Question 1

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health?

Accepted Answer

A specific gravity will detect if the patient has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not directly indicated.

Question 2

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems?

Accepted Answer

To gauge a patients magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with hypermagnesemia.

Question 3

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

Accepted Answer

Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause acidosis, not alkalosis.

Question 4

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acidbase imbalance?

Accepted Answer

The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is exhibited by hypoventilation and decreased $\mathrm{PaCO}_{2}$. CNS disturbances are found in extreme hyponatremia and fluid overload.

Question 5

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: $\mathrm{pH} 7.26, \mathrm{PaCO}_{2} 28, \mathrm{HCO}_{3} 11 \mathrm{mEq} / \mathrm{L}$. How would you interpret these results?

Accepted Answer

A low pH indicates acidosis (normal $\mathrm{pH}$ is 7.35 to 7.45 ). The $\mathrm{PaCO}_{3}$ is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The $\mathrm{pH}$ bicarbonate more closely corresponds with a decrease in $\mathrm{pH}$, making the metabolic component the primary problem.

Question 6

You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

Accepted Answer

Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli, phlebitis, and fluid overload are not indications of infiltration.

Question 7

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

Accepted Answer

Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.

Question 8

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

Accepted Answer

Ideally, both arms and hands are carefully inspected before choosing a specific venipuncture site that does not interfere with mobility. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes. The site does not necessarily need to be devoid of hair.

Question 9

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?

Accepted Answer

Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to water pressure. Diffusion is the movement of solutes from an area of greater concentration to lesser concentration; the solutes in an intact vascular system are unable to move so diffusion normally should not be taking place. Active transport is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.

Question 10

You are the surgical nurse caring for a 65 -year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

Accepted Answer

Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and, less commonly, in the feet. Hypophosphatemia creates central nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence. Signs of hyperkalemia include paresthesias and anxiety.

Question 11

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in $\mathrm{pH}$. What is the cause of this partial inability?

Accepted Answer

The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance. The lungs regulate and reabsorb carbonic acid to change and maintain $\mathrm{pH}$. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in $\mathrm{pH}$. Carbonic acid works as the chemical medium to exchange $\mathrm{O}_{2}$ and $\mathrm{CO}_{2}$ in the lungs to maintain a stable $\mathrm{pH}$ whereas the kidneys use bicarbonate as the chemical medium to maintain a stable $\mathrm{pH}$ by moving and eliminating $\mathrm{H}+$.

Question 12

You are caring for a 65 -year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance?

Accepted Answer

Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia. This patient would not be at risk for hypercalcemia; hyperparathyroidism and cancer account for almost all cases of hypercalcemia. The nasogastric tube is removing stomach acid and will likely raise $\mathrm{pH}$. Respiratory acidosis is unlikely since no change was reported in the patients respiratory status.

Question 13

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

Accepted Answer

Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in preparing for IV therapy. A local reaction could result in irritation to the IV site, or, in the extreme, it could result in anaphylaxis, which can be life threatening. Both hands should always be gloved when preparing for IV insertion, and latex-free gloves must be used or the patient must report not having latex allergies. The skin is not usually cleansed with normal saline prior to insertion. Removing excessive hair at the selected site is always secondary to allergy inquiry.

Question 14

A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas $(\mathrm{ABG})$ is drawn. The $\mathrm{ABG}$ has the following values: $\mathrm{pH} 7.21, \mathrm{PaCO}_{2} 64 \mathrm{~mm} \mathrm{Hg}$, $\mathrm{HCO}_{3}=24 \mathrm{~mm} \mathrm{Hg}$. What does the ABG reflect?

Accepted Answer

The $\mathrm{pH}$ is below $7.40, \mathrm{PaCO}_{2}$ is greater than 40 , and the $\mathrm{HCO}_{3}$ is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The $\mathrm{HCO}_{3}$ of 24 is within the normal range so it is not metabolic alkalosis. The $\mathrm{pH}$ of 7.21 indicates an acidosis, not alkalosis. The $\mathrm{pH}$ of 7.21 indicates it is an acidosis but the $\mathrm{HCO}_{3}$ of 24 is within the normal range, ruling out metabolic acidosis.

Question 15

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of $200 \mathrm{~mL}$ of normal saline solution over 15 minutes. This intervention will achieve which of the following?

Accepted Answer

If a patient is not excreting enough urine, the health care provider needs to determine whether the
depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to $200 \mathrm{~mL}$ of normal saline solution over 15 minutes. The response by a patient with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.

Question 16

The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?

Accepted Answer

In elderly patients, the clinical manifestations of fluid and electrolyte disturbances may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the elderly person. There is no mention of medications in the stem of the question or any specific evidence given for the need for readmission to the hospital. Confusion is never normal, common, or expected in the elderly. Urinary retention does normally cause confusion.

Question 17

A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and $40 \mathrm{~mL}$ of urine is present. What is the nurses most likely explanation for the low urine output?

Accepted Answer

Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.

Question 18

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?

Accepted Answer

Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.

Question 19

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone $(\mathrm{ADH})$ ?

Accepted Answer

Increased serum sodium causes increased thirst and the release of ADH by the posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are suppressed, the kidney excretes more water to restore normal osmolality. Levels of potassium, hemoglobin, and platelets do not directly affect $\mathrm{ADH}$ release.

Question 20

A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients $\mathrm{PaCO}_{2}$ has been between 56 and $64 \mathrm{~mm} \mathrm{Hg}$ for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?

Accepted Answer

When $\mathrm{PaCO}_{2}$ chronically exceeds $50 \mathrm{~mm} \mathrm{Hg}$, it creates insensitivity to $\mathrm{CO}_{2}$ in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. No information indicates the patients calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the patients intracranial pressure and create confusion. Increasing the oxygen would not stimulate the patient to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.

Quiz 13: Fluid and Electrolytes: Balance and Disturbance

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) . Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health?

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems?

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acidbase imbalance?

You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: $\mathrm{pH} 7.26, \mathrm{PaCO}_{2} 28, \mathrm{HCO}_{3} 11 \mathrm{mEq} / \mathrm{L}$ . How would you interpret these results?

You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in $\mathrm{pH}$ . What is the cause of this partial inability?

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of $200 \mathrm{~mL}$ of normal saline solution over 15 minutes. This intervention will achieve which of the following?

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone $(\mathrm{ADH})$ ?

Quiz 13: Fluid and Electrolytes: Balance and Disturbance

You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) . Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patients health?

You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the following health problems?

You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acidbase imbalance?

You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in pH\mathrm{pH}pH . What is the cause of this partial inability?

The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL200 \mathrm{~mL}200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?

A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH) (\mathrm{ADH}) (ADH) ?

A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in $\mathrm{pH}$ . What is the cause of this partial inability?

One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of $200 \mathrm{~mL}$ of normal saline solution over 15 minutes. This intervention will achieve which of the following?

You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone $(\mathrm{ADH})$ ?