Textbook of Medical-Surgical Nursing

BRUNNER & SUDDARTH'S TEXTBOOK OF MEDICAL-SURGICAL NURSING 15TH EDITION HINKLE TEST BANK
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
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
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
NAT: Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
TOP: Chapter 10: Principles of Fluid and Electrolytes
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand
NOT: Multiple Choice
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
NAT: Client Needs: Physiological Integrity: Physiological Adaptation
TOP: Chapter 10: Principles of Fluid and Electrolytes
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