Textbook of Medical-Surgical Nursing

BRUNNER & SUDDARTH'S TEXTBOOK OF MEDICAL-SURGICAL

NURSING 15TH EDITION HINKLE TEST BANK

TEST BANK

AllStudyGuides

CLICK HERE TO ACCESS FULL TEST BANK

BRUNNER & SUDDARTH'S TEXTBOOK OF MEDICAL-SURGICAL NURSING 15TH EDITION HINKLE TEST BANK

Chapter 10: Fluid and Electrolytes

Hinkle: Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 15th Edition

MULTIPLE CHOICE

1. The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic hormone

secretion. The plan of care includes assessment of specific gravity every four hours. The results of this

test will allow the nurse to assess which aspect of the client's health?

A. Nutritional status

B. Potassium balance

C. Calcium balance

D. Fluid volume status

ANS: D

Rationale: Specific gravity measures the density of urine compared with water and can assess the

ability of the kidneys to excrete or conserve water. Therefore, specific gravity will detect if the client

has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and calcium levels are not

directly indicated.

PTS: 1 REF: p. 230

NAT: Client Needs: Physiological Integrity: Physiological Adaptation

TOP: Chapter 10: Principles of Fluid and Electrolytes

KEY: Integrated Process: Nursing Process

BLM: Cognitive Level: Apply

NOT: Multiple Choice

2. The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing the

client's most recent laboratory reports, the nurse notes that the client's magnesium levels are high. The

nurse should prioritize assessment for what health problem?

A. Diminished deep tendon reflexes

B. Tachycardia

C. Cool, clammy skin

D. Acute flank pain

ANS: A

Rationale: To gauge a client's 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.

PTS: 1 REF: p. 254






3. The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third

spacing. Based on this change in status, the nurse should expect the client to exhibit signs and

symptoms of which imbalance?

A. Metabolic alkalosis

B. Hypermagnesemia

C. Hypercalcemia

D. Hypovolemia

ANS: D

C L I C K H E R E T O D O W N L O A D C O M P L E T E T E S T B A N K S


Rationale: 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.

PTS: 1 REF: p. 226






4. A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room.

The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse is aware

that hyperventilation is the most common cause of which acid–base imbalance?

A. Respiratory acidosis

B. Respiratory alkalosis

C. Increased PaCO2

D. Metabolic acidosis

ANS: B

Rationale: Extreme anxiety can lead to hyperventilation, the most common cause of acute respiratory

alkalosis. During hyperventilation, CO2 is lost through the lungs, creating an alkalotic state and a low

PaCO2. Acute respiratory acidosis occurs in emergency situations, such as pulmonary edema, and is

exhibited by hypoventilation and decreased PaCO2. Metabolic acidosis results from the loss of

bicarbonate, not CO2.

PTS: 1 REF: p. 255






5. The emergency-room nurse is caring for a trauma client who has the following arterial blood gas

results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results?

A. Respiratory acidosis with no compensation

B. Metabolic alkalosis with compensatory alkalosis

C. Metabolic acidosis with no compensation

D. Metabolic acidosis with compensatory respiratory alkalosis

ANS: D

Rationale: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also low, which

causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely

corresponds with a decrease in pH, making the metabolic component the primary problem.

PTS: 1 REF: p. 261

NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies



BLM: Cognitive Level: Analyze


6. While assessing a client's peripheral IV site, the nurse observes edema and coolness around the

insertion site. How should the nurse document this observation?

A. Air embolism

B. Phlebitis

C. Infiltration



D. Fluid overload

ANS: C

Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding

tissue 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,

and a significant decrease in the flow rate. An air embolism occurs when air enters the vein; it does not

have any local manifestations at the IV site but may produce palpitations, dyspnea, hypotension, and

chest pain. Phlebitis, an inflammation of the vein, is characterized by redness, warmth, and tenderness

at the IV site. Fluid volume overload produces systemic manifestations and is not apparent at the IV

site.

PTS: 1 REF: p. 268






7. The nurse is performing an admission assessment on a 79-year-old client newly admitted for end-stage

liver disease. What principle should guide the nurse's assessment of the client's skin turgor?

A. Overhydration is common among healthy older adults.

B. Dehydration causes the skin to appear spongy.

C. Inelastic skin turgor is a normal part of aging.

D. Skin turgor cannot be assessed in clients over the age of 70.

ANS: C

Rationale: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor

cannot be assessed in older clients. Dehydration, not overhydration, causes inelastic skin with tenting.

Overhydration, not dehydration, causes the skin to appear edematous and spongy.

PTS: 1 REF: p. 236

NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential





8. A nurse in the neurologic ICU has received a prescription to infuse a hypertonic solution into a client

with increased intracranial pressure. This solution will increase the number of dissolved particles in the

client's blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the

blood volume. This process is best described with which of the following terms?

A. Hydrostatic pressure

B. Osmosis and osmolality

C. Diffusion

D. Active transport

ANS: B

Rationale: 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.

PTS: 1 REF: p. 226



NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs:

Physiological Integrity: Basic Care and Comfort



BLM: Cognitive Level: Understand


9. The surgical nurse is caring for a client who is postoperative day 1 following a thyroidectomy. The

client reports tingling in the lips and fingers. The client also reports an intermittent spasm in the wrist

and hand and exhibits increased muscle tone. Which electrolyte imbalance should the nurse first

suspect?

A. Hypophosphatemia

B. Hypocalcemia

C. Hypermagnesemia

D. Hyperkalemia

ANS: B

Rationale: 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.

PTS: 1 REF: p. 248






10. A nurse, who is orienting a newly licensed nurse, is planning care for a nephrology client. The nurse

states, “A client with kidney disease partially loses the ability to regulate changes in pH.” What is the

cause of this partial inability?

A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH.

B. The kidneys buffer acids through electrolyte changes.

C. The kidneys reabsorb and regenerate bicarbonate to maintain a stable pH.

D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

ANS: C

Rationale: The kidneys regulate the bicarbonate level in the extracellular fluid; 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 pH. The

kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to changes in pH.

Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable

pH, whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving

and eliminating H+.

PTS: 1 REF: p. 259



KEY: Integrated Process: Teaching/Learning





11. The nurse is caring for a client admitted to the medical unit 72 hours ago with pyloric stenosis. A

nasogastric tube was placed upon admission, and since that time the client has been on low intermittent

suction. Upon review of the morning's blood work, the nurse notices that the client's potassium is

below reference range. The nurse should assess for signs and symptoms of what imbalance?

A. Hypercalcemia

B. Metabolic acidosis

C. Metabolic alkalosis

D. Respiratory acidosis

ANS: C

Rationale: 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 client 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 pH. Respiratory acidosis is unlikely since no change was reported in the client's respiratory

status.

PTS: 1 REF: p. 261






12. The nurse is caring for a client who has a peripheral IV in place for fluid replacement. When caring for

the client's IV site, the nurse should:

A. ensure that anticoagulants are placed on hold for the duration of IV therapy.

B. replace the IV dressing with a new, clean dressing if it is soiled.

C. ensure that the tubing is firmly anchored to the client's skin.

D. periodically remove hair from 2 cm around the IV site.

ANS: C

Rationale: Anchoring the IV tubing prevents it from being accidentally dislodged. Anticoagulants are

not contraindicated during IV therapy. Soiled dressings should be replaced with a new sterile dressing,

not a clean dressing. Hair removal is unnecessary.

PTS: 1 REF: p. 267

NAT: Client Needs: Safe, Effective Care Environment: Safety and Infection Control





13. A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas

(ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 24 mm Hg.

Which condition does the ABG reflect?

A. Respiratory acidosis

B. Metabolic alkalosis

C. Respiratory alkalosis

D. Metabolic acidosis

ANS: A



Rationale: The pH is below 7.35, PaCO2 is greater than 40, and the HCO3 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 HCO3 of 24 is within the normal range, so it is not metabolic alkalosis.

The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis, but the

HCO3 of 24 is within the normal range, ruling out metabolic acidosis.

PTS: 1 REF: p. 262

NAT: Client Needs: Safe, Effective Care Environment: Management of Care | Client Needs:

Physiological Integrity: Basic Care and Comfort | Client Needs: Physiological Integrity: Physiological

Adaptation TOP: Chapter 10: Principles of Fluid and Electrolytes




14. One day after a client is admitted to the medical unit, the nurse determines that the client is oliguric.

The nurse notifies the acute-care nurse practitioner who prescribes a fluid challenge of 200 mL of

normal saline solution over 15 minutes. This intervention will help to achieve what goal?

A. Distinguish hyponatremia from hypernatremia.

B. Evaluate pituitary gland function.

C. Distinguish reduced renal blood flow from decreased renal function.

D. Provide an effective treatment for hypertension-induced oliguria.

ANS: C

Rationale: If a client 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 mL of

normal saline solution over 15 minutes. The response by a client 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.

PTS: 1 REF: p. 236






15. The community health nurse is performing a home visit to an 80-year-old client recovering from hip

surgery. The nurse notes that the client seems uncharacteristically confused at times and has dry

mucous membranes. When asked about fluid intake, the client 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 nurse's best response?

A. "I will need to have your medications adjusted, so you will need to be readmitted to the

hospital for a complete workup."

B. "Limiting your fluids can create imbalances that can result in confusion, so let’s try

adjusting the timing of your fluids."

C. "It is normal to be a little confused following surgery, and it is safe not to urinate at night."

D. “Confusion and bladder issues are a normal consequence of aging, so I am not too

concerned.”

ANS: B



Rationale: In older adult clients, 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

older adult. There is no specific evidence given for the need for readmission to the hospital. Confusion

is never normal, common, or expected in older adults.

PTS: 1 REF: p. 234

NAT: Client Needs: Physiological Integrity: Basic Care and Comfort





16. A client comes into the emergency department (ED) by ambulance with a hip fracture after slipping

and falling while at home. The client is alert and oriented but anxious and reports thirst. The client’s

pupils are equal and reactive to light and accommodation, and the heart rate is elevated. An indwelling

urinary catheter is inserted, and 40 mL of urine is present. What is the nurse's most likely explanation

for the client’s urinary output?

A. The client urinated prior to arrival to the ED and will probably not need to have the

urinary catheter kept in place.

B. The client likely has a traumatic brain injury, lacks antidiuretic hormone, and needs

vasopressin.

C. The client is experiencing symptoms of heart failure and is releasing atrial natriuretic

peptide, which results in decreased urine output.

D. The client is having a sympathetic reaction, which has stimulated the renin–

angiotensin–aldosterone system, which results in diminished urine output.

ANS: D

Rationale: In response to the acute stress of falling at home, the sympathetic nervous system is

activated. 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 most likely causing the lower urine output. The client urinating prior to arrival to the ED is

unlikely; the fall and hip injury would make the ability to urinate difficult. No assessment information

indicates the client has a head injury or heart failure.

PTS: 1 REF: p. 232






17. A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best

reduce the client's risk for electrolyte disturbances?

A. Maintain a low-sodium diet.

B. Encourage the use of over-the-counter calcium supplements.

C. Ensure the client has sufficient potassium intake.

D. Encourage fluid intake.

ANS: C

Rationale: Thiazide diuretics, such as hydrochlorothiazide, cause potassium loss, and it is important to

maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a

low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra

calcium intake, and increased fluid intake does not reduce the client's risk for electrolyte disturbances.



PTS: 1 REF: p. 253






18. The nurse is evaluating a newly admitted client's laboratory results, which include several values that

are outside of reference ranges. Which of the following alterations would cause the release of

antidiuretic hormone (ADH)?

A. Increased serum sodium

B. Decreased serum potassium

C. Decreased hemoglobin

D. Increased platelets

ANS: A

Rationale: Increased serum sodium causes increased osmotic pressure, 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 ADH release.

PTS: 1 REF: p. 232






19. The nurse is providing care for a client with chronic obstructive pulmonary disease. When describing

the process of respiration, the nurse explains to a newly licensed nurse how oxygen and carbon dioxide

are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing which

process?

A. Diffusion

B. Osmosis

C. Active transport

D. Filtration

ANS: A

Rationale: Diffusion is the natural tendency of a substance to move from an area of higher

concentration to one of lower concentration. It occurs through the random movement of ions and

molecules. Examples of diffusion are the exchange of oxygen and carbon dioxide between the

pulmonary capillaries and alveoli and the tendency of sodium to move from the extracellular fluid

compartment, where the sodium concentration is high, to the intracellular fluid, where its

concentration is low. Osmosis occurs when two different solutions are separated by a membrane that is

impermeable to the dissolved substances; fluid shifts through the membrane from the region of low

solute concentration to the region of high solute concentration until the solutions are of equal

concentration. Active transport implies that energy must be expended for the movement to occur

against a concentration gradient. Movement of water and solutes occurring from an area of high

hydrostatic pressure to an area of low hydrostatic pressure is filtration.

PTS: 1 REF: p. 228




BLM: Cognitive Level: Remember




20. When planning the care of a client with a fluid imbalance, the nurse understands that in the human

body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes

this to occur?

A. Active transport of hydrogen ions across the capillary walls

B. Pressure of the blood in the renal capillaries

C. Action of the dissolved particles contained in a unit of blood

D. Hydrostatic pressure resulting from the pumping action of the heart

ANS: D

Rationale: Hydrostatic pressure is the pressure created by the weight of fluid against the wall that

contains it. In the body, hydrostatic pressure in blood vessels results from the weight of fluid itself and

the force resulting from cardiac contraction. This pressure causes water and electrolytes from the

arterial capillary bed to pass into the interstitial fluid, in this instance, as a result of the pumping action

of the heart; this process is known as filtration. Active transport does not move water and electrolytes

from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles

in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal

filtration.

PTS: 1 REF: p. 228






21. Baroreceptors in the left atrium and in the carotid and aortic arches respond to changes in the

circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as

endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect?

A. Decrease in the release of aldosterone

B. Increase of filtration in the Loop of Henle

C. Decrease in the reabsorption of sodium

D. Decrease in glomerular filtration

ANS: D

Rationale: Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration,

increases the release of aldosterone, and increases sodium and water reabsorption. None of the other

listed options occurs with increased sympathetic stimulation.

PTS: 1 REF: p. 232

NAT: Client Needs: Safe, Effective Care Environment: Management of Care





22. The nurse is caring for a client who has been involved in a motor vehicle accident. The client's labs

indicate a minimally elevated serum creatinine level. The nurse should further assess which body

system for signs of injury?

A. Renal

B. Cardiac

C. Pulmonary

D. Nervous

ANS: A

Rationale: Serum creatinine is a sensitive measure of renal function. It is not an indicator of cardiac,

pulmonary, or nervous system impairments.



PTS: 1 REF: p. 233






23. The nurse is caring for a client who is to receive IV daunorubicin, a chemotherapeutic agent. The nurse

starts the infusion and checks the insertion site as per protocol. During the most recent check, the nurse

observes that the IV has infiltrated so the nurse stops the infusion. What is the nurse's priority concern

with this infiltration?

A. Extravasation of the medication

B. Discomfort to the client

C. Blanching at the site

D. Hypersensitivity reaction to the medication

ANS: A

Rationale: Irritating medications, such as chemotherapeutic agents, can cause pain, burning, and

redness at the site. Blistering, inflammation, and necrosis of tissues can occur. The extent of tissue

damage is determined by the medication concentration, the quantity that extravasated, infusion site

location, the tissue response, and the extravasation duration. Extravasation is the priority over the other

listed consequences.

PTS: 1 REF: p. 268






24. The nurse caring for a client post colon resection is assessing the client on the second postoperative

day. The nasogastric tube remains patent and is draining moderate amounts of greenish fluid. Which

assessment finding would suggest that the client's potassium level is too low?

A. Diarrhea

B. Paresthesias

C. Increased muscle tone

D. Joint pain

ANS: B

Rationale: Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle

weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), and

arrhythmias. The client would not have diarrhea because increased bowel motility is inconsistent with

hypokalemia. Joint pain is not a symptom of hypokalemia, nor is increased muscle tone.

PTS: 1 REF: p. 245






25. The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung

cancer with bone metastases. The client reports a new onset of weakness with abdominal pain, and

further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize

that this client may be experiencing which electrolyte imbalance?

A. Hypernatremia



B. Hypomagnesemia

C. Hypophosphatemia

D. Hypercalcemia

ANS: D

Rationale: The most common causes of hypercalcemia are malignancies and hyperparathyroidism.

Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration

occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule.

Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are

neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic

manifestation of hypomagnesemia, and this scenario does not mention tetany. The client's presentation

is inconsistent with hypophosphatemia.

PTS: 1 REF: p. 250






26. A medical nurse educator is reviewing a client's recent episode of metabolic acidosis with members of

the nursing staff. What should the educator describe about the role of the kidneys in metabolic

acidosis?

A. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.

B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.

C. The kidneys react rapidly to compensate for imbalances in the body.

D. The kidneys regulate the bicarbonate level in the intracellular fluid.

ANS: B

Rationale: 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. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and excrete

bicarbonate ions to help restore balance. The kidneys obviously cannot compensate for the metabolic

acidosis created by kidney disease. Renal compensation for imbalances is relatively slow (a matter of

hours or days).

PTS: 1 REF: p. 259






27. The nurse in the medical intensive care unit is caring for a client who is in respiratory acidosis due to

inadequate ventilation. Which diagnosis could the client have that could cause inadequate ventilation?

A. Endocarditis

B. Multiple myeloma

C. Guillain–Barré syndrome

D. Overdose of amphetamines

ANS: C



Rationale: Respiratory acidosis is always due to inadequate excretion of CO2 with inadequate

ventilation, resulting in elevated plasma CO2 concentrations and, consequently, increased levels of

carbonic acid. Acute respiratory acidosis occurs in emergency situations, such as acute pulmonary

edema, aspiration of a foreign object, atelectasis, pneumothorax, overdose of sedatives, sleep apnea,

administration of oxygen to a client with chronic hypercapnia (excessive CO2 in the blood), severe

pneumonia, and acute respiratory distress syndrome. Respiratory acidosis can also occur in diseases

that impair respiratory muscles, such as muscular dystrophy, myasthenia gravis, and Guillain–Barré

syndrome. The other listed diagnoses are not associated with respiratory acidosis.

PTS: 1 REF: p. 262






28. A client has questioned the nurse's administration of intravenous (IV) normal saline, asking, "Wouldn't

sterile water be a more appropriate choice than saltwater?" Under what circumstances would the nurse

administer electrolyte-free water intravenously?

A. Never, because it rapidly enters red blood cells, causing them to rupture.

B. When the client is severely dehydrated, resulting in neurologic signs and symptoms

C. When the client is in excess of calcium and/or magnesium ions

D. When a client's fluid volume deficit is due to acute or chronic kidney disease

ANS: A

Rationale: IV solutions contain dextrose or electrolytes mixed in various proportions with water. Pure,

electrolyte-free water can never be given by IV because it rapidly enters red blood cells and causes

them to rupture.

PTS: 1 REF: p. 264






29. The nurse is called to a client's room by a family member who voices concern about the client's status.

On assessment, the nurse finds the client tachypneic, lethargic, weak, and exhibiting a diminished

cognitive ability. The nurse also identifies 3+ pitting edema. What electrolyte imbalance is the most

plausible cause of this client's signs and symptoms?

A. Hypocalcemia

B. Hyponatremia

C. Hyperchloremia

D. Hypophosphatemia

ANS: C

Rationale: The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis:

hypervolemia and hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished

cognitive ability; and hypertension occur. If untreated, hyperchloremia can lead to a decrease in

cardiac output, arrhythmias, and coma. A high chloride level is accompanied by a high sodium level

and fluid retention. With hypocalcemia, tetany would be expected to occur. There would not be edema

with hyponatremia. Signs or symptoms of hypophosphatemia are mainly neurologic.

PTS: 1 REF: p. 257








30. Diagnostic testing has been prescribed to differentiate between normal anion gap acidosis and high

anion gap acidosis in an acutely ill client. What health problem often precedes normal anion gap

acidosis?

A. Metastases

B. Excessive potassium intake

C. Water intoxication

D. Excessive administration of chloride

ANS: D

Rationale: Normal anion gap acidosis results from the direct loss of bicarbonate, as in diarrhea, lower

intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive

administration of chloride; and the administration of parenteral nutrition without bicarbonate or

bicarbonate-producing solutes (e.g., lactate). Based on these facts, the other listed options are

incorrect.

PTS: 1 REF: p. 260






31. The nurse is caring for a client with a diagnosis of pancreatitis. The client was admitted from a

homeless shelter and is a vague historian. The client appears malnourished and on day 3 of the client's

admission, total parenteral nutrition (TPN) has been started. Why should the nurse start the infusion of

TPN slowly?

A. Clients receiving TPN are at risk for hypercalcemia if calories are started too rapidly.

B. Malnourished clients receiving parenteral nutrition are at risk for hypophosphatemia if

calories are started too aggressively.

C. Malnourished clients who receive fluids too rapidly are at risk for hypernatremia.

D. Clients receiving TPN need a slow initiation of treatment in order to allow digestive

enzymes to accumulate.

ANS: B

Rationale: The nurse identifies clients who are at risk for hypophosphatemia and monitors them.

Because malnourished clients receiving parenteral nutrition are at risk when calories are introduced too

aggressively, preventive measures involve gradually introducing the solution to avoid rapid shifts of

phosphorus into the cells. Clients receiving TPN are not at risk for hypercalcemia or hypernatremia if

calories or fluids are started to rapidly. Digestive enzymes are not a relevant consideration.

PTS: 1 REF: p. 256






32. The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment

finding would be most consistent with this diagnosis?

A. Hypertension

B. Kussmaul respirations

C. Increased DTRs

D. Shallow respirations



ANS: D

Rationale: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and

shallow respirations. The nurse also observes for decreased DTRs and changes in the level of

consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe

metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also kidney disease. This type of

client is associated with decreased DTRs, not increased DTRs.

PTS: 1 REF: p. 254






33. A client's most recent laboratory results show a slight decrease in potassium. The health care provider

has opted to forgo drug therapy but has suggested increasing the client's dietary intake of potassium.

What should the nurse recommend?

A. Apples

B. Fish

C. Rice

D. Bananas

ANS: D

Rationale: Bananas are high in potassium. Apples, fish, and rice are not high in potassium.

PTS: 1 REF: p. 245






34. The nurse is assessing the client for the presence of a Chvostek sign. Which electrolyte imbalance

would a positive Chvostek sign indicate?

A. Hypermagnesemia

B. Hyponatremia

C. Hypocalcemia

D. Hyperkalemia

ANS: C

Rationale: The nurse can induce Chvostek sign by tapping the client's facial nerve adjacent to the ear.

A brief contraction of the upper lip, nose, or side of the face indicates Chvostek sign. Both

hypomagnesemia and hypocalcemia may be indicated by a positive Chvostek sign.

PTS: 1 REF: p. 249






35. The intensive care unit nurse is caring for a client who experienced trauma in a workplace accident.

The client is reporting dyspnea because of abdominal pain. An arterial blood gas test reveals the

following results: pH 7.28, PaCO2 50 mm Hg, HCO3– 20 mEq/L. The nurse should recognize the

likelihood of which acid–base disorder(s)?

A. Respiratory acidosis only

B. Respiratory acidosis and metabolic alkalosis



C. Respiratory alkalosis and metabolic acidosis

D. Respiratory acidosis and metabolic acidosis

ANS: D

Rationale: Clients can simultaneously experience two or more independent acid–base disorders. This

client has a pH value below normal, a PCO2 value above 45 mm HG, and a HCO3– value of less than

22 mEq/L, which is indicative of both respiratory acidosis and metabolic acidosis.

PTS: 1 REF: p. 262






MULTIPLE RESPONSE

36. A client with hypokalemia is to receive intravenous (IV) potassium replacement. Which action should

the nurse take when administering potassium intravenously? Select all that apply.

A. Administer potassium by IV push.

B. Assess blood urea nitrogen (BUN) and serum creatinine prior to potassium administration.

C. Monitor complete blood count during potassium infusion.

D. Follow the facility policy for infusion of potassium.

E. Report a reduced urinary output to the health care provider.

ANS: B, D, E

Rationale: Potassium should be administered by an infusion pump and should never be given by IV

push to avoid rapid replacement. Because potassium is excreted by the kidneys, BUN, serum

creatinine, and urinary output should be assessed prior to and during administration of IV potassium.

Abnormal laboratory results or decreased or absent urinary output should be reported to the health care

provider. Because potassium administration does not affect blood cells, the complete blood count does

not need to be monitored during administration of potassium. The nurse should check facility policy

on the administration of IV potassium to ensure safe care.

PTS: 1 REF: p. 245





NOT: Multiple Response

37. A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in

older adults. Which factors contribute to this phenomenon? Select all that apply.

A. Decreased kidney mass

B. Increased conservation of sodium

C. Increased total body water

D. Decreased renal blood flow

E. Decreased excretion of potassium

ANS: A, D, E

Rationale: Dehydration in older adults is common as a result of decreased kidney mass, decreased

glomerular filtration rate, decreased renal blood flow, decreased ability to concentrate urine, inability

to conserve sodium, decreased excretion of potassium, and a decrease of total body water.

PTS: 1 REF: p. 233 NAT: Client Needs: Health Promotion and Maintenance







38. The nurse is providing discharge education to a client who had hypophosphatemia while in the

hospital. The client has a diet prescribed that is high in phosphate. Which foods should the nurse teach

this client to include in the diet? Select all that apply.

A. Milk

B. Beef

C. Potatoes

D. Green vegetables

E. Liver

ANS: A, B, E

Rationale: If the client experiences mild hypophosphatemia, foods rich in phosphorus, such as milk

and milk products, meats, and beans, should be encouraged. Potatoes and green leafy vegetables are

not rich in phosphorus.

PTS: 1 REF: p. 241







Textbook of Medical-Surgical Nursing

Create successful ePaper yourself

Delete template?

Save as template?