NCLEX Practice Exam for Fluids, Electrolytes & Homeostasis 1

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1. Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function?

  1. Assessing dietary intake
  2. Decreasing fluid intake
  3. Providing limited physical activity
  4. Turning, coughing, and deep breathing

2. A 12-year-old boy was admitted in the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing intervention should be included in the care of plan for the client?

  1. Room temperature reduction
  2. Fluid restriction of 2,000 ml/day
  3. Axillary temperature measurements every 4 hours
  4. Antiemetic agent administration

3. Tom is ready to be discharged from the medical-surgical unit after 5 days of hospitalization. Which client statement indicates to the nurse that Tom understands the discharge teaching about cellular injury?

  1. “I do not have to see my doctor unless i have problems.”
  2. “I can stop taking my antibiotics once I am feeling better.”
  3. “If I have redness, drainage, or fever, I should call my healthcare provider.”
  4. “I can return to my normal activities as soon as I go home.”

4. Nurse Katee is caring for Adam, a 22-year-old client, in a long-term facility. Which nursing intervention would be appropriate when identifying nursing interventions aimed at promoting and preventing contractures? Select all that apply.

  1. Clustering activities to allow uninterrupted periods of rest
  2. Maintaining correct body alignment at all times
  3. Monitoring intake and output, using a urometer if necessary
  4. Using a footboard or pillows to keep feet in correct position
  5. Performing active and passive range-of-motion exercises
  6. Weighing the client daily at the same time and in the same clothes

5. A 36-year-old male client is about to be discharged from the the hospital after 5 days due to surgery. Which intervention should be included in the home health care nurse’s instructions about measures to prevent constipation?

  1. Discouraging the client from eating large amounts of roughage-containing foods in the diet.
  2. Encouraging the client to use laxatives routinely to ensure adequate bowel elimination.
  3. Instructing the client to establish a bowel evacuation schedule that changes every day.
  4. Instructing the client to fill a 2-L bottle with water every night and drink it the next day.

6. Mr. McPartlin suffered abrasions and lacerations after a vehicular accident. He was hospitalized and was treated for a couple of weeks. When planning care for a client with cellular injury, the nurse should consider which scientific rationale?

  1. Nutritional needs remain unchanged for the well-nourished adult.
  2. Age is an insignificant factor in cellular repair.
  3. The presence of infection may slow the healing process.
  4. Tissue with inadequate blood supply may heal faster.

7. A 22-year-old lady is displaying facial grimaces during her treatment in the hospital due to burn trauma. Which nursing intervention should be included for reducing pain due to cellular injury?

  1. Administering anti-inflammatory agents as prescribed
  2. Elevating the injured area to decrease venous return to the heart
  3. Keeping the skin clean and dry
  4. Applying warm packs initially to reduce edema

8. Lisa, a client with altered urinary function, is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling?

  1. Inserting an indwelling Foley catheter
  2. Having the client perform Kegel exercises
  3. Keeping the skin clean and dry
  4. Using pads or diapers on the client

9. Jeron is admitted in the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client?

  1. Prevention of fluid volume excess
  2. Maintenance of adequate oxygenation
  3. Education about infection prevention
  4. Pain reduction

10. Mang Rogelio, a 32-year-old patient, is about to be discharged from the acute care setting. Which nursing intervention is the most important to include in the plan of care?

  1. Stress-reduction techniques
  2. Home environment evaluation
  3. Skin-care measures
  4. Participation in activities of daily living

11. Mrs. dela Riva is in her first trimester of pregnancy. She has been lying all day because her OB-GYN requested her to have a complete bed rest. Which nursing intervention is appropriate when addressing the client’s need to maintain skin integrity?

  1. Monitoring intake and output accurately
  2. Instructing the client to cough and deep-breathe every 2 hours
  3. Keeping the linens dry and wrinkle free
  4. Using a foot board to maintain correct anatomic position

12. Maya, who is admitted in a hospital, is scheduled to have her general checkup and physical assessment. Nurse Timothy observed a reddened area over her left hip. Which should the nurse do first?

  1. Massage the reddened are for a few minutes
  2. Notify the physician immediately
  3. Arrange for a pressure-relieving device
  4. Turn the client to the right side for 2 hours

13. Pierro was noted to be displaying facial grimaces after nurse Kara assessed his complaints of pain rated as 8 on a scale of 1 (no pain) 10 10 (worst pain). Which intervention should the nurse do?

  1. Administering the client’s ordered pain medication immediately
  2. Using guided imagery instead of administering pain medication
  3. Using therapeutic conversation to try to discourage pain medication
  4. Attempting to rule out complications before administering pain medication

14. Nurse Marthia is teaching her students about bacterial control. Which intervention is the most important factor in preventing the spread of microorganism?

  1. Maintenance of asepsis with indwelling catheter insertion
  2. Use of masks, gowns, and gloves when caring for clients with infection
  3. Correct handwashing technique
  4. Cleanup of blood spills with sodium hydrochloride

15. A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse Mark’s care. Which nursing intervention should be included the care plan of Mark for his patient?

  1. Administering I.V. and oral fluids
  2. Clustering necessary activities throughout the day
  3. Assessing color, odor, and amount of sputum
  4. Monitoring serum albumin and total protein levels

16. Khaleesi is admitted in the hospital due to having lower than normal potassium level in her bloodstream. Her medical history reveals vomiting and diarrhea prior to hospitalization. Which foods should the nurse instruct the client to increase?

  1. Whole grains and nuts
  2. Milk products and green, leafy vegetables
  3. Pork products and canned vegetables
  4. Orange juice and bananas

17. Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation. Which nursing intervention is the most appropriate for the client who is subsequently developing respiratory alkalosis?

  1. Administering sodium chloride I.V.
  2. Encouraging slow, deep breaths
  3. Preparing to administer sodium bicarbonate
  4. Administer low-flow oxygen therapy

18. Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth, and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many milliliters should the nurse document as the client’s intake.

  1. 2,230
  2. 2,740
  3. 2,470
  4. 2,320

19. Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the blood-pressure cuff is inflated?

  1. Positive Trousseau’s sign
  2. Positive Chvostek’s sign
  3. Tetany
  4. Paresthesia

20. Lab tests revealed that patient Z’s [Na+] is 170 mEq/L. Which clinical manifestation would nurse Natty expect to assess?

  1. Tented skin turgor and thirst
  2. Muscle twitching and tetany
  3. Fruity breath and Kussmaul’s respirations
  4. Muscle weakness and paresthesia

21. Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2), 60 mm Hg. When attempting to improve the client’s blood gas values through improved ventilation and oxygen therapy, which is the client’s primary stimulus for breathing?

  1. High PCO2
  2. Low PO2
  3. Normal pH
  4. Normal bicarbonate (HCO3)

22. A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?

  1. Assessing urinary intake and output
  2. Obtaining the client’s weight weekly at different times of the day
  3. Monitoring arterial blood gas (ABG) results
  4. Maintaining I.V. therapy at the keep-vein-open rate

23. Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?

  1. 14-year-old Elena who is taking diuretics
  2. 16-year-old John Joseph with ileostomy
  3. 16-year-old Gabriel with metabolic acidosis
  4. 18-year-old Albert who has renal disease

24. Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

  1. Instituting seizure precaution to prevent injury
  2. Instructing the client on the importance of preventing infection
  3. Avoiding the use of tight tourniquet when drawing blood
  4. Teaching the client the importance of early ambulation

25. Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?

  1. Potassium
  2. Phosphate
  3. Chloride
  4. Sodium

26. Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate?

  1. Potassium supplements
  2. Kayexalate
  3. Calcium gluconate
  4. Sodium tablets

27. Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia?

  1. Muscle pain and acute rhabdomyolysis
  2. Hot, flushed skin and diaphoresis
  3. Soft-tissue calcification and hyperreflexia
  4. Increased respiratory rate and depth

28. Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to assess in planning the care for the client?

  1. Sodium level
  2. Magnesium level
  3. Potassium level
  4. Calcium level

29. Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of 24 mEq/L. Based on these results, which intervention should the nurse implement?

  1. Instructing the client to breathe slowly into a paper bag
  2. Administering low-flow oxygen
  3. Encouraging the client to cough and deep breathe
  4. Nothing, because these ABG values are within normal limits.

30. A client is diagnosed with metabolic acidosis, which would the nurse expect the health care provider to order?

  1. Potassium
  2. Sodium bicarbonate
  3. Serum sodium level
  4. Bronchodilator

31. Lee Angela’s lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you would interpret this serum chloride level as:

  1. high
  2. low
  3. within normal range
  4. high normal

32. Which of the following conditions is associated with elevated serum chloride levels?

  1. cystitis
  2. diabetes
  3. eclampsia
  4. hypertension

33. In the extracellular fluid, chloride is a major:

  1. compound
  2. ion
  3. anion
  4. cation

34. Nursing intervention for the patient with hyperphosphatemia include encouraging intake of:

  1. amphogel
  2. Fleets phospho-soda
  3. milk
  4. vitamin D

35. Etiologies associated with hypocalcemia may include all of the following except:

  1. renal failure
  2. inadequate intake calcium
  3. metastatic bone lesions
  4. vitamin D deficiency

36. Which of the following findings would the nurse expect to asses in hypercalcemia?

  1. prolonged QRS complex
  2. tetany
  3. petechiae
  4. urinary calculi

37. Which of the following is not an appropriate nursing intervention for a patient with hypercalcemia?

  1. administering calcitonin
  2. administering calcium gluconate
  3. administering loop diuretics
  4. encouraging ambulation

38. A patient in which of the following disorders is at high risk to develop hypermagnesemia?

  1. insulin shock
  2. hyperadrenalism
  3. nausea and vomiting
  4. renal failure

39. Nursing interventions for a patient with hypermagnesemia  include administering calcium gluconate to:

  1. increase calcium levels
  2. antagonize the cardiac effects of magnesium
  3. lower calcium levels
  4. lower magnesium levels

40. For a patient with hypomagnesemia, which of the following medications may become toxic?

  1. Lasix
  2. Digoxin
  3. calcium gluconate
  4. CAPD

41. Which of the following is the most important physical assessment parameter the nurse would consider when assessing fluid and electrolyte imbalance?

  1. skin turgor
  2. intake and output
  3. osmotic pressure
  4. cardiac rate and rhythm

42. Insensible fluid losses include:

  1. urine
  2. gastric drainage
  3. bleeding
  4. perspiration

43. Which of the following intravenous solutions would be appropriate for a patient with severe hyponatremia secondary to syndrome of inappropriate antidiuretic hormone (SIADH)?

  1. hypotonic solution
  2. hypertonic solution
  3. isotonic solution
  4. normotonic solution

44. Aldosterone secretion in response to fluid loss will result in which one of the following electrolyte imbalances?

  1. hypokalemia
  2. hyperkalemia
  3. hyponatremia
  4. hypernatremia

45. When assessing a patient for signs of fluid overload, the nurse would expect to observe:

  1. bounding pulse
  2. flat neck veins
  3. poor skin turgor
  4. vesicular

46. The physician has ordered IV replacement of potassium for a patient with severe hypokalemia. The nurse would administer this:

  1. by rapid bolus
  2. diluted in 100 cc over 1 hour
  3. diluted in 10 cc over 10 minutes
  4. IV push

47. Which of the following findings would the nurse exp[ect to assess in a patient with hypokalemia?

  1. hypertension
  2. pH below 7.35
  3. hypoglycemia
  4. hyporeflexia

48. Vien is receiving oral potassium supplements for his condition. How should the supplements be administered?

  1. undiluted
  2. diluted
  3. on an empty stomach
  4. at bedtime

49. Normal venous blood pH ranges from:

  1. 6.8 to 7.2
  2. 7.31 to 7.41
  3. 7.35 to 7.45
  4. 7.0 to 8.0

50. Respiratory regulation of acids and bases involves:

  1. hydrogen
  2. hydroxide
  3. oxygen
  4. carbon dioxide

51. To determine if a patient’s respiratory system is functioning, the nurse would assess which of the following parameters:

  1. respiratory rate
  2. pulse
  3. arterial blood gas
  4. pulse oximetry

52. Which of the following conditions is an equal decrease of extracellular fluid (ECF) solute and water volume?

  1. hypotonic FVD
  2. isotonic FVD
  3. hypertonic FVD
  4. isotonic FVE

53. When monitoring the daily weight of a patient with fluid volume deficit (FVD), the nurse is aware that fluid loss may be considered when weight loss begins to exceed:

  1. 0.25 lb
  2. 0.50 lb
  3. 1 lb
  4. 1 kg

54. Dietary recommendations for a patient with a hypotonic fluid excess should include:

  1. decreased sodium intake
  2. increased sodium intake
  3. increased fluid intake
  4. intake of potassium-rich foods

55. Osmotic pressure is created through the process of:

  1. osmosis
  2. diffusion
  3. filtration
  4. capillary dynamics

56. A rise in arterial pressure causes the baroreceptors and stretch receptors to signal an inhibition of the sympathetic nervous system, resulting in:

  1. decreased sodium reabsorption
  2. increased sodium reabsorption
  3. decreased urine output
  4. increased urine output

57. Normal serum sodium concentration ranges from:

  1. 120 to 125 mEq/L
  2. 125 to 130 mEq/L
  3. 136 to 145 mEq/L
  4. 140 to 148 mEq/L

58. When assessing a patient for electrolyte balance, the nurse is aware that etiologies for hyponatremia include:

  1. water gain
  2. diuretic therapy
  3. diaphoresis
  4. all of the following

59. Nursing interventions for a patient with hyponatremia include:

  1. administering hypotonic IV fluids
  2. encouraging water intake
  3. restricting fluid intake
  4. restricting sodium intake

60. The nurse would analyze an arterial pH of 7.46 as indicating:

  1. acidosis
  2. alkalosis
  3. homeostasis
  4. neutrality
Answers and Rationales
  1. Answer: A. Assessing dietary intake. Assessing dietary intake provides a foundation for the client’s usual practices and may help determine if the client is prone to constipation or diarrhea. Limited physical activity may contribute to constipation due to decreased peristalsis. Turning, coughing and deep breathing help promote gas exchange. Fluid intake should be increased to aid bowel elimination.
  2. Answer: A. Room temperature reduction. For patient with hyperthermia, reducing the room temperature may help decrease the body temperature. Tepid baths, cool compresses, and cooling blanket may also be necessary. Antipyretics, and not antiemetics, are indicated to reduce fever. Oral or rectal temperature measurements are generally accepted and are more accurate than axillary measurements. Fluids should be encouraged, not restricted to compensate for insensible losses.
  3. Answer: C. “If I have redness, drainage, or fever, I should call my healthcare provider.”. Knowledge that redness, drainage, or fever — signs of infection associated with cellular injury — require reporting indicates that the client has understood the nurse’s discharge teaching. Follow-up checkups should be encouraged with an emphasis of antibiotic compliance even if the client feels better. There are usually activity limitations after cellular injury.
  4. Answer: B, D, E. Correct body alignment, preventing footdrop, and range-of-motion exercises will help prevent contractures. Clustering activities will help promote adequate rest. Monitoring intake and output and weighing the client will help maintain fluid and electrolyte balance.
  5. Answer: D. Instructing the client to fill a 2-L bottle with water every night and drink it the next day. Adequate fluids and fiber in the diet are key to preventing constipation. Having the client fill a 2-L bottle with water every night and drink it the next day is one method for ensuring the client receives at least 2,000 ml of water daily. The client also should be instructed to drink any other fluids throughout the day. High fiber or roughage foods are encouraged. Laxatives should not be used routinely for bowel elimination. They should be used only as a last resort, because clients may become dependent on them. A regular bowel evacuation schedule should be established.
  6. Answer: C. The presence of infection may slow the healing process. Infection impairs wound healing. Adequate blood supply is essential for healing. If inadequate, healing is slowed. Nutritional needs, including protein and caloric needs, increase for all clients undergoing cellular repair because adequate protein and caloric intake is essential to optimal cellular repair. Elderly clients may have decreased blood flow to the skin, organ atrophy and diminished function, and altered immunity. These conditions slow cellular repair and increase the risk of infection.
  7. Answer: A. Administering anti-inflammatory agents as prescribed. Anti-inflammatory agents help reduce edema and relieve pressure on nerve endings, subsequently reducing pain. Elevating the injured area increases venous return to the heart. Maintaining clean, dry skin aids in preventing skin breakdown. Cool packs, not warm packs, should be used initially to cause vasoconstriction and reduce edema.
  8. Answer: B. Having the client perform Kegel exercises. Kegel exercises, which help strengthen the muscles in the perineal area, are used to maintain urinary continence. To perform these exercises, the client tightens pelvic floor muscles for 4 seconds 10 times at least 20 times each day, stopping and starting the urinary flow. Inserting an indwelling Foley catheter increases the risk for infection and should be avoided. The nurse should encourage the client to develop a toileting schedule based on normal urinary habits. However, suggesting bathroom use every 8 hours may be too long an interval to wait. Pads or diapers should be used only as a resort.
  9. Answer: B. Maintenance of adequate oxygenation. For the client with asthma and infection, oxygenation is the priority. Maintaining adequate oxygenation reduces the risk of physiologic injury from cellular hypoxia, which is the leading cause of cell death. A fluid volume deficit resulting from fever and diaphoresis, not excess, is more likely for this client. No information regarding pain is provided in this scenario. Teaching about infection control is not appropriate at this time but would be appropriate before discharge.
  10. Answer: B. Home environment evaluation. After discharge, the client is responsible for his own care and health maintenance management. Discharge includes assessing the home environment for determining the client’s ability to maintain his health at home.
  11. Answer: C. Keeping the linens dry and wrinkle free. Keeping the linens dry and wrinkle-free aids in preventing moisture and pressure from interfering with adequate blood supply to the tissues, helping to maintain skin integrity. Using a foot board is appropriate for maintaining normal body function position. Monitoring intake and output aids in assessing and maintaining bladder function.. Coughing and deep breathing help promote gas exchange.
  12. Answer: D. Turn the client to the right side for 2 hours. Turning the client to the right side relieves the pressure and promotes adequate blood supply to the left hip. A reddened area is never massaged, because this may increase the damage to the already reddened, damaged area. The health care provider does not need to be notified immediately. However, the health care provider should be informed of this finding the next time he is on the unit. Arranging for a pressure-relieving device is appropriate, but this is done after the client has been turned.
  13. Answer: D. Attempting to rule out complications before administering pain medication. When intervening with a client complaining of pain, the nurse must always determine if the pain is expected pain or a complication that requires immediate nursing intervention. This must be done before administering the medication. Guided imagery should be used along with, not instead of, administration of pain medication. The nurse should medicate the client and not discourage medication.
  14. Answer: C. Correct handwashing technique. Handwashing remains the most effective procedure for controlling microorganisms and the incidence of nosocomial infections. Aseptic technique is essential with invasive procedures, including indwelling catheters. Masks, gowns, and gloves are necessary only when the likelihood of exposure to blood or body fluids is high. Spills of blood from clients with acquired immunodeficiency syndrome should be cleaned with sodium hydrochloride.
  15. Answer: A. Administering I.V. and oral fluids. The client’s assessment findings would lead the nurse to suspect that the client is dehydrated. Administering I.V. fluids is appropriate. Assessing sputum would be appropriate for a client with problems associated with impaired gas exchange or ineffective airway clearance. Monitoring albumin and protein levels is appropriate for clients experiencing inadequate nutrition. Clustering activities helps with energy conservation and promotes rest.
  16. Answer: D. Orange juice and bananas. The client with hypokalemia needs to increase the intake of foods high in potassium. Orange juice and bananas are high in potassium, along with raisins, apricots, avocados, beans, and potatoes. Whole grains and nuts would be encouraged for the client with hypomagnesemia; milk products and green, leafy vegetables are good sources of calcium for the client with hypocalcemia. Pork products and canned vegetables are high in sodium and are encouraged for the client with hyponatremia.
  17. Answer: B. Encouraging slow, deep breaths. The client who is hyperventilating and subsequently develops respiratory alkalosis is losing too much carbon dioxide. Measures that result in the retention of carbon dioxide are needed. Encourage slow, deep breathing to retain carbon dioxide and reverse respiratory alkalosis. Administering low-flow oxygen therapy is appropriate for chronic respiratory acidosis. Administering sodium bicarbonate is appropriate for treating metabolic acidosis, and administering sodium chloride is appropriate for metabolic alkalosis.
  18. Answer: C. 2,470. The fluid intake includes 8 oz (240 ml) of apple juice, 850 ml of water, 2 cups (480 ml) of beef broth, and 900 ml of I.V. fluid for a total of 2,470 ml intake for the shift.
  19. Answer: A. Positive Trousseau’s sign. In a client with hypocalcemia, a positive Trousseau’s sign refers to carpopedal spasm that develops usually within 2 to 5 minutes after applying and inflating a blood pressure cuff to about 20 mm Hg higher than systolic pressure on the upper arm. This spasm occurs as the blood supply to the ulnar nerve is obstructed. Chvostek’s sign refers to twitching of the facial nerve when tapping below the earlobe. Paresthesia refers to the numbness or tingling. Tetany is a clinical manifestation of hypocalcemia denoted by tingling in the tips of the fingers around the mouth, and muscle spasms in the extremities and face.
  20. Answer: A. Tented skin turgor and thirst. Hypernatremia refers to elevated serum sodium levels, usually above 145 mEq/L. Typically, the client exhibits tented skin turgor and thirst in conjunction with dry, sticky mucous membranes, lethargy, and restlessness. Muscle weakness and paresthesia are associated with hypokalemia; fruity breath and Kussmaul’s respirations are associated with diabetic ketoacidosis. Muscle twitching and tetany may be seen with hypercalcemia or hyperphosphatemia.
  21. Answer: B. Low PO2. A chronically elevated PCO2 level (above 50 mmHg) is associated with inadequate response of the respiratory center to plasma carbon dioxide. The major stimulus to breathing then becomes hypoxia (low PO2). High PCO2 and normal pH and HCO3 levels would not be the primary stimuli for breathing in this client.
  22. Answer: A. Assessing urinary intake and output. For the client with fluid volume deficit, assessing the client’s urine output (using a urometer if necessary) is essential to ensure an output of at least 30 ml/hour. The client should be weighed daily, not weekly, and at same time each day, usually in the morning. Monitoring ABGs is not necessary for this client. Rather, serum electrolyte levels would most likely be evaluated. The client also would have an I.V. rate at least 75 ml/hour, if not higher, to correct the fluid volume deficit.
  23. Answer: D. Albert who has renal disease. Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. Clients receiving diuretics, with ileostomies, or with metabolic acidosis may be hypokalemic and should be encouraged to eat foods high in potassium.
  24. Answer: A. Instituting seizure precaution to prevent injury. Instituting seizure precaution is an appropriate intervention, because the client with hypomagnesemia is at risk for seizures. Hypophosphatemia may produce changes in granulocytes, which would require the nurse to instruct the client about measures to prevent infection. Avoiding the use of a tight tourniquet when drawing blood helps prevent pseudohyperkalemia. Early ambulation is recommended to reduce calcium loss from bones during hospitalization.
  25. Answer: D. Sodium. Sodium is the electrolyte whose level is the primary determinant of the extracellular fluid concentration. Sodium a cation (e.g., positively charged ion), is the major electrolyte in extracellular fluid. Chloride, an anion (e.g., negatively charged ion), is also present in extracellular fluid, but to a lesser extent. Potassium (a cation) and phosphate (an anion) are the major electrolytes in the intracellular fluid.
  26. Answer: B. Kayexalate. The client’s potassium level is elevated; therefore, Kayexalate would be ordered to help reduce the potassium level. Kayexalate is a cation-exchange resin, which can be given orally, by nasogastric tube, or by retention enema. Potassium is drawn from the bowel and excreted through the feces. Because the client’s potassium level is already elevated, potassium supplements would not be given. Neither calcium gluconate nor sodium tablets would address the client’s elevated potassium level.
  27. Answer: B. Hot, flushed skin and diaphoresis. Hypermagnesemia is manifested by hot, flushed skin and diaphoresis. The client also may exhibit hypotension, lethargy, drowsiness, and absent deep tendon reflexes. Muscle pain and acute rhabdomyolysis are indicative of hypophosphatemia. Soft-tissue calcification and hyperreflexia are indicative of hyperphosphatemia. Increased respiratory rate and depth are associated with metabolic acidosis.
  28. Answer: C. Potassium level. Diuretics such as furosemide may deplete serum potassium, leading to hypokalemia. When the client is also taking digoxin, the subsequent hypokalemia may potentiate the action of digoxin, placing the client at risk for digoxin toxicity. Diuretic therapy may lead to the loss of other electrolytes such as sodium, but the loss of potassium in association with digoxin therapy is most important. Hypocalcemia is usually associated with inadequate vitamin D intake or synthesis, renal failure, or use of drugs, such as aminoglycosides and corticosteroids. Hypomagnesemia generally is associated with poor nutrition, alcoholism, and excessive GI or renal losses, not diuretic therapy.
  29. Answer: C. Encouraging the client to cough and deep breathe. The ABG results indicate respiratory acidosis requiring improved ventilation and increased oxygen to the lungs. Coughing and deep breathing can accomplish this. The nurse would administer high oxygen levels because the client does not have chronic obstructive pulmonary disease. Breathing into a paper bag is appropriate for a client hyperventilating and experiencing respiratory alkalosis. Some action is necessary, because the ABG results are not within normal limits.
  30. Answer: B. Sodium bicarbonate. Metabolic acidosis results from excessive absorption or retention of acid or excessive excretion of bicarbonate. A base is needed. Sodium bicarbonate is a base and is used to treat documented metabolic acidosis. Potassium, serum sodium determinations, and a bronchodilator would be inappropriate orders for this client.
  31. Answer: C. within normal range. Normal serum concentrations of chloride range from 95 to 108 mEq/L.
  32. Answer: C. eclampsia. Eclampsia is associated with increased levels of serum chloride.
  33. Answer: C. anion. Chloride is a major anion found in the extracellular fluid. A compound occurs when two ions are bound together. Chloride is an ion, but this choice is too general. HCO3 is a cation.
  34. Answer: A. amphogel. Administration of phosphate binders (amphogel and basagel) will reduce the serum phosphate levels.
  35. Answer: C. metastatic bone lesions. Metastatic bone lesions are associated with hypercalcemia due to accelerated bone metabolism and release of calcium into the serum. Renal failure, inadequate calcium intake, and vitamin D deficiency may cause hypocalcemia.
  36. Answer: D. urinary calculi. Urinary calculi may occur with hypercalcemia. Shortened, not prolonged QRS complex would be seen in hypercalcemia. Tetany and petechiae are signs of hypocalcemia.
  37. Answer: B. administering calcium gluconate. Calcium gluconate is used for replacement in deficiency states. Calcitonin and loop diuretics are used to lower serum calcium.
  38. Answer: D. renal failure. Renal failure can reduce magnesium excretion, leading to hypermagnesemia. Diabetic ketoacidosis, not insulin shock is a cause of hypermagnesemia. Hypoadrenalism, not hyperadrenalism is a cause of hypermagnesemia. Nausea and vomiting lead to hypomagnesemia.
  39. Answer: B. antagonize the cardiac effects of magnesium. In a patient with hypermagnesemia, administration of calcium gluconate will antagonize the cardiac effects of magnesium. Although calcium gluconate will raise serum calcium levels, that is not the purpose of administration. Calcium gluconate does not lower calcium or magnesium levels.
  40. Answer: B. Digoxin. In hypomagnesemia, a patient on digoxin is likely to develop digitalis toxicity. Neither A nor C has toxicity as a side effect. CAPD is not a medication.
  41. Answer: D. cardiac rate and rhythm. Cardiac rate and rhythm are the most important physical assessment parameter to measure. Skin turgor, intake and output are physical assessment parameters a nurse would consider when assessing fluid and electrolyte imbalance, but choice d is the most important.
  42. Answer: D. perspiration. Perspiration and the fluid lost via the lungs are termed insensible losses; normally, insensible losses equal about 1000 cc/day.
  43. Answer: B. hypertonic solution. When hyponatremia is severe, hypertonic solutions may be used but should be infused with caution due to the potential for development of CHF. In SIADH, isotonic and hypotonic solutions are not indicated, because urine output is minimal, so water is retained. this water retention dilutes serum sodium levels, making the patient hyponatremic and necessitating administration of hypertonic solutions to balance sodium and water. Normotonic solutions do not exist.
  44. Answer: A. hypokalemia. Aldosterone is secreted in response to fluid loss. Aldosterone causes sodium reabsorption and potassium elimination, further exacerbating hypokalemia.
  45. Answer: A. bounding pulse. Bounding pulse is a sign of fluid overload as more volume in the vessels causes a stronger sensation against the blood vessel walls. Flat neck veins and vesicular breath sounds are normal findings. Poor skin turgor is consistent with dehydration.
  46. Answer: B. diluted in 100 cc over 1 hour. Potassium must be well diluted and given slowly because rapid administration will cause cardiac arrest.
  47. Answer: D. hyporeflexia. Hyporeflexia is a symptom of hypokalemia
  48. Answer: B. diluted. Oral potassium supplements are known to irritate gastrointestinal (GI) mucosa and should be diluted.
  49. Answer: B. 7.31 to 7.41. Normal venous blood pH ranges from 7.31 to 7.41. Normal arterial blood pH ranges from 7.35 to 7.45.
  50. Answer: D. carbon dioxide. Respiratory regulation of acid-base balance involves the elimination or retention of carbon dioxide.
  51. Answer: C. arterial blood gas. Arterial blood gases will indicate CO2 and O2 levels. This is an indication that the respiratory system is functioning. Respiratory rate can reveal data about other systems, such as the brain, making letter c a better choice. Pulse rate is not measure of respiratory status. Pulse oximetry yields oxygen saturation levels, which is not a measure of acid-base balance.
  52. Answer: B. isotonic FVD. Isotonic FVD involves an equal decrease in solute concentration and water volume.
  53. Answer: B. 0.50 lb. Weight loss of more than 0.50 lb. is considered to be fluid loss.
  54. Answer: B. increased sodium intake. Hypotonic fluid volume excess (FVE) involves an increase in water volume without an increase in sodium concentration. Increased sodium intake is part of the management of this condition.
  55. Answer: B. diffusion. In diffusion, the solute moves from an area of higher concentration to one of lower concentration, creating osmotic pressure. Osmotic pressure is related to the process of osmosis. Filtration is created by hydrostatic pressure. Capillary dynamics are related to fluid exchange at the intravascular and interstitial levels.
  56. Answer: D. increased urine output. Arterial baroreceptors and stretch receptors help maintain fluid balance by increasing urine output in response to a rise in arterial pressure.
  57. Answer: C. 136 to 145 mEq/L. Normal serum sodium level ranges from 136 to 145 mEq/L.
  58. Answer: D. all of the following. Water gain, diuretic therapy, and diaphoresis are etiologies of hyponatremia.
  59. Answer: C. restricting fluid intake. Hyponatremia involves a decreased concentration of sodium in relation to fluid volume, so restricting fluid intake is indicated.
  60. Answer: B. alkalosis. Alkalosis is indicated by a pH above 7.45.
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