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Question 1:

A nurse is caring for a client who has metabolic alkalosis and is receiving sodium chloride and potassium chloride IV fluids. The nurse should monitor for which of the following complications of this therapy?

A. Hypernatremia. B. Hypokalemia. C. Hyperchloremic acidosis. D. Hypochloremic alkalosis.

Answer and Explanation

Choice A:

Hypernatremia is not a likely complication of sodium chloride and potassium chloride IV fluids, because these fluids do not contain excessive amounts of sodium. Hypernatremia is more likely to occur with hypertonic saline solutions or excessive sodium intake.

Choice B:

Hypokalemia is not a likely complication of sodium chloride and potassium chloride IV fluids, because these fluids contain potassium, which can help prevent or correct hypokalemia. Hypokalemia is more likely to occur with diuretic therapy, vomiting, or diarrhea.

Choice C:

Hyperchloremic acidosis is a likely complication of sodium chloride and potassium chloride IV fluids, because these fluids can increase the serum chloride level and lower the serum bicarbonate level, resulting in a metabolic acidosis. Hyperchloremic acidosis can also worsen the client's existing metabolic alkalosis by impairing the renal excretion of hydrogen ions.

Choice D:

Hypochloremic alkalosis is not a likely complication of sodium chloride and potassium chloride IV fluids, because these fluids do not cause a loss of chloride or an increase in bicarbonate. Hypochloremic alkalosis is more likely to occur with vomiting, gastric suctioning, or diuretic therapy.

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Question 2:

A nurse is evaluating the effectiveness of IV fluid therapy for a client who has dehydration. Which of the following findings indicates improvement?

A. Decreased urine specific gravity. B. Increased hematocrit level. C. Decreased skin turgor. D. Increased serum osmolarity.

Answer and Explanation

Choice A:

Decreased urine specific gravity indicates improvement in hydration status. Urine specific gravity is a measure of the concentration of solutes in the urine. It reflects the ability of the kidney to concentrate or dilute urine. A high urine specific gravity (>1.030) indicates concentrated urine, which can be caused by dehydration, reduced renal blood flow, or increased fluid loss. A low urine specific gravity (<1.010) indicates diluted urine, which can be caused by overhydration, diuretic use, or impaired renal function. A normal urine specific gravity ranges from 1.010 to 1.030.

Choice B:

Increased hematocrit level indicates worsening of dehydration. Hematocrit is the percentage of red blood cells in the total blood volume. It is affected by the plasma volume and the number of red blood cells. A high hematocrit (>47% for males and >42% for females) indicates hemoconcentration, which can be caused by dehydration, polycythemia, or hypoxia. A low hematocrit (<37% for males and <32% for females) indicates hemodilution, which can be caused by overhydration, anemia, or hemorrhage. A normal hematocrit ranges from 37% to 47% for males and 32% to 42% for females.

Choice C:

Decreased skin turgor indicates persistent dehydration. Skin turgor is the elasticity of the skin that reflects its hydration status. It is assessed by pinching a fold of skin on the chest, abdomen, or forearm and releasing it. Normally, the skin should return to its original position in less than 3 seconds. If the skin remains elevated or takes longer to return, it indicates poor skin turgor, which can be caused by dehydration, aging, or edema.

Choice D:

Increased serum osmolarity indicates worsening of dehydration. Serum osmolarity is a measure of the concentration of solutes in the blood plasma. It reflects the balance between water and electrolytes in the body fluids. A high serum osmolarity (>300 mOsm/kg) indicates hyperosmolarity, which can be caused by dehydration, hypernatremia, hyperglycemia, or mannitol infusion. A low serum osmolarity (<280 mOsm/kg) indicates hypoosmolarity, which can be caused by overhydration, hyponatremia, syndrome of inappropriate antidiuretic hormone secretion (SIADH), or diuretic use. A normal serum osmolarity ranges from 280 to 300 mOsm/kg.

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Question 3:

A nurse is planning care for a client who has hyponatremia and is receiving IV fluid therapy with 3% sodium chloride solution. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

A. Administer the solution via a central line. B. Monitor serum sodium levels every 4 hours. C. Titrate the infusion rate according to urine output. D. Assess for signs of fluid overload. E. Keep an accurate intake and output record.

Answer and Explanation

Choice A:

Administer the solution via a central line. This is correct because 3% sodium chloride solution is a hypertonic solution that can cause phlebitis and tissue damage if infused peripherally. A central line can deliver the solution more safely and effectively.

Choice B:

Monitor serum sodium levels every 4 hours. This is correct because serum sodium levels can indicate the effectiveness of the therapy and the risk of complications such as hypernatremia or cerebral edema. The normal range of serum sodium is 135 to 145 mEq/L.

Choice C:

Titrate the infusion rate according to urine output. This is incorrect because the infusion rate of 3% sodium chloride solution should be titrated according to serum sodium levels, not urine output. Urine output can be affected by other factors such as renal function, fluid intake, and diuretics.

Choice D:

Assess for signs of fluid overload. This is correct because 3% sodium chloride solution can cause fluid shifts from the intracellular and interstitial spaces to the intravascular space, leading to fluid overload. Signs of fluid overload include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated central venous pressure (CVP), weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit.

Choice E:

Keep an accurate intake and output record. This is correct because intake and output records can help monitor the fluid balance and identify any excesses or deficits. Intake includes oral fluids, intravenous fluids, tube feedings, and blood products. Output includes urine, stool, vomitus, drainage, and insensible losses.

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Question 4:

A nurse is caring for a client who has diabetic ketoacidosis and is receiving an insulin infusion and IV fluids containing dextrose and normal saline. The nurse should monitor for which of the following complications of fluid therapy?

A. Hypernatremia. B. Hyperkalemia. C. Fluid volume deficit. D. Cerebral edema.

Answer and Explanation

Choice A:

Hypernatremia is not a likely complication of fluid therapy for diabetic ketoacidosis (DKA) Hypernatremia occurs when there is a loss of water or an excess of sodium in the body. Fluid therapy for DKA usually involves normal saline and dextrose, which do not cause hypernatremia. In fact, fluid therapy may help correct the dehydration and hyperosmolality that are associated with DKA.

Choice B:

Hyperkalemia is also not a likely complication of fluid therapy for DKA. Hyperkalemia occurs when there is an excess of potassium in the blood. Fluid therapy for DKA usually involves insulin infusion, which helps lower the potassium level by driving it into the cells. Insulin also helps lower the blood glucose level and reverse the acidosis that are characteristic of DKA.

Choice C:

Fluid volume deficit is a common manifestation of DKA, not a complication of fluid therapy. Fluid volume deficit occurs when there is a loss of fluid and electrolytes from the body due to osmotic diuresis, vomiting, and increased respiratory rate. Fluid therapy for DKA aims to restore the fluid volume and correct the electrolyte imbalances that result from fluid loss.

Choice D:

Cerebral edema is a potential complication of fluid therapy for DKA, especially in children and young adults. Cerebral edema occurs when there is an increase in intracranial pressure due to swelling of the brain tissue. Fluid therapy for DKA may cause cerebral edema by altering the osmotic gradient between the blood and the brain, leading to fluid shifts into the brain cells. Cerebral edema can cause neurological symptoms such as headache, confusion, seizures, and coma.

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Question 5:

A nurse is administering albumin to a client who has hypovolemic shock due to hemorrhage. The nurse understands that albumin is which of the following types of solutions?

A. Crystalloid. B. Colloid. C. Hypertonic. D. Hypotonic.

Answer and Explanation

Choice A:

Crystalloid solutions are fluids that contain electrolytes and can diffuse across semipermeable membranes. They are used to treat dehydration, electrolyte imbalances, and hypovolemia. However, they are not as effective as colloids in expanding the intravascular volume and maintaining the blood pressure. Therefore, choice A is incorrect.

Choice B:

Colloid solutions are fluids that contain large molecules such as proteins, starches, or gelatin that cannot cross the capillary membrane. They exert an osmotic pressure that draws fluid from the interstitial and intracellular spaces into the intravascular space. They are used to treat hypovolemic shock, burns, and hemorrhage. Albumin is a type of colloid solution that is derived from human plasma and contains 5% or 25% protein. It increases the plasma volume and the blood pressure by increasing the oncotic pressure. Therefore, choice B is correct.

Choice C:

Hypertonic solutions are fluids that have a higher osmolarity than the blood plasma. They draw water out of the cells and into the intravascular space. They are used to treat hyponatremia, cerebral edema, and severe dehydration. However, they can cause fluid overload, hypertension, and cellular dehydration if given in excess. Therefore, choice C is incorrect.

Choice D:

Hypotonic solutions are fluids that have a lower osmolarity than the blood plasma. They provide free water and electrolytes to the cells and the interstitial space. They are used to treat hypernatremia, cellular dehydration, and fluid loss due to burns or diuresis. However, they can cause fluid shifts from the intravascular space to the interstitial and intracellular spaces, resulting in hypovolemia, hypotension, and edema. Therefore, choice D is incorrect.

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Question 6:

A nurse is evaluating the effectiveness of fluid therapy for a client who has hypernatremia. Which of the following findings indicates improvement? (Select all that apply.)

A. Decreased thirst. B. Increased urine output. C. Decreased serum sodium level. D. Increased level of consciousness. E. Decreased edema.

Answer and Explanation

Choice A:

Decreased thirst. This is a sign of improvement because hypernatremia causes increased thirst due to high sodium levels in the blood. Decreased thirst indicates that the fluid therapy has restored the normal balance of sodium and water in the body.

Choice B:

Increased urine output. This is a sign of improvement because hypernatremia can cause decreased urine output due to dehydration or kidney dysfunction. Increased urine output indicates that the fluid therapy has replenished the body's water and helped the kidneys excrete excess sodium.

Choice C:

Decreased serum sodium level. This is a sign of improvement because hypernatremia is defined as a serum sodium level higher than 145 mEq/L. Decreased serum sodium level indicates that the fluid therapy has diluted the blood and lowered the sodium concentration to within the normal range.

Choice D:

Increased level of consciousness. This is a sign of improvement because hypernatremia can cause confusion, lethargy, or coma due to the effects of high sodium levels on the brain. Increased level of consciousness indicates that the fluid therapy has improved the brain function and reduced the risk of brain injury.

Choice E:

Decreased edema. This is not a sign of improvement because hypernatremia does not cause edema, which is the accumulation of fluid in the interstitial spaces. Edema is more likely to occur in conditions such as hypervolemia (excess fluid volume) or hyponatremia (low sodium levels) Decreased edema may indicate that the fluid therapy has caused fluid overload or electrolyte imbalance, which can be harmful.

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Question 7:

A nurse is caring for a client who has metabolic alkalosis as a result of prolonged nasogastric suctioning. The nurse should expect which of the following arterial blood gas values?

A. pH 7.50, PaCO2 40 mm Hg, HCO3- 30 mEq/L. B. pH 7.35, PaCO2 35 mm Hg, HCO3- 24 mEq/L. C. pH 7.25, PaCO2 50 mm Hg, HCO3- 26 mEq/L. D. pH 7.30, PaCO2 30 mm Hg, HCO3- 18 mEq/L.

Answer and Explanation

Choice A:

pH 7.50, PaCO2 40 mm Hg, HCO3- 30 mEq/L. This choice is correct because it shows a high pH, a normal PaCO2, and a high HCO3-, which are consistent with metabolic alkalosis. Metabolic alkalosis occurs when there is a loss of acid or a gain of base in the body fluids, such as from prolonged nasogastric suctioning. The kidneys try to compensate by excreting more bicarbonate, but this process is slow and incomplete.

Choice B:

pH 7.35, PaCO2 35 mm Hg, HCO3- 24 mEq/L. This choice is incorrect because it shows normal values for pH, PaCO2, and HCO3-, which indicate no acid-base imbalance. A client with metabolic alkalosis would have an elevated pH and bicarbonate level.

Choice C:

pH 7.25, PaCO2 50 mm Hg, HCO3- 26 mEq/L. This choice is incorrect because it shows a low pH, a high PaCO2, and a normal HCO3-, which are consistent with respiratory acidosis. Respiratory acidosis occurs when there is impaired gas exchange or hypoventilation, leading to an accumulation of carbon dioxide in the blood. The kidneys try to compensate by retaining more bicarbonate, but this process is slow and incomplete.

Choice D:

pH 7.30, PaCO2 30 mm Hg, HCO3- 18 mEq/L. This choice is incorrect because it shows a low pH, a low PaCO2, and a low HCO3-, which are consistent with metabolic acidosis. Metabolic acidosis occurs when there is a gain of acid or a loss of base in the body fluids, such as from diabetic ketoacidosis or diarrhea. The lungs try to compensate by increasing the rate and depth of breathing to expel more carbon dioxide, but this process is fast and limited.

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Question 8:

A nurse is reviewing the laboratory report of a client who has diabetic ketoacidosis (DKA) Which of the following findings should the nurse expect?

A. Serum glucose 600 mg/dL. B. Serum bicarbonate 28 mEq/L. C. Serum potassium 2.5 mEq/L. D. Serum sodium 150 mEq/L.

Answer and Explanation

Choice A:

Serum glucose 600 mg/dL. This is an expected finding for a client who has diabetic ketoacidosis (DKA) DKA results from a deficiency of insulin, which leads to hyperglycemia and ketosis. The normal range for serum glucose is 70 to 110 mg/dL.

Choice B:

Serum bicarbonate 28 mEq/L. This is not an expected finding for a client who has DKA. A client who has DKA experiences ketosis, which results in ketones in the urine and blood. The nurse should expect a client who has DKA to have an HCO3- less than 15 mEq/L. This decreased value is due to an increased production of ketones, which results in metabolic acidosis. The normal range for serum bicarbonate is 22 to 26 mEq/L.

Choice C:

Serum potassium 2.5 mEq/L. This is not an expected finding for a client who has DKA. A client who has DKA experiences osmotic diuresis and subsequent dehydration, which can cause electrolyte imbalances. The nurse should expect a client who has DKA to have elevated serum potassium levels due to the movement of potassium from the intracellular to the extracellular space in response to acidosis. The normal range for serum potassium is 3.5 to 5 mEq/L.

Choice D:

Serum sodium 150 mEq/L. This is not an expected finding for a client who has DKA. A client who has DKA experiences osmotic diuresis and subsequent dehydration, which can cause electrolyte imbalances. The nurse should expect a client who has DKA to have decreased serum sodium levels due to the dilutional effect of excess glucose in the blood. The normal range for serum sodium is 136 to 145 mEq/L.

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Question 9:

A nurse is providing discharge instructions to a client who has chronic heart failure and is prescribed furosemide, a loop diuretic. Which of the following dietary modifications should the nurse include in the teaching? (Select all that apply.)

A. Increase intake of foods high in potassium. B. Decrease intake of foods high in sodium. C. Increase intake of foods high in calcium. D. Decrease intake of foods high in protein. E. Increase intake of fluids as tolerated.

Answer and Explanation

Choice A:

Furosemide is a potassium-wasting diuretic that may reduce the potassium level in your blood. To counteract the loss of potassium, you should try to eat enough potassium-rich foods in your diet. Some examples of potassium-rich foods include bananas, orange juice, apricots, acorn squash, butternut squash, Hubbard squash, prunes, raisins, and bran products.

Choice B:

Furosemide is used to treat high blood pressure and edema by causing the kidneys to get rid of unneeded water and salt from the body into the urine. To enhance the effect of furosemide and prevent fluid retention, you should decrease intake of foods high in sodium. Some examples of sodium-rich foods include processed meats, canned soups, pickles, cheese, salted nuts, and snack foods.

Choice C:

Furosemide does not affect the calcium level in your blood significantly. Therefore, there is no need to increase intake of foods high in calcium when taking furosemide. However, you should still consume adequate amounts of calcium for your bone health and other functions. Some examples of calcium-rich foods include milk, yogurt, cheese, broccoli, kale, and fortified cereals.

Choice D:

Furosemide does not affect the protein level in your blood significantly. Therefore, there is no need to decrease intake of foods high in protein when taking furosemide. However, you should still consume moderate amounts of protein for your muscle health and other functions. Some examples of protein-rich foods include eggs, fish, poultry, meat, beans, nuts, and seeds.

Choice E:

Furosemide can cause dehydration and electrolyte imbalance by increasing urine output. Therefore, you should increase intake of fluids as tolerated to prevent these complications. You should drink enough water to keep your urine clear or pale yellow. You should also avoid alcohol and caffeine as they can worsen dehydration.

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Question 10:

A nurse is caring for a client who has metabolic acidosis and is receiving sodium bicarbonate IV bolus and infusion to correct the pH imbalance. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the therapy?

A. Serum sodium. B. Serum potassium. C. Serum chloride. D. Serum bicarbonate.

Answer and Explanation

Choice A:

Serum sodium is not directly related to the acid-base balance of the body. Sodium bicarbonate therapy does not affect the serum sodium level significantly. Therefore, monitoring serum sodium is not an effective way to evaluate the effectiveness of the therapy.

Choice B:

Serum potassium is inversely related to the serum pH. As the pH increases, the potassium level decreases, and vice versa. Sodium bicarbonate therapy raises the pH and lowers the potassium level. Therefore, monitoring serum potassium is important to prevent hypokalemia, but it does not directly reflect the acid-base balance of the body.

Choice C:

Serum chloride is inversely related to the serum bicarbonate level. As the bicarbonate level increases, the chloride level decreases, and vice versa. Sodium bicarbonate therapy increases the bicarbonate level and decreases the chloride level. Therefore, monitoring serum chloride is important to prevent hypochloremia, but it does not directly reflect the acid-base balance of the body.

Choice D:

Serum bicarbonate is directly related to the acid-base balance of the body. The normal range of serum bicarbonate is 22 to 26 mEq/L. In metabolic acidosis, the bicarbonate level is low, and in metabolic alkalosis, it is high. Sodium bicarbonate therapy aims to increase the bicarbonate level and correct metabolic acidosis. Therefore, monitoring serum bicarbonate is the most effective way to evaluate the effectiveness of the therapy.

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Question 11:

A nurse is reviewing the laboratory results of a client who has chronic kidney disease and notes that the serum phosphate level is elevated. The nurse should anticipate that which of the following electrolyte levels will be decreased?

A. Sodium. B. Magnesium. C. Calcium. D. Bicarbonate.

Answer and Explanation

Choice A:

Sodium. Sodium is not affected by serum phosphate level in chronic kidney disease (CKD) patients. Sodium level is mainly regulated by the renin-angiotensin-aldosterone system and the antidiuretic hormone. Sodium level can be altered by fluid intake, fluid loss, diuretics, or salt restriction, but not by phosphate level.

Choice B:

Magnesium. Magnesium is also not affected by serum phosphate level in CKD patients. Magnesium level is mainly influenced by dietary intake, intestinal absorption, renal excretion, and exchange with bone and soft tissues. Magnesium level can be altered by malnutrition, malabsorption, diarrhea, vomiting, diuretics, or alcoholism, but not by phosphate level.

Choice C:

Calcium. Calcium is the correct answer because calcium and phosphate have an inverse relationship in the body. When serum phosphate level is elevated, as in CKD patients, serum calcium level tends to decrease. This is because high phosphate level binds to calcium and forms insoluble complexes that are deposited in soft tissues and bones. This reduces the amount of free calcium in the blood and triggers the secretion of parathyroid hormone (PTH), which further lowers the calcium level by increasing its excretion in the urine.

Choice D:

Bicarbonate. Bicarbonate is not directly affected by serum phosphate level in CKD patients. Bicarbonate level is mainly determined by the acid-base balance in the body. Bicarbonate level can be altered by metabolic acidosis or alkalosis, respiratory acidosis or alkalosis, renal failure, or diarrhea, but not by phosphate level.

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Question 12:

A nurse is providing dietary teaching to a client who has hypocalcemia due to hypoparathyroidism. Which of the following foods should the nurse recommend? (Select all that apply.)

A. Cheese. B. Broccoli. C. Almonds. D. Bananas. E. Sardines.

Answer and Explanation

Choice A:

Cheese is a good source of calcium, which is essential for bone health and muscle contraction. Calcium also helps regulate the heart rhythm and blood clotting. Cheese can provide about 200 mg of calcium per ounce.

Choice B:

Broccoli is a cruciferous vegetable that contains goitrogens, which are substances that can interfere with thyroid hormone synthesis and cause or worsen hypothyroidism. Hypothyroidism can lead to low levels of parathyroid hormone (PTH), which is responsible for maintaining calcium balance in the body. Therefore, broccoli should be avoided or limited by clients who have hypocalcemia due to hypoparathyroidism.

Choice C:

Almonds are rich in magnesium, which is a mineral that helps regulate calcium absorption and metabolism. Magnesium also plays a role in nerve and muscle function, blood pressure, and blood sugar control. Almonds can provide about 80 mg of magnesium per ounce.

Choice D:

Bananas are high in potassium, which is a mineral that can affect the balance of calcium in the body. High levels of potassium can cause hyperkalemia, which can lower the serum calcium level by increasing the renal excretion of calcium and decreasing the release of PTH. Therefore, bananas should be avoided or limited by clients who have hypocalcemia due to hypoparathyroidism.

Choice E:

Sardines are a type of oily fish that contain vitamin D, which is a fat-soluble vitamin that helps increase the intestinal absorption of calcium and phosphorus. Vitamin D also works with PTH to regulate the bone resorption and formation of calcium. Sardines can provide about 250 IU of vitamin D per 3 ounces.

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Question 13:

A nurse is caring for a client who has dehydration due to vomiting and diarrhea. The client's blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 22/min. The nurse should anticipate a prescription for which of the following types of IV fluids?

A. Dextrose 5% in water (D5W) B. Lactated Ringer's (LR) C. Dextrose 5% in 0.45% sodium chloride (D5W/0.45% NaCl) D. Dextrose 5% in lactated Ringer's (D5LR)

Answer and Explanation

Choice A:

Dextrose 5% in water (D5W) is a hypotonic solution that provides free water and calories, but no electrolytes. It is used to treat hypernatremia and cellular dehydration, but it can cause fluid shifts from the intravascular to the intracellular space, leading to cerebral edema and decreased blood pressure. This is not appropriate for a client who has dehydration due to vomiting and diarrhea, as they need to restore their intravascular volume and electrolyte balance.

Choice B:

Lactated Ringer's (LR) is an isotonic solution that contains sodium, chloride, potassium, calcium, and lactate. It is used to treat fluid loss from burns, trauma, surgery, or sepsis. It also helps to correct metabolic acidosis by providing bicarbonate precursors. This is the best choice for a client who has dehydration due to vomiting and diarrhea, as they need to replace their fluid and electrolyte losses and maintain their acid-base balance.

Choice C:

Dextrose 5% in 0.45% sodium chloride (D5W/0.45% NaCl) is a hypertonic solution that provides free water, calories, and sodium. It is used to treat hypovolemia and hyponatremia, but it can cause fluid shifts from the intracellular to the intravascular space, leading to cellular dehydration and increased blood pressure. This is not appropriate for a client who has dehydration due to vomiting and diarrhea, as they already have low blood pressure and cellular dehydration.

Choice D:

Dextrose 5% in lactated Ringer's (D5LR) is a hypertonic solution that provides free water, calories, sodium, chloride, potassium, calcium, and lactate. It is used to treat hypovolemia and metabolic acidosis, but it can cause fluid shifts from the intracellular to the intravascular space, leading to cellular dehydration and increased blood pressure. This is not appropriate for a client who has dehydration due to vomiting and diarrhea, as they already have low blood pressure and cellular dehydration.

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Question 14:

A nurse is evaluating a client who has fluid volume overload and received furosemide 40 mg IV bolus 1 hr ago. Which of the following findings indicates that the medication was effective?

A. The client reports increased thirst. B. The client's urine output is 250 mL/hr. C. The client's heart rate is 100/min. D. The client's weight is unchanged.

Answer and Explanation

Choice A:

The client reports increased thirst. This is not an indication that the medication was effective, because increased thirst can be a sign of dehydration or electrolyte imbalance caused by excessive diuresis. Furosemide can cause loss of water and sodium, potassium, calcium, magnesium, and chloride in the urine.

Choice B:

The client's urine output is 250 mL/hr. This is an indication that the medication was effective, because furosemide is a loop diuretic that inhibits the reabsorption of sodium and water in the ascending limb of the loop of Henle, resulting in increased urine output and decreased fluid volume. A normal urine output is about 30 to 60 mL/hr, so a urine output of 250 mL/hr indicates a significant diuretic effect.

Choice C:

The client's heart rate is 100/min. This is not an indication that the medication was effective, because a high heart rate can be a sign of hypovolemia, hypotension, or cardiac stress caused by furosemide. Furosemide can lower the blood pressure and reduce the preload and afterload on the heart, but it can also trigger compensatory mechanisms such as increased sympathetic activity and renin-angiotensin-aldosterone system activation, which can increase the heart rate.

Choice D:

The client's weight is unchanged. This is not an indication that the medication was effective, because weight loss is expected with furosemide therapy due to fluid removal. Furosemide can cause a rapid and significant reduction in fluid volume, which can be measured by daily weight changes. A weight loss of 1 kg corresponds to a fluid loss of about 1 L.

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Question 15:

A nurse is planning care for a client who has overhydration and hyponatremia. Which of the following actions should the nurse include in the plan? (Select all that apply.)

A. Monitor neurological status. B. Administer sodium polystyrene sulfonate as prescribed. C. Provide oral hygiene frequently. D. Restrict sodium intake as prescribed. E. Encourage foods high in protein.

Answer and Explanation

Choice A:

Monitoring neurological status is a priority intervention for a client who has overhydration and hyponatremia because these conditions can cause cerebral edema, increased intracranial pressure, and altered mental status. The nurse should assess the client for signs of confusion, lethargy, seizures, and coma, and report any changes to the provider.

Choice B:

Administering sodium polystyrene sulfonate is not indicated for a client who has overhydration and hyponatremia. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. It has no effect on sodium levels or fluid balance.

Choice C:

Providing oral hygiene frequently is a supportive intervention for a client who has overhydration and hyponatremia, but it is not a priority. Oral hygiene can help prevent dry mouth, infections, and discomfort caused by fluid retention and electrolyte imbalance. However, it does not address the underlying causes or complications of the disorder.

Choice D:

Restricting sodium intake as prescribed is an essential intervention for a client who has overhydration and hyponatremia. Sodium intake can affect the serum sodium level and the fluid balance in the body. Excessive sodium intake can worsen fluid retention and edema, while inadequate sodium intake can exacerbate hyponatremia. The nurse should follow the provider's orders regarding sodium restriction and educate the client on how to avoid high-sodium foods and beverages.

Choice E:

Encouraging foods high in protein is not appropriate for a client who has overhydration and hyponatremia. Protein intake can affect the serum osmolality and the fluid distribution in the body. High-protein foods can increase the osmotic pressure in the blood vessels, drawing more fluid from the interstitial and intracellular spaces. This can worsen overhydration and hyponatremia by diluting the serum sodium level further. The nurse should consult with a dietitian regarding the optimal protein intake for the client.

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Question 16:

A patient has been admitted with a potassium level of 6.8 mEq/L. The nurse would expect which of the following electrocardiogram (ECG) changes as a result of this laboratory value?

A. U waves. B. Absent P waves. C. Elevated T waves. D. Inverted QRS complexes.

Answer and Explanation

Choice A:

U waves are not a sign of high potassium level, but rather of low potassium level (hypokalemia) Hypokalemia can cause ST segment depression, T wave flattening or inversion, and prominent U waves.

Choice B:

Absent P waves are not a sign of high potassium level, but rather of a severe conduction block or atrial fibrillation. High potassium level can cause P wave widening or flattening, and PR prolongation, but not complete disappearance of P waves.

Choice C:

Elevated T waves are the most common and earliest sign of high potassium level (hyperkalemia) Hyperkalemia can cause tall, peaked, symmetric T waves that may merge with the QRS complex. This is the correct answer.

Choice D:

Inverted QRS complexes are not a sign of high potassium level, but rather of ventricular arrhythmias or myocardial infarction. High potassium level can cause QRS widening and bizarre QRS morphology, but not inversion.

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Question 17:

The nurse is caring for a patient who has been vomiting and has diarrhea for 3 days and now has muscle weakness and paresthesias in his hands and feet, along with an irregular pulse rate and rhythm, and shallow respirations with crackles on auscultation of his lungs bilaterally. The nurse suspects that these symptoms are most likely due to which electrolyte imbalance?

A. Hypercalcemia. B. Hypokalemia. C. Hypermagnesemia. D. Hypophosphatemia.

Answer and Explanation

Choice A:

lcemia. This is a condition of having too much calcium in the blood. It can cause muscle weakness, constipation, nausea, vomiting, confusion, and irregular heartbeat. However, it does not typically cause paresthesias (tingling or numbness), diarrhea, or crackles in the lungs.

Choice B:

emia. This is a condition of having too low potassium in the blood. It can cause muscle weakness, paresthesias, irregular heartbeat, shallow respirations, and increased risk of digoxin toxicity (a medication used to treat heart failure) It can also cause vomiting and diarrhea, which can worsen the potassium loss. This choice matches the symptoms of the patient.

Choice C:

gnesemia. This is a condition of having too much magnesium in the blood. It can cause muscle weakness, nausea, vomiting, low blood pressure, bradycardia (slow heart rate), and respiratory depression. However, it does not usually cause paresthesias, diarrhea, or crackles in the lungs.

Choice D:

sphatemia. This is a condition of having too low phosphate in the blood. It can cause muscle weakness, bone pain, rickets (softening of bones), and impaired cellular function. However, it does not typically cause paresthesias, irregular heartbeat, shallow respirations, or crackles in the lungs.

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Question 18:

A nurse is caring for a client who has hypomagnesemia due to chronic alcohol use disorder. Which of the following actions should the nurse take?

A. Administer magnesium sulfate IV. B. Monitor the client's blood pressure and heart rate. C. Encourage the client to increase intake of green leafy vegetables. D. Prepare to administer calcium gluconate IV. E. Assess the client for Chvostek's sign and Trousseau's sign.

Answer and Explanation

Choice A:

Administer magnesium sulfate IV. This is correct because magnesium sulfate is the treatment of choice for severe hypomagnesemia. It can rapidly increase the blood level of magnesium and correct the symptoms of deficiency.

Choice B:

Monitor the client's blood pressure and heart rate. This is incorrect because monitoring vital signs is not a specific intervention for hypomagnesemia. However, it is important to monitor the client for signs of hypotension and bradycardia, which can occur as adverse effects of magnesium sulfate therapy.

Choice C:

Encourage the client to increase intake of green leafy vegetables. This is correct because green leafy vegetables are rich sources of dietary magnesium. Increasing the intake of magnesium-rich foods can help prevent or treat mild hypomagnesemia.

Choice D:

Prepare to administer calcium gluconate IV. This is incorrect because calcium gluconate is not indicated for hypomagnesemia. Calcium gluconate is used to treat hypocalcemia, which can occur as a complication of hypomagnesemia. However, calcium gluconate should not be given until the magnesium level is corrected, as low magnesium can impair the response to calcium.

Choice E:

Assess the client for Chvostek's sign and Trousseau's sign. This is correct because Chvostek's sign and Trousseau's sign are clinical tests for neuromuscular irritability, which can occur in hypomagnesemia. Chvostek's sign is elicited by tapping the facial nerve in front of the ear and observing for facial twitching. Trousseau's sign is elicited by inflating a blood pressure cuff above the systolic pressure for 3 minutes and observing for carpal spasm.

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Question 19:

A nurse is reviewing laboratory results for a client who has hypokalemia. Which of the following findings should the nurse expect?

A. Decreased serum pH. B. Increased serum calcium. C. Decreased serum magnesium. D. Increased serum bicarbonate.

Answer and Explanation

Choice A:

ed serum pH. This is incorrect because hypokalemia usually causes increased serum pH, not decreased. This is because low potassium levels can lead to metabolic alkalosis, a condition where the blood is too alkaline due to loss of acid from the body. This can happen in cases of vomiting, diuretic use, or mineralocorticoid excess.

Choice B:

ed serum calcium. This is incorrect because hypokalemia does not directly affect serum calcium levels. However, hypokalemia can cause hypomagnesemia, or low magnesium levels, which can in turn cause hypercalcemia, or high calcium levels. This is because magnesium is needed for the secretion of parathyroid hormone (PTH), which regulates calcium balance in the body. Low magnesium levels can lead to increased PTH secretion and increased calcium reabsorption from the bones and kidneys.

Choice C:

ed serum magnesium. This is correct because hypokalemia and hypomagnesemia often occur together, especially in cases of chronic diarrhea, malabsorption, alcoholism, or diuretic use. This is because potassium and magnesium are both lost in the urine or stool when these conditions are present. Hypomagnesemia can also cause hypokalemia by impairing the reabsorption of potassium in the kidneys and increasing the entry of potassium into the cells.

Choice D:

ed serum bicarbonate. This is incorrect because hypokalemia usually causes decreased serum bicarbonate, not increased. This is because low potassium levels can lead to metabolic acidosis, a condition where the blood is too acidic due to accumulation of acid in the body. This can happen in cases of diabetic ketoacidosis, renal tubular acidosis, or chronic kidney disease.

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Question 20:

A nurse is caring for a client who has metabolic acidosis due to diabetic ketoacidosis (DKA) Which of the following manifestations should the nurse monitor?

A. Kussmaul respirations. B. Bradypnea. C. Muscle spasms. D. Numbness and tingling of extremities.

Answer and Explanation

Choice A:

Kussmaul respirations are a type of deep, rapid breathing that occurs in response to metabolic acidosis. The body tries to compensate for the excess acid by blowing off carbon dioxide through the lungs. Kussmaul respirations are a common manifestation of diabetic ketoacidosis (DKA), which is a severe form of metabolic acidosis caused by the accumulation of ketones in the blood. The nurse should monitor the client's respiratory rate, depth, and pattern, as well as the arterial blood gas results, to assess the severity of metabolic acidosis and the effectiveness of treatment.

Choice B:

Bradypnea is a condition of abnormally slow breathing, usually less than 12 breaths per minute. Bradypnea can result from respiratory acidosis, which is a condition of excess carbon dioxide in the blood due to hypoventilation or impaired gas exchange. Bradypnea is not a manifestation of metabolic acidosis, which is a condition of excess acid in the blood due to increased production or decreased elimination of hydrogen ions. Therefore, choice B is incorrect.

Choice C:

Muscle spasms are involuntary contractions of the skeletal muscles that can cause pain and discomfort. Muscle spasms can result from hypocalcemia, which is a condition of low calcium levels in the blood. Hypocalcemia can occur in metabolic acidosis due to the binding of calcium with excess hydrogen ions, reducing the availability of free calcium for muscle contraction. However, muscle spasms are not a specific or common manifestation of metabolic acidosis, and they can have other causes such as dehydration, electrolyte imbalance, or muscle injury. Therefore, choice C is incorrect.

Choice D:

Numbness and tingling of extremities are sensations of reduced or abnormal feeling in the arms or legs. Numbness and tingling can result from hypokalemia, which is a condition of low potassium levels in the blood. Hypokalemia can occur in metabolic acidosis due to the movement of potassium from the intracellular to the extracellular space in exchange for hydrogen ions, which are then excreted by the kidneys. However, numbness and tingling are not specific or common manifestations of metabolic acidosis, and they can have other causes such as nerve compression, peripheral neuropathy, or hyperventilation. Therefore, choice D is incorrect.

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Question 21:

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse report to the provider? (Select all that apply.)

A. Jugular vein distension. B. Weight gain of 2 kg in one day. C. Decreased hematocrit. D. Bounding pulse. E. Flat neck veins.

Answer and Explanation

Choice A:

Jugular vein distension is a sign of fluid overload because it indicates increased pressure in the right atrium and superior vena cava due to excess blood volume.

Choice B:

Weight gain of 2 kg in one day is a sign of fluid overload because it reflects fluid retention in the body. A weight gain of 1 kg (2.2 lb) is equivalent to 1 L of fluid.

Choice C:

Decreased hematocrit is a sign of fluid overload because it indicates hemodilution or dilution of the blood due to excess fluid in the intravascular space.

Choice D:

Bounding pulse is a sign of fluid overload because it reflects increased cardiac output and stroke volume due to excess blood volume.

Choice E:

Flat neck veins are not a sign of fluid overload, but rather a sign of fluid deficit or dehydration. In fluid overload, neck veins will be distended or elevated.

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Question 22:

The nurse is caring for a patient with severe burns who is receiving IV fluid resuscitation with lactated Ringer's solution. The nurse understands that this type of solution is used for this patient because it:

A. Provides free water and replaces electrolytes. B. Expands intravascular volume and replaces electrolytes. C. Pulls fluid into the vascular space from the cells. D. Moves fluid into the cells to replace cellular dehydration.

Answer and Explanation

Choice A:

This is incorrect because lactated Ringer's solution does not provide free water, which is water without electrolytes. Free water is used to correct cellular dehydration, not fluid loss from burns.

Choice B:

This is correct because lactated Ringer's solution is an isotonic fluid that has the same osmotic pressure as blood. It expands intravascular volume and replaces electrolytes that are lost from burns. It also contains sodium lactate, which is metabolized to bicarbonate and helps correct metabolic acidosis.

Choice C:

This is incorrect because lactated Ringer's solution does not pull fluid into the vascular space from the cells. This would be the effect of a hypertonic fluid, which has a higher osmotic pressure than blood. Hypertonic fluids are not recommended for burn patients because they can cause cellular dehydration and increase the risk of hypernatremia.

Choice D:

This is incorrect because lactated Ringer's solution does not move fluid into the cells to replace cellular dehydration. This would be the effect of a hypotonic fluid, which has a lower osmotic pressure than blood. Hypotonic fluids are not recommended for burn patients because they can cause intravascular depletion and hypotension.

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Question 23:

The nurse is preparing to hang a bag of 0.9% sodium chloride (normal saline) for a patient who has hyponatremia. The nurse knows that this type of solution is:

A. Hypotonic and will move fluid out of the vascular space. B. Hypertonic and will move fluid into the vascular space. C. Isotonic and will expand the vascular space. D. Isotonic and will have no effect on fluid movement.

Answer and Explanation

Choice A:

This is incorrect because 0.9% sodium chloride (normal saline) is an isotonic solution, not a hypotonic one. Isotonic solutions have the same concentration of solutes as blood plasma and do not cause fluid movement across the cell membrane.

Choice B:

This is incorrect because 0.9% sodium chloride (normal saline) is an isotonic solution, not a hypertonic one. Hypertonic solutions have a higher concentration of solutes than blood plasma and cause fluid to move out of the cells and into the vascular space.

Choice C:

This is correct because 0.9% sodium chloride (normal saline) is an isotonic solution that will expand the vascular space by adding fluid without changing the concentration of solutes. This is useful for patients with hyponatremia (low sodium level in the blood) who need to restore their fluid and electrolyte balance.

Choice D:

This is incorrect because 0.9% sodium chloride (normal saline) is an isotonic solution that will expand the vascular space by adding fluid without changing the concentration of solutes. It will not have no effect on fluid movement, as it will increase the intravascular volume.

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Question 24:

A nurse is administering dextrose 10% in water (D10W) to a patient who needs some nutrition with glucose. Which of the following assessments should the nurse perform? (Select all that apply.)

A. Monitor blood glucose levels. B. Check for signs of phlebitis at the IV site. C. Assess for fluid overload. D. Evaluate serum sodium levels. E. Observe for signs of hypoglycemia.

Answer and Explanation

Choice A:

The nurse should monitor blood glucose levels because dextrose 10% in water (D10W) is a hypertonic solution that contains glucose and can raise the blood sugar level of the patient. The nurse should check the blood glucose level before and after administering D10W to prevent hyperglycemia or hypoglycemia.

Choice B:

The nurse should check for signs of phlebitis at the IV site because D10W is acidic and can cause venous irritation. Phlebitis is inflammation of the vein that can result from chemical, mechanical or bacterial causes. Signs of phlebitis include pain, redness, swelling, warmth and tenderness at the IV site.

Choice C:

The nurse should assess for fluid overload because D10W is quickly metabolized, leaving behind water that can move into the interstitial space. Fluid overload can cause edema, dyspnea, crackles, distended neck veins, increased blood pressure and decreased urine output. The nurse should monitor the intake and output, vital signs, weight and breath sounds of the patient.

Choice D:

The nurse does not need to evaluate serum sodium levels because D10W does not contain sodium or affect the sodium balance of the patient. D10W is used to provide some nutrition with glucose, not to correct electrolyte imbalances.

Choice E:

The nurse does not need to observe for signs of hypoglycemia because D10W is unlikely to cause hypoglycemia unless there is a sudden interruption or discontinuation of the infusion. Hypoglycemia is a low blood sugar level that can cause shakiness, diaphoresis, confusion, weakness, hunger and headache. The nurse should monitor the blood glucose level and administer D10W at a steady rate to prevent hypoglycemia.

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Question 25:

The nurse is caring for a patient with an IV infusion in his left arm that was started 2 hours ago in the emergency department (ED) The patient complains of pain at the IV site and rates it as an 8 on a scale of 0 to 10. The nurse assesses the site and notes edema, erythema, and coolness to touch around the insertion site. What is the most appropriate action by the nurse?

A. Apply warm compresses to the site and elevate the arm. B. Slow down the infusion rate and document the findings. C. Stop the infusion, remove the IV catheter, and start a new IV in another site. D. Notify the physician and obtain an order for an antihistamine.

Answer and Explanation

Choice A:

Applying warm compresses to the site and elevating the arm may help to reduce pain and swelling, but they do not address the underlying cause of the problem, which is likely infiltration or phlebitis of the IV site. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing edema, coolness, and pallor. Phlebitis occurs when the vein becomes inflamed, causing pain, erythema, and warmth. Both conditions require immediate removal of the IV catheter and restarting a new IV in another site.

Choice B:

Slowing down the infusion rate and documenting the findings may be appropriate actions after removing the IV catheter and starting a new IV in another site, but they are not sufficient to resolve the problem. Slowing down the infusion rate may reduce the discomfort and prevent further complications, but it does not stop the leakage or inflammation of the IV site. Documenting the findings is important for legal and quality improvement purposes, but it does not provide any intervention for the patient's pain or risk of infection.

Choice C:

Stopping the infusion, removing the IV catheter, and starting a new IV in another site is the most appropriate action by the nurse. This action prevents further damage to the tissue or vein, reduces the risk of infection, and restores adequate IV access for fluid and medication administration. The nurse should also apply a sterile dressing to the affected site, monitor for signs of infection or complications, and notify the physician if needed. This is the correct answer.

Choice D:

Notifying the physician and obtaining an order for an antihistamine is not an appropriate action by the nurse. This action implies that the patient is having an allergic reaction to the IV fluid or medication, which is not supported by the assessment findings. An antihistamine may help to reduce itching or swelling, but it does not address the cause of the pain or prevent further tissue or vein damage. The nurse should notify the physician after removing the IV catheter and starting a new IV in another site, and only if there are signs of infection or complications that require medical intervention.

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Question 26:

The nurse is preparing to insert a central venous catheter into a patient's right internal jugular vein using ultrasound guidance. What is an important step that the nurse should perform before inserting the catheter?

A. Shave the hair around the insertion site. B. Obtain informed consent from the patient. C. Administer prophylactic antibiotics to the patient. D. Place the patient in Trendelenburg position.

Answer and Explanation

Choice A:

Shaving the hair around the insertion site is not recommended because it can cause skin irritation and increase the risk of infection.

Choice B:

Obtaining informed consent from the patient is important, but it is not a step that the nurse should perform before inserting the catheter. Informed consent should be obtained by the physician or advanced practice nurse who will perform the procedure.

Choice C:

Administering prophylactic antibiotics to the patient is not a routine practice for central venous catheter insertion. Antibiotics may be indicated for patients with certain risk factors, such as immunosuppression, but they should be prescribed by the physician or advanced practice nurse.

Choice D:

Placing the patient in Trendelenburg position is an important step that the nurse should perform before inserting the catheter. This position helps to distend the jugular vein and reduce the risk of air embolism during catheter insertion.

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Question 27:

The nurse is monitoring a patient who has a central venous catheter in place for signs of complications. Which of the following are potential complications of central venous catheters? (Select all that apply.)

A. Pneumothorax. B. Air embolism. C. Catheter-related bloodstream infection. D. Catheter occlusion. E. Hematoma formation.

Answer and Explanation

Choice A:

Pneumothorax: This is a condition where air accumulates in the pleural space, causing the lung to collapse. It can occur during insertion of a central venous catheter if the needle or catheter punctures the lung or the pleura.

Choice B:

Air embolism. This is a condition where air bubbles enter the bloodstream and obstruct blood flow. It can occur during insertion, removal or maintenance of a central venous catheter if air enters the catheter or the vein.

Choice C:

Catheter-related bloodstream infection. This is an infection that occurs when microorganisms colonize the catheter or the insertion site and enter the bloodstream. It can cause fever, chills, sepsis and other serious complications. It can be prevented by using strict aseptic technique and following infection control guidelines.

Choice D:

Catheter occlusion. This is a condition where the catheter lumen becomes blocked by blood clots, fibrin sheaths, precipitates or kinks. It can impair the infusion or withdrawal of fluids and medications. It can be prevented by flushing the catheter regularly with saline or heparin solutions.

Choice E:

Hematoma formation. This is a condition where blood accumulates under the skin or in the tissues around the insertion site. It can occur due to bleeding from the punctured vein or artery, or from trauma to the site. It can cause pain, swelling, bruising and infection.

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