the p8 in combination with an elevated carbon dioxide level indicates that theclient2s breathing is inadequate to meet gas exchange needs of the body% (nadequate .idney function would have

an impact on bicarbonate levels% -icarbonate levels would be increased if excessive inta.e of al.aline foods were






Rationa%e $ The acidic level of the p8 in combination with an elevated carbon dioxide level indicates that theclient2s breathing is inadequate to meet gas exchange needs of the body% (nadequate .idney function would have

an impact on bicarbonate levels% -icarbonate levels would be increased if excessive inta.e of al.aline foods were


Rationa%e !$ The acidic level of the p8 in combination with an elevated carbon dioxide level indicates that theclient2s breathing is inadequate to meet gas exchange needs of the body% (nadequate .idney function would have

an impact on bicarbonate levels% -icarbonate levels would be increased if excessive inta.e of al.aline foods wereto blame, and diarrhea and vomiting would cause a metabolic, not a respiratory, picture%

&%o'a% Rationa%e:



C%ient Need *u':

Nursing+ntegrated Con"epts: )ursing "rocess$ valuation

)earning -ut"ome: (dentify the normal range of acid;base balance and name three important regulators of p8 in

the blood%

Question 6

Type: MCSA

The nurse is reviewing the client2s most recent arterial blood gas, and finds values of p8$ 9%#<, pC! +$ :+, and

8C!#$ +=% The nurse interprets these results to mean$

1. The .idneys are compensating for respiratory acidosis%

2. The respiratory system is compensating for metabolic al.alosis%

. The .idneys are compensating for respiratory al.alosis%

!. The p8 is normal%

Corre"t #ns$er: 0

Rationa%e 1$ 4hile the p8 is only mildly acidic, it points to acidosis, the pC!+ is elevated and the bicarbonate is

elevated% As a result of elevated carbon dioxide levels, the .idneys are attempting to compensate by raising bicarbonate levels, and have corrected enough to bring p8 close to normal%

Rationa%e 2$ 4hile the p8 is only mildly acidic, it points to acidosis, the pC!+ is elevated and the bicarbonate iselevated% As a result of elevated carbon dioxide levels, the .idneys are attempting to compensate by raising

bicarbonate levels, and have corrected enough to bring p8 close to normal%

Rationa%e $ 4hile the p8 is only mildly acidic, it points to acidosis, the pC!+ is elevated and the bicarbonate is

elevated% As a result of elevated carbon dioxide levels, the .idneys are attempting to compensate by raising

bicarbonate levels, and have





Rationa%e !$ 4hile the p8 is only mildly acidic, it points to acidosis, the pC!+ is elevated and the bicarbonate iselevated% As a result of elevated carbon dioxide levels, the .idneys are attempting to compensate by raising

bicarbonate levels, and have corrected enough to bring p8 close to normal%

&%o'a% Rationa%e:




)earning -ut"ome: (dentify the normal range of acid;base balance and name three important regulators of p8 inthe blood%

Question /

Type: MCSA

The nurse is caring for a client who lives alone and was found to be confused and disoriented% The client has been

ta.ing medications improperly, and has elevated calcium levels from ta.ing too many calcium supplements>elevated sodium and chloride levels from missing dosages of diuretics and excessive salt inta.e> and an elevated

potassium level secondary to ta.ing potassium supplements improperly% 4hich electrolyte imbalance is of

greatest importance to correct?

1. Sodium

2. Chloride

. Calcium

!. "otassium

Corre"t #ns$er: <

Rationa%e 1$ 4hile any electrolyte imbalance is serious and must be addressed, elevated potassium is of highest

priority because it can cause cardiac rhythm anomalies, resulting in death, and must be quic.ly corrected%levated sodium, chloride, and calcium levels must be addressed, and can have serious consequences, but are not

li.ely to be as serious as the elevated potassium%

Rationa%e 2$ 4hile any electrolyte imbalance is serious and must be addressed, elevated potassium is of highest



Rationa%e $ 4hile any electrolyte imbalance is serious and must be addressed, elevated potassium is of highest







Rationa%e !$ 4hile any electrolyte imbalance is serious and must be addressed, elevated potassium is of highest priority because it can cause cardiac rhythm anomalies, resulting in death, and must be quic.ly corrected%

levated sodium, chloride, and calcium levels must be addressed, and can have serious consequences, but are not


&%o'a% Rationa%e:


C%ient Need *u':


)earning -ut"ome: 5ist important electrolytes, their normal ranges, and manifestations of imbalances%

Question 0

Type: MCSA

The nurse is reviewing the client2s serum electrolyte laboratory results and finds the following$ sodium 0#=,

chloride 0/+, potassium #%, calcium =%=, and magnesium +%9% The nurse attributes the electrolyte balance towhich of the following?

1. Missing doses of diuretics

2. xcessive use of antacids

. (mproper use of potassium supplements

!. xcessive salt inta.e

Corre"t #ns$er: +

Rationa%e 1$ xcessive use of antacids can result in elevated magnesium levels @hypermagnesemia% The client2s

sodium, chloride, and potassium levels are all within normal limits, which would be unli.ely if the

hypermagnesemia were caused by renal failure%

Rationa%e 2$ xcessive use of antacids can result in elevated magnesium levels @hypermagnesemia% The client2ssodium, chloride, and potassium levels are all within normal limits, which would be unli.ely if the


Rationa%e $ xcessive use of antacids can result in elevated magnesium levels @hypermagnesemia% The client2s

sodium, chloride, and potassium levels are all within normal limits, which would be unli.ely if thehypermagnesemia were caused by renal failure%

Rationa%e !$ xcessive use of antacids can result in elevated magnesium levels @hypermagnesemia% The client2s

sodium, chloride, and potassium levels are all within normal limits, which would be unli.ely if the


&%o'a% Rationa%e:







C%ient Need *u':


)earning -ut"ome: 5ist important electrolytes, their normal ranges, and manifestations of imbalances%

Question

Type: MCSA

The nurse is caring for a client diagnosed with respiratory acidosis, and directs the plan of care to provide which

of these priority interventions?

1. (ncrease fluid inta.e%

2. 8ave the client breathe into a paper bag%

. Administer oxygen%

!. ncourage the client to ta.e deep breaths%

Corre"t #ns$er: <

Rationa%e 1$ *espiratory acidosis is caused by inadequate gas exchange, and would best be treated by having the

client ta.e deeper breaths to blow off excess carbon dioxide% !xygen will increase p!+ levels but will not reduce

carbon dioxide levels% (ncreased fluid inta.e would be appropriate for metabolic acidosis, but will have no affecton respiratory acidosis% A paper bag would be helpful to reverse respiratory al.alosis but will worsen respiratory

acidosis%

Rationa%e 2$ *espiratory acidosis is caused by inadequate gas exchange, and would best be treated by having the

client ta.e deeper breaths to blow off excess carbon dioxide% !xygen will increase p!+ levels but will not reducecarbon dioxide levels% (ncreased fluid inta.e would be appropriate for metabolic acidosis, but will have no affect

on respiratory acidosis% A paper bag would be helpful to reverse respiratory al.alosis but will worsen respiratory

acidosis%

Rationa%e $ *espiratory acidosis is caused by inadequate gas exchange, and would best be treated by having theclient ta.e deeper breaths to blow off excess carbon dioxide% !xygen will increase p!+ levels but will not reduce

carbon dioxide levels% (ncreased fluid inta.e would be appropriate for metabolic acidosis, but will have no affect

on respiratory acidosis% A paper bag would be helpful to reverse respiratory al.alosis but will worsen respiratory

acidosis%

Rationa%e !$ *espiratory acidosis is caused by inadequate gas exchange, and would best be treated by having the

client ta.e deeper breaths to blow off excess carbon dioxide% !xygen will increase p!+ levels but will not reduce

carbon dioxide levels% (ncreased fluid inta.e would be appropriate for metabolic acidosis, but will have no affecton respiratory acidosis% A paper bag would be helpful to reverse respiratory al.alosis but will worsen respiratory

acidosis%





)earning -ut"ome: )ame four acid;base imbalances and state how they are treated%

Question 11

Type: MCSA

The nurse is caring for an elderly client with a nursing diagnosis of 7luid olume eficit% 4hich of the following

actions would yield the best indicator of the effectiveness of the nursing plan of care?

1. "inch the s.in on the bac. of the hand, and time how long it ta.es to return to normal%

2. "inch the s.in on the sternum, and time how long it ta.es to return to normal

. Monitor the client2s white blood cell count%

!. Monitor the client2s inta.e and output%

Corre"t #ns$er: +

Rationa%e 1$ The most effective means of evaluating the client2s response to treatment is to monitor s.in turgor,

which is best tested on the sternum or forehead, especially in elderly clients, whose loss of s.in elasticity would

reduce the response of s.in return on the hand% 4hite blood cell count would not change with improving fluidvolume, although a deficit caused by an infection would require monitoring of 4-C for resolution of the

infection% (nta.e and output should be monitored on this client, but are not the best indicator of resolution of fluid

volume deficit because they will normali&e before s.in turgor%

Rationa%e 2$ The most effective means of evaluating the client2s response to treatment is to monitor s.in turgor,which is best tested on the sternum or forehead, especially in elderly clients, whose loss of s.in elasticity would

reduce the response of s.in return on the hand% 4hite blood cell count would not change with improving fluid

volume, although a deficit caused by an infection would require monitoring of 4-C for resolution of theinfection% (nta.e and output should be monitored on this client, but are not the best indicator of resolution of fluid


Rationa%e $ The most effective means of evaluating the client2s response to treatment is to monitor s.in turgor,

which is best tested on the sternum or forehead, especially in elderly clients, whose loss of s.in elasticity wouldreduce the response of s.in return on the hand% 4hite blood cell count would not change with improving fluid

volume, although a deficit caused by an infection would require monitoring of 4-C for resolution of the

infection% (nta.e and output should be monitored on this client, but are not the best indicator of resolution of fluidvolume deficit because they will normali&e before s.in turgor%

Rationa%e !$ The most effective means of evaluating the client2s response to treatment is to monitor s.in turgor,which is best tested on the sternum or forehead, especially in elderly clients, whose loss of s.in elasticity would

reduce the response of s.in return on the hand% 4hite blood cell count would not change with improving fluidvolume, although a deficit caused by an infection would require monitoring of 4-C for resolution of the

infection% (nta.e and output should be monitored on this client, but are not the best indicator of resolution of fluid


&%o'a% Rationa%e:







C%ient Need *u':


)earning -ut"ome: iscuss nursing care for clients with fluid or acid;base disorders%

Question 12

Type: MCSA

The nurse is caring for a client with fluid volume excess secondary to congestive heart failure and chronic renal

failure% 4hich of the following physician2s orders would the nurse question?

1. Administer diuretics%

2. *estrict fluids%

. aily weights

!. 8igh;sodium diet

Corre"t #ns$er: <

Rationa%e 1$ Clients with excess fluids require a low;sodium diet because water retention increases with sodium

increases% iuretics, fluid restriction, and daily weights would all be appropriate orders for this client%

Rationa%e 2$ Clients with excess fluids require a low;sodium diet because water retention increases with sodiumincreases% iuretics, fluid restriction, and daily weights would all be appropriate orders for this client%

Rationa%e $ Clients with excess fluids require a low;sodium diet because water retention increases with sodiumincreases% iuretics, fluid restriction, and daily weights would all be appropriate orders for this client%

Rationa%e !$ Clients with excess fluids require a low;sodium diet because water retention increases with sodium

increases% iuretics, fluid restriction, and daily weights would all be appropriate orders for this client%

&%o'a% Rationa%e:

Cogniti(e )e(e%: Applying


C%ient Need *u':

Nursing+ntegrated Con"epts: )ursing "rocess$ "lanning)earning -ut"ome: iscuss nursing care for clients with fluid or acid;base disorders%

Question 1

Type: 7(-

The nurse understands that the human body contains roughly </ liters, of which DDDDDliters are intracellular





*tandard Te3t:

Corre"t #ns$er: #E0+E0:E+:

Rationa%e $ Approximately +E# or +: liters of fluid are intracellularApproximately 0E# or 0: liters of fluid are

extracellularApproximately # liters of extracellular fluid are found within the plasma, considered intravascular

fluidApproximately F of the extracellular fluid or 0+ liters ma.e up the interstitial and trancellular fluid

&%o'a% Rationa%e:

Cogniti(e )e(e%: 'nderstanding


C%ient Need *u':


)earning -ut"ome:

Question 1!

Type: MCMA

The nurse is reviewing a clientGs laboratory studies% The extracellular fluid contains$@Select all that apply

*tandard Te3t: Select all that apply%

1. Sodium

2. Chloride

. Magnesium

!. "rotein

. Sulfate

Corre"t #ns$er: 0,+,#,<

Rationa%e 1$ xtracellular fluid contains sodium and other salts that brea. up into electrically charged particles

when dissolved in water



Rationa%e $ xtracellular fluid contains sodium and other salts that brea. up into electrically charged particles


Rationa%e !$ xtracellular fluid contains sodium and other salts that brea. up into electrically charged particleswhen dissolved in water





Rationa%e $ xtracellular fluid contains sodium and other salts that brea. up into electrically charged particleswhen dissolved in water

&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':


)earning -ut"ome:

Question 1

Type: MCSA

The nurse is explaining how to a client how fluid and electrolytes get from one body compartment to another%

Characteristics of transport mechanisms include$

1. !smosis is the passage of water from an area of higher concentration to an area of lower concentration

2. iffusion occurs when molecules move across a semipermeable membrane from an area of higher solute

concentration to an area of lower solute concentration

. 7iltration is the process by which water and solutes move across capillary membranes pushed by osmotic pressure

!. AT" enables the movement of magnesium and potassium ions across cell membranes

Corre"t #ns$er: +

Rationa%e 1$ !smosis is the passage of water from an area of higher solute concentration and out of an area of

lower solute concentration

Rationa%e 2$ iffusion is the movement of molecules randomly in all directions from a region of high

concentration to an area of low concentration

Rationa%e $ 7iltration is the transfer of water and dissolved substances from a region of high pressure to a region

of low pressure> filtration moves in one particular direction because of hydrostatic pressure

Rationa%e !$ Active transport occurs when it is necessary to move sodium or potassium ions across cell

membranes from an area of low concentration to an area of high concentration> energy must be expended, and isreleased from the cell in the form of adenosine triphosphate @AT"

&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':





Nursing+ntegrated Con"epts: )ursing "rocess$ (mplementation

)earning -ut"ome:

Question 16

Type: MCMA

The nurse is assessing a client at the change of shift% The clientGs respiratory rate has increased since the previous

day% The nurse performs a focused assessment to determine if the client has other manifestations of fluid excess,

such as$@Select all that apply


1. 4eight loss

2. Cool extremities

. dema

!. 8ypertension

. "eriorbital edema

Corre"t #ns$er: #,<,:

Rationa%e 1$ 7luid volume deficit may manifest itself with weight loss

Rationa%e 2$ Cool extremities are a manifestation of fluid deficit

Rationa%e $ dema is a manifestation of fluid excess

Rationa%e !$ 8ypertension may be a manifestation of fluid excess

Rationa%e $ "eriorbital edema is a manifestation frequently seen in fluid volume excess

&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':

Nursing+ntegrated Con"epts: )ursing "rocess$ Assessment)earning -ut"ome:

Question 1/

Type: MCMA

The nurse records and notes all potential fluid output from a client, including






)earning -ut"ome:

Question 21

Type: MCMA

The nurse identifies characteristics of buffer regulation as including$@Select all that apply


1. The bodyGs buffering system is more acid than base

2. -uffers neutrali&e excess acids or bases

. -uffers are the last defense against acid;base balance changes in the body

!. The main buffer pair is sodium bicarbonate and carbonic acid

. The p8 remains within its normal range as long as a ration of +/ parts of bicarbonate to 0 part of carbonic acid

Corre"t #ns$er: +,<,:

Rationa%e 1$ The bodyGs buffering system is more base than acid, due to the strong tendency toward acidity

because acids are continually produced during metabolism

Rationa%e 2$ -uffers neutrali&e excess acids or bases, preventing mar.ed changes in hydrogen ion concentration

Rationa%e $ -uffers are the bodyGs first line of defense against acid;base balance changes in the body

Rationa%e !$ The main buffer pair is sodium bicarbonate and carbonic acid%

Rationa%e $ )ormal p8 is dependent on a ration of +/$0 of bicarbonate to carbonic acid

&%o'a% Rationa%e:


C%ient Need: 8ealth "romotion and Maintenance

C%ient Need *u':


)earning -ut"ome:

Question 22

Type: MCMA

The nurse is reviewing a clientGs blood wor., noting the bicarbonate and carbon dioxide levels% 4hich of the

following would the nurse expect to see clinically in a client?@Select all that apply






1. 4ith a low p8, and an increased level of carbon dioxide, the rate and depth of respirations will increase to

compensate

2. 4ith a high p8, and a low carbon dioxide, the client may be hyperventilating

. 4ith a high bicarbonate, the p8 will be higher, and the rate and depth of respirations are reduced in order toretain carbon dioxide

!. 4ith a high bicarbonate, the p8 will be lower, and the depth and rate of respirations will be unchanged

. 4ith an increase in the rate and depth of respirations, the p8 will increase

Corre"t #ns$er: 0,+,#,:

Rationa%e 1$ 4he

Rationa%e 2$ 4he

Rationa%e $ 4he

Rationa%e !$ 4he

Rationa%e $ 4he

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 2

Type: MCSA

The nurse understands that the client with renal failure may be unable to$@Select all that apply

1. To reabsorb and regenerate bicarbonate

2. xcrete bicarbonate and retain hydrogen ions in order to increase p8

. *eabsorb and regenerate bicarbonate and excrete hydrogen ions to increase p8

!. "rovide the short term regulation of acid base balance





. *etain hydrogen ions in order to ma.e more acid available to offset the bicarbonate

Corre"t #ns$er: #

Rationa%e 1$ The .idneys maintain acid;base balance by selectively excreting or conserving bicarbonate and

hydrogen ions

Rationa%e 2$ The .idneys maintain acid;base balance by selectively excreting or conserving bicarbonate andhydrogen ions

Rationa%e $ The .idneys maintain acid;base balance by selectively excreting or conserving bicarbonate andhydrogen ions

Rationa%e !$ The .idneys maintain acid;base balance by selectively excreting or conserving bicarbonate and

hydrogen ions

Rationa%e $ The .idneys maintain acid;base balance by selectively excreting or conserving bicarbonate andhydrogen ions

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 2!

Type: MCSA

The nurse expects to observe the following manifestations of metabolic acidosis upon physical assessment of the

client$

1. Carpopedal spasm

2. Convulsions

. Iussmaul breathing

!. 8yperventilation

Corre"t #ns$er: #

Rationa%e 1$ Carpopedal

Rationa%e 2$ Carpopedal





Rationa%e $ Carpopedal

Rationa%e !$ Carpopedal

&%o'a% Rationa%e:




)earning -ut"ome:

Question 2

Type: MCMA

The nurse is caring for a client who begins to complain of di&&iness, numbness and tingling in the toes and

fingers% The nurse notes a respiratory rate of </% A-Hs would most li.ely confirm the following$@Select all that

apply


1. p8 below 9%<

2. "aC!+ below #: mm 8g

. *espiratory acidosis

!. *espiratory al.alosis

. p8 above 9%<:


Rationa%e 1$ (n this clinical scenario, the p8 is li.ely to be above 9%<:

Rationa%e 2$ (n this clinical scenario, the p8 is li.ely to be above 9%<:

Rationa%e $ (n this clinical scenario, the p8 is li.ely to be above 9%<:

Rationa%e !$ (n this clinical scenario, the p8 is li.ely to be above 9%<:

Rationa%e $ (n this clinical scenario, the p8 is li.ely to be above 9%<:

&%o'a% Rationa%e:







The nurse is caring for a post;operative client who has undergone a gastric resection% The client is complaining of

di&&iness, and tingling of the fingers% The client is currently )"!, with an )H tube to low intermittent suction%

The following are appropriate nursing actions for this client$

1. Change suction to high intermittent

2. Administer sedatives

. (rrigate the )H tube with tap water

!. iscontinue )H suctioning

Corre"t #ns$er: <

Rationa%e 1$ The nasogastric suction may have caused the loss of hydrogen ions, causing metabolic al.alosis

Rationa%e 2$ This client may show signs of tetany, disorientation and sei&ures> sedatives are not indicated and

may increase disorientation

Rationa%e $ The )H tube should be irrigated with normal saline instead of tap water to counter lost electrolytesfrom the gastric secretion removal

Rationa%e !$ )H suctioning should be discontinued and nausea and vomiting should be treated with antiemetics

&%o'a% Rationa%e:



C%ient Need *u':Nursing+ntegrated Con"epts: )ursing "rocess$ (mplementation

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Question 20

Type: MCMA

The nurse is admitting a client from the emergency room with a diagnosis of metabolic al.alosis% Appropriate

treatment and nursing interventions for this client include$@Select all that apply


1. Administer chloride

2. Administer oxygen

. Maintain a patent (

!. ncourage fluids





. ncourage ambulation


Rationa%e 1$ Chloride will be administered to facilitate the excretion of bicarbonate by the .idneys

Rationa%e 2$ !xygen may be required if respirations are depressed or oxygen saturation drops

Rationa%e $ A patent ( is necessary to restore normal fluids volume, as well as treating the underlying cause

Rationa%e !$ The client may experience polyuria followed by volume deficit and thirst

Rationa%e $ This client is at ris. for sei&ures> ambulation should not be encouraged until condition is stable

&%o'a% Rationa%e:



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Question 2

Type: MCMA

The nurse is caring for a client whose (J! is being monitored% 'nmeasurable fluid losses include$@Select all that

apply


1. xtreme diaphoresis

2. *apid, deep respirations

. 'rine

!. )H drainage

. ( fluid

Corre"t #ns$er: 0,+

Rationa%e 1$ xtremely diaphoretic clients may lose significant amounts of fluids that contribute to fluid

imbalance

Rationa%e 2$ *apid deep respirations will contribute to fluid losses, but cannot be measured





Rationa%e $ 'rine is a measurable type of output

Rationa%e !$ )H drainage is a measurable type of output

Rationa%e $ ( fluids are measurable inta.e

&%o'a% Rationa%e:



C%ient Need *u':


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Question

Type: MCSA

The nurse is explaining the importance of measuring inta.e and output to the client and his family% (nta.e thatmust be measured includes$

1. 'rine

2. Stool

. H( suction

!. (ce chips

. 4ound drainage

Corre"t #ns$er: <

Rationa%e 1$ 'rine is output that must be measured

Rationa%e 2$ 'rine is output that must be measured

Rationa%e $ 'rine is output that must be measured

Rationa%e !$ 'rine is output that must be measured

Rationa%e $ 'rine is output that must be measured

&%o'a% Rationa%e:



C%ient Need *u':






)earning -ut"ome:

Question 1

Type: MCMA

The nurse is caring for a client with acid;base imbalance in collaboration with the health care team% The

information that needs to be conveyed to the team includes$@Select all that apply


1. Continued urinary output

2. Changes in level of consciousness

. p8 greater than 9%<:

!. (mbalance of (J!

. -aseline vital signs

Corre"t #ns$er: +,#,<

Rationa%e 1$ A change in urinary output or nasogastric tube output would be significant to report

Rationa%e 2$ A change in urinary output or nasogastric tube output would be significant to report

Rationa%e $ A change in urinary output or nasogastric tube output would be significant to report

Rationa%e !$ A change in urinary output or nasogastric tube output would be significant to report

Rationa%e $ A change in urinary output or nasogastric tube output would be significant to report

&%o'a% Rationa%e:



C%ient Need *u':


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Question 2

Type: MCSA

The nurse is reviewing the expected outcomes for a client with electrolyte imbalance% xpected outcomes include

all of the following except$





Corre"t #ns$er:

&%o'a% Rationa%e:

Cogniti(e )e(e%:

C%ient Need:

C%ient Need *u':

Nursing+ntegrated Con"epts:

)earning -ut"ome:

Question

Type: MCMA

The nurse is reviewing a clientGs care plan% Appropriate nursing interventions for a client with electrolyte

imbalance due to prerenal failure include$@Select all that apply


1. 4ee.ly weights

2. *ecording inta.e and output

. !ffering several small meals of sodium;enhances, low protein diet

!. *eorient client as needed

. "rovide emotional support


Rationa%e 1$ The nurse will monitor the clientGs weight daily

Rationa%e 2$ The clientGs inta.e and output needs to be monitored and recorded

Rationa%e $ The appropriate diet includes several small meals per day of a sodium;restricted, low protein diet,

which will decrease fluid retention, and potentially toxic byproducts of protein metabolism that the client is

unable to excrete

Rationa%e !$ Clients with alteration in fluid and electrolyte balance often become confused

Rationa%e $ The client and family need opportunity to express concerns about the disease process and possibilityof dialysis treatment

&%o'a% Rationa%e:



C%ient Need *u':





2. )ormal serum sodium level$ #%:;:%/ mqE5

. )ormal serum calcium level$ =%:;0/%: mgEdl

!. )ormal serum calcium level$ :;0/: mqE5

. )ormal serum calcium level$ 0%#;+%0 mqE5

Corre"t #ns$er: 0,#

Rationa%e 1$ )ormal serum sodium levels are between 0#:;0<9 mqE5

Rationa%e 2$ )ormal serum sodium levels are between 0#:;0<9 mqE5

Rationa%e $ )ormal serum sodium levels are between 0#:;0<9 mqE5

Rationa%e !$ )ormal serum sodium levels are between 0#:;0<9 mqE5

Rationa%e $ )ormal serum sodium levels are between 0#:;0<9 mqE5

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 6Type: MCSA

The nurse is reviewing the laboratory studies of a client and notes a serum sodium value of 0B= mqE5% xpected

clinical manifestations this value would include$

1. !liguria and fever

2. Constipation and decreased blood pressure

. Muscle tremor and arrhythmias

!. i&&iness and confusion

Corre"t #ns$er: 0

Rationa%e 1$ !liguria, fever, thirst, flushed s.in and dry stic.y mucous membranes are common manifestations o

hypernatremia





Rationa%e 2$ Constipation and decreased blood pressure are common manifestations of hypo.alemia

Rationa%e $ Muscle tremor and arrhythmias are common manifestations of hypocalcemia

Rationa%e !$ i&&iness and confusion are common manifestations of hypomagnesemia

&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':


)earning -ut"ome:

Question /

Type: MCSA

A client is admitted to the acute care facility for anorexia and nausea% The nurse would expect to note imbalancesof which electrolytes?

1. "hosphorus and chloride

2. Magnesium and potassium

. Magnesium and calcium

!. Sodium and potassium

Corre"t #ns$er: #

Rationa%e 1$ Common manifestations of chloride and phosphorus imbalances include increased muscle

excitability, tetany, decreased respirations, stupor, rapid deep breathing, muscle wea.ness, paresthesias,numbness, tingling, lethargy, speech defects, renal failure, arrhythmias and muscle twitching

Rationa%e 2$ Common manifestations of potassium imbalance include decreased muscle function, decreased

reflexes, decreased blood pressure, nausea, muscle wea.ness, diarrhea, oliguria

Rationa%e $ Common manifestations of imbalances in magnesium and calcium include anorexia and nausea, aswell as constipation, cramps, tetany, bleeding, hypotension

Rationa%e !$ Manifestations of imbalances in sodium and potassium include muscle wea.ness, decreased s.in

turgor, headache, tremor, sei&ures, thirst, fever, flushed s.in, oliguria, rapid, wea., irregular pulse> nausea and

vomiting> ileus> oliguria

&%o'a% Rationa%e:






C%ient Need:

C%ient Need *u':


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Question 0

Type: MCSA

The nurse is reviewing electrolytes, and their functions with a client who has a history of electrolyte imbalance%

!ne of the ma6or cations noted in teeth and bones is$

1. Magnesium

2. Calcium

. "otassium

!. "hosphorus

Corre"t #ns$er: +

Rationa%e 1$ Magnesium is a ma6or cation in (C7

Rationa%e 2$ Magnesium is a ma6or cation in (C7

Rationa%e $ Magnesium is a ma6or cation in (C7

Rationa%e !$ Magnesium is a ma6or cation in (C7

&%o'a% Rationa%e:


C%ient Need:

C%ient Need *u':


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Question

Type: 7(-

The nurse understands that the human body contains roughly </ liters, of which DDDDDliters are intracellular%

*tandard Te3t:

Corre"t #ns$er: #E0+E0:E+:





Rationa%e $ Approximately K, or +: liters, of fluid are intracellular%> Approximately L, or 0: liters, of fluid areextracellular%> Approximately # liters of extracellular fluid are found within the plasma, considered intravascular

fluid%> Approximately F of the extracellular fluid, or 0+ liters, ma.e up the interstitial and transcellular fluid%

&%o'a% Rationa%e:




)earning -ut"ome:

Question !

Type: MCMA

The nurse is reviewing a clientGs laboratory studies% The extracellular fluid contains$


1. Sodium%

2. Chloride%

. Magnesium%

!. "rotein%

. Sulfate%



when dissolved in water%



Rationa%e $ xtracellular fluid contains sodium and other salts that brea. up into electrically charged particles


Rationa%e !$ xtracellular fluid contains sodium and other salts that brea. up into electrically charged particleswhen dissolved in water%

Rationa%e $ xtracellular fluid contains sodium and other salts that brea. up into electrically charged particleswhen dissolved in water%

&%o'a% Rationa%e:







C%ient Need *u':


)earning -ut"ome:

Question !1

Type: MCSA

The nurse is explaining to a client how fluid and electrolytes get from one body compartment to another%Characteristics of transport mechanisms include$

1. !smosis is the passage of water from an area of higher concentration to an area of lower concentration%

2. iffusion occurs when molecules move across a semipermeable membrane from an area of higher solute

concentration to an area of lower solute concentration%

. 7iltration is the process by which water and solutes move across capillary membranes pushed by osmotic

pressure%

!. AT" enables the movement of magnesium and potassium ions across cell membranes%

Corre"t #ns$er: +

Rationa%e 1$ !smosis is the passage of water from an area of higher solute concentration and out of an area of

lower solute concentration%

Rationa%e 2$ iffusion is the movement of molecules randomly in all directions from a region of highconcentration to an area of low concentration%

Rationa%e $ 7iltration is the transfer of water and dissolved substances from a region of high pressure to a region

of low pressure% 7iltration moves in one particular direction because of hydrostatic pressure

Rationa%e !$ Active transport occurs when it is necessary to move sodium or potassium ions across cell

membranes from an area of low concentration to an area of high concentration% nergy must be expended, and isreleased from the cell in the form of adenosine triphosphate @AT"%

&%o'a% Rationa%e:




)earning -ut"ome:

Question !2

Type: MCMA





The nurse is assessing a client at the change of shift% The clientGs respiratory rate has increased since the previousday% The nurse performs a focused assessment to determine whether the client has other manifestations of fluid

excess, such as$


1. 4eight loss%

2. Cool extremities%

. dema%

!. 8ypertension%

. "eriorbital edema%

Corre"t #ns$er: #,<,:

Rationa%e 1$ 7luid volume deficit can manifest itself with weight loss%

Rationa%e 2$ Cool extremities are a manifestation of fluid deficit%

Rationa%e $ dema is a manifestation of fluid excess%

Rationa%e !$ 8ypertension can be a manifestation of fluid excess%

Rationa%e $ "eriorbital edema is a manifestation frequently seen in fluid volume excess%

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question !

Type: MCMA

The nurse records and notes all potential fluid output from a client, including$


1. 7eces%

2. 'rine%

. "erspiration%





Rationa%e 1$ lectrolytes, including sodium, control and regulate water balance%

Rationa%e 2$ lectrolytes, including potassium and bicarbonate, are involved in acidbase regulation%

Rationa%e $ lectrolytes, including phosphorus, are involved in many chemical actions of cells%

Rationa%e !$ lectrolytes, including phosphorus, calcium, and magnesium, are involved in neuromuscular

reactions, such as cardiac function%

Rationa%e $ Serum concentration is not a function of electrolytes%

&%o'a% Rationa%e:



C%ient Need *u':


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Question !

Type: MCSA

The nurse is reviewing a clientGs laboratory results% The clientGs arterial p8 is 9%#% This value is noted as$

1. 4ithin normal limits%

2. 5ow normal%

. 8igh normal%

!. -elow normal%

Corre"t #ns$er: <

Rationa%e 1$ The normal p8 or arterial blood is between 9%#: and 9%<:%

Rationa%e 2$ The lowest normal p8 is 9%#:%

Rationa%e $ The highest normal p8 is 9%<:%

Rationa%e !$ This value is below the normal range for p8 of arterial blood%

&%o'a% Rationa%e:



C%ient Need *u':






)earning -ut"ome:

Question !6

Type: MCMA

The nurse identifies characteristics of buffer regulation, including$


1. The bodyGs buffering system is more acid than base%

2. -uffers neutrali&e excess acids or bases%

. -uffers are the last defense against acidbase balance changes in the body%

!. The main buffer pair is sodium bicarbonate and carbonic acid%

. The p8 remains within its normal range as long as the ratio is +/ parts of bicarbonate to 0 part of carbonic acid


Rationa%e 1$ The bodyGs buffering system is more base than acid, due to the strong tendency toward acidity

because acids are continually produced during metabolism%

Rationa%e 2$ -uffers neutrali&e excess acids or bases, preventing mar.ed changes in hydrogen ion concentration%

Rationa%e $ -uffers are the bodyGs first line of defense against acidbase balance changes in the body%

Rationa%e !$ The main buffer pair is sodium bicarbonate and carbonic acid%

Rationa%e $ )ormal p8 is dependent on a ratio of +/$0 of bicarbonate to carbonic acid%

&%o'a% Rationa%e:



C%ient Need *u':

Nursing+ntegrated Con"epts: (mplementation

)earning -ut"ome:

Question !/Type: MCMA

The nurse is reviewing a clientGs blood wor., noting the bicarbonate and carbon dioxide levels% 4hich of the

following would the nurse expect to see clinically in the client?






1. 4ith a low p8, and an increased level of carbon dioxide, the rate and depth of respirations will increase tocompensate%

2. 4ith a high p8, and a low carbon dioxide, the client might be hyperventilating%

. 4ith a high bicarbonate, the p8 will be higher, and the rate and depth of respirations are reduced in order to

retain carbon dioxide%

!. 4ith a high bicarbonate, the p8 will be lower, and the depth and rate of respirations will be unchanged%

. 4ith an increase in the rate and depth of respirations, the p8 will increase%


Rationa%e 1$

Rationa%e 2$

Rationa%e $

Rationa%e !$

Rationa%e $

&%o'a% Rationa%e:



C%ient Need *u':


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Question !0

Type: MCMA

The nurse understands that the client with renal failure might be unable to$


1. *eabsorb and regenerate bicarbonate%

2. xcrete bicarbonate and retain hydrogen ions in order to increase p8%

. *eabsorb and regenerate bicarbonate and excrete hydrogen ions to increase p8%

!. "rovide the short;term regulation of acidbase balance%

. *etain hydrogen ions in order to ma.e more acid available to offset the bicarbonate%





Corre"t #ns$er: 0,#,:

Rationa%e 1$ The .idneys maintain acidbase balance by selectively excreting or conserving bicarbonate andhydrogen ions%

Rationa%e 2$ The .idneys maintain acidbase balance by selectively excreting or conserving bicarbonate and

hydrogen ions%

Rationa%e $ The .idneys maintain acidbase balance by selectively excreting or conserving bicarbonate andhydrogen ions%

Rationa%e !$ The .idneys maintain acidbase balance by selectively excreting or conserving bicarbonate and

hydrogen ions%

Rationa%e $ The .idneys maintain acidbase balance by selectively excreting or conserving bicarbonate and

hydrogen ions%

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question !

Type: MCSA

The nurse expects to observe the following manifestations of metabolic acidosis upon physical assessment of the

client$

1. Carpopedal spasm

2. Convulsions

. IussmaulGs breathing

!. 8yperventilation

Corre"t #ns$er: #

Rationa%e 1$

Rationa%e 2$

Rationa%e $

Rationa%e !$





&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question

Type: MCMA

The nurse is caring for a client who begins to complain of di&&iness, numbness, and tingling in the toes andfingers% The nurse notes a respiratory rate of </% A-Hs would most li.ely confirm the following$


1. p8 below 9%<

2. "aC!+ below #: mm 8g

. *espiratory acidosis

!. *espiratory al.alosis

. p8 above 9%<:


Rationa%e 1$ (n this clinical scenario, the p8 is li.ely to be above 9%<:%

Rationa%e 2$ (n this clinical scenario, the p8 is li.ely to be above 9%<:%

Rationa%e $ (n this clinical scenario, the p8 is li.ely to be above 9%<:%

Rationa%e !$ (n this clinical scenario, the p8 is li.ely to be above 9%<:%

Rationa%e $ (n this clinical scenario, the p8 is li.ely to be above 9%<:%

&%o'a% Rationa%e:


C%ient Need *u':


)earning -ut"ome:

Question 1

Type: MCMA





The nurse is caring for a client with severe diarrhea, nausea, and vomiting% xpected findings upon physicalassessment and review of laboratory studies include$


1. (ncreased breathing%

2. Change in level of consciousness%

. p8 below 9%#:%

!. p8 above 9%#:%

. 5ow bicarbonate level%


Rationa%e 1$ The respiratory system increases breathing to try to blow off excess acid%

Rationa%e 2$ The respiratory system increases breathing to try to blow off excess acid%

Rationa%e $ The respiratory system increases breathing to try to blow off excess acid%

Rationa%e !$ The respiratory system increases breathing to try to blow off excess acid%

Rationa%e $ The respiratory system increases breathing to try to blow off excess acid%

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 2

Type: MCSA

The nurse is caring for a postoperative client who has undergone a gastric resection% The client is complaining of

di&&iness and tingling of the fingers% The client is currently )"!, with an )H tube to low intermittent suction%

4hich of the following is an appropriate nursing action for this client?

1. Change suction to high intermittent%

2. Administer sedatives%

. (rrigate the )H tube with tap water%





!. iscontinue )H suctioning%

Corre"t #ns$er: <

Rationa%e 1$ The nasogastric suction might have caused the loss of hydrogen ions, causing metabolic al.alosis%

Rationa%e 2$ This client might show signs of tetany, disorientation, and sei&ures> sedatives are not indicated, and

might increase disorientation%

Rationa%e $ The )H tube should be irrigated with normal saline instead of tap water, to counter lost electrolytes

from the gastric secretion removal%

Rationa%e !$ )H suctioning should be discontinued, and nausea and vomiting should be treated with antiemetics%

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question

Type: MCMA

The nurse is admitting a client from the mergency epartment with a diagnosis of metabolic al.alosis%Appropriate treatment and nursing interventions for this client include$


1. Administer chloride%

2. Administer oxygen%

. Maintain a patent (%

!. ncourage fluids%

. ncourage ambulation%


Rationa%e 1$ Chloride will be administered to facilitate the excretion of bicarbonate by the .idneys%

Rationa%e 2$ !xygen might be required if respirations are depressed or if oxygen saturation drops%

Rationa%e $ A patent ( is necessary to restore normal fluids volume, as well as treating the underlying cause%





Rationa%e !$ The client might experience polyuria followed by volume deficit and thirst%

Rationa%e $ This client is at ris. for sei&ures> ambulation should not be encouraged until her condition is stable%

&%o'a% Rationa%e:




)earning -ut"ome:

Question !

Type: MCMA

The nurse is caring for a client whose (J! is being monitored% (mmeasurable fluid losses include$


1. xtreme diaphoresis%

2. *apid, deep respirations%

. 'rine%

!. )H drainage%

. ( fluid%

Corre"t #ns$er: 0,+

Rationa%e 1$ xtremely diaphoretic clients can lose significant amounts of fluids that contribute to fluidimbalance%

Rationa%e 2$ *apid deep respirations will contribute to fluid losses, but cannot be measured%

Rationa%e $ 'rine is a measurable type of output%

Rationa%e !$ )H drainage is a measurable type of output%

Rationa%e $ ( fluids are measurable inta.e%

&%o'a% Rationa%e:



C%ient Need *u':






)earning -ut"ome:

Question

Type: MCSA

The nurse is explaining the importance of measuring inta.e and output to the client and his family% (nta.e that

must be measured includes$

1. 'rine%

2. Stool%

. H( suction%

!. (ce chips%

. 4ound drainage%

Corre"t #ns$er: 0

Rationa%e 1$ 'rine is output that must be measured%

Rationa%e 2$ 'rine is output that must be measured%

Rationa%e $ 'rine is output that must be measured%

Rationa%e !$ 'rine is output that must be measured%

Rationa%e $ 'rine is output that must be measured%

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 6

Type: MCMA

The nurse is caring for a client with acidbase imbalance in collaboration with the healthcare team% Theinformation that needs to be conveyed to the team includes$


1. Continued urinary output%

2. Changes in level of consciousness%





. p8 greater than 9%<:%

!. (mbalance of (J!%

. -aseline vital signs%

Corre"t #ns$er: +,#,<

Rationa%e 1$ A change in urinary output or nasogastric tube output would be significant to report%

Rationa%e 2$ A change in urinary output or nasogastric tube output would be significant to report%

Rationa%e $ A change in urinary output or nasogastric tube output would be significant to report%

Rationa%e !$ A change in urinary output or nasogastric tube output would be significant to report%

Rationa%e $ A change in urinary output or nasogastric tube output would be significant to report%

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question /

Type: MCMA

The nurse is reviewing a clientGs care plan% Appropriate nursing interventions for a client with electrolyteimbalance due to prerenal failure include$


1. 4ee.ly weights%

2. *ecording inta.e and output%

. !ffering several small meals of a sodium;enhanced, low;protein diet%

!. *eorient client as needed%

. "rovide emotional support%


Rationa%e 1$ The nurse will monitor the clientGs weight daily%





Rationa%e 2$ The clientGs inta.e and output needs to be monitored and recorded%

Rationa%e $ The appropriate diet includes several small meals per day of a sodium;restricted, low;protein diet,

which will decrease fluid retention and potentially toxic byproducts of protein metabolism that the client is unabl

to excrete%

Rationa%e !$ Clients with alteration in fluid and electrolyte balance often become confused%

Rationa%e $ The client and family need opportunity to express concerns about the disease process and possibilityof dialysis treatment%

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 0

Type: MCSA

The nurse is reviewing the laboratory results of a client with muscle cramps% The electrolyte most li.ely out of

balance is$

1. Sodium%

2. "otassium%

. Calcium%

!. -icarbonate%

Corre"t #ns$er: #

Rationa%e 1$ 8yponatremia can manifest as muscle wea.ness%

Rationa%e 2$ 8yponatremia can manifest as muscle wea.ness%

Rationa%e $ 8yponatremia can manifest as muscle wea.ness%

Rationa%e !$ 8yponatremia can manifest as muscle wea.ness%

&%o'a% Rationa%e:



C%ient Need *u':






)earning -ut"ome:

Question

Type: MCMA

A client is admitted to the acute care setting for manifestations of fluid and electrolyte imbalance% !n review of

the clientGs serum electrolyte values, the nurse notes abnormal calcium and sodium values% )ormal values forthese two electrolytes are$


1. )ormal serum sodium level$ 0#:0<9 mqE5

2. )ormal serum sodium level$ #%::%/ mqE5

. )ormal serum calcium level$ =%:0/%: mgEdl

!. )ormal serum calcium level$ :0/: mqE5

. )ormal serum calcium level$ 0%#+%0 mqE5

Corre"t #ns$er: 0,#

Rationa%e 1$ )ormal serum sodium levels are between 0#:and 0<9 mqE5

Rationa%e 2$ )ormal serum sodium levels are between 0#: and 0<9 mqE5

Rationa%e $ )ormal serum sodium levels are between 0#: and 0<9 mqE5

Rationa%e !$ )ormal serum sodium levels are between 0#: and 0<9 mqE5

Rationa%e $ )ormal serum sodium levels are between 0#: and 0<9 mqE5Cognitive 5evel$ 'nderstanding

&%o'a% Rationa%e:

Cogniti(e )e(e%: )ormal serum sodium levels are between 0#: and 0<9 mqE5Cognitive 5evel$ 'nderstanding


C%ient Need *u':


)earning -ut"ome:

Question 6

Type: MCSA

The nurse is reviewing the laboratory studies of a client, and notes a serum sodium value of 0B= mqE5% xpected

clinical manifestations of this value would include$

1. !liguria and fever%





2. Constipation and decreased blood pressure%

. Muscle tremor and arrhythmias%

!. i&&iness and confusion%

Corre"t #ns$er: 0

Rationa%e 1$ !liguria> fever> thirst> flushed s.in> and dry, stic.y mucous membranes are common manifestations

of hypernatremia%

Rationa%e 2$ Constipation and decreased blood pressure are common manifestations of hypo.alemia%

Rationa%e $ Muscle tremor and arrhythmias are common manifestations of hypocalcemia%

Rationa%e !$ i&&iness and confusion are common manifestations of hypomagnesemia%

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 61

Type: MCSA

A client is admitted to the acute care facility for anorexia and nausea% The nurse would expect to note imbalances

of which electrolytes?

1. "hosphorus and chloride

2. Magnesium and potassium

. Magnesium and calcium

!. Sodium and potassium

Corre"t #ns$er: #

Rationa%e 1$ Common manifestations of chloride and phosphorus imbalances include increased muscleexcitability> tetany> decreased respirations> stupor> rapid, deep breathing> muscle wea.ness> paresthesias>

numbness> tingling> lethargy> speech defects> renal failure> arrhythmias> and muscle twitching%

Rationa%e 2$ Common manifestations of potassium imbalance include decreased muscle function, decreased

reflexes, decreased blood pressure, nausea, muscle wea.ness, diarrhea, and oliguria%





Rationa%e $ Common manifestations of imbalances in magnesium and calcium include anorexia and nausea, aswell as constipation, cramps, tetany, bleeding, and hypotension%

Rationa%e !$ Manifestations of imbalances in sodium and potassium include muscle wea.ness> decreased s.in

turgor> headache> tremor> sei&ures> thirst> fever> flushed s.in> oliguria> rapid, wea., irregular pulse> nausea and

vomiting> ileus> and oliguria%

&%o'a% Rationa%e:



C%ient Need *u':


)earning -ut"ome:

Question 62

Type: MCSA

The nurse is reviewing electrolytes and their functions with a client who has a history of electrolyte imbalance%!ne of the ma6or cations noted in teeth and bones is$

1. Magnesium%

2. Calcium%

. "otassium%

!. "hosphorus%

Corre"t #ns$er: +

Rationa%e 1$ Magnesium is a ma6or cation in (C7%

Rationa%e 2$ Magnesium is a ma6or cation in (C7%

Rationa%e $ Magnesium is a ma6or cation in (C7%

Rationa%e !$ Magnesium is a ma6or cation in (C7%

&%o'a% Rationa%e:



C%ient Need *u':


Ramont2e Rev TIF Ch26

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