A client with hypoparathyroidism complains of numbness and tingling in his fingers and around the mouth.  The nurse would assess for what electrolyte imbalance?

1. Hypernatremia

2. Hypocalcemia

3. Hypokalemia

4. Hyperkalemia

2. Hypocalcemia

Rationale:  Hypoparathyroidism can cause low serum calcium levels.  Numbness and tingling in extremities and in the circumoral area around the mouth are the hallmark signs of hypocalcemia.  

Normal calcium level is 9 to 11 mg/dL.

The nurse evaluates which of the following clients to be at risk for developing hypernatremia?

1. 50 year old with pneumonia, diaphoresis, and high fever.

2. 62 year old with CHF taking loop diuretics

3. 39 year old with diarrhea and vomiting

4. 60 year old with lung cancer and syndrome of inappropriate antidiuretic hormone (SIADH)

1. 50 year old with pneumonia, diaphoresis and a high fever

Rationale:  Diaphoresis and high fever can lead to free water loss through the skin, resulting in hypernatremia.

Loop diuretics are more likely to result in a hypovolemic hyponatremia.  Diarrhea and vomitting cause both sodium and water losses.  Clients with SIADH have hyponatremia due to increased water reabsorption in the renal tubules.

A client is admitted with diabetic ketoacidosis and, with treatment, has a normal blood glucose, pH, and serum osmolality.  During assessment, the client complains of weakness in the legs.  Which of the following is a priority nursing intervention?

1. Request a physical therapy consult from the physician.

2. Ensure the client is safe from falls and check the most recent potassium level.

3. Allow uninterrupted rest periods throughout the day.

4. Encourage the client to increase intake of dairy products and green leafy vegetables.

2. Ensure the client is safe from falls and check the most recent potassium level.

Rationale:  In the treatment of diabetic ketoacidosis the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium.  Client safety and the correction of low potassium levels are a priority.  The weakness in the legs is a clinical manifestation of the hypokalemia.  Dairy products and green, leafy vegetables are a source of calcium.

A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally.  After administering the drug the priority nursing action is to monitor

1. urine output

2. blood pressure

3. bowel movements

4. ECG for tall, peaked T waves

3. bowel movements

Rationale:  Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements.  If the client does not have stools, the drug cannot work properly.  

Blood pressure and ruine output are not of primary importance.  The nurse would already expect changes in T waves with hyperkalemia.  

Normal serum potassium is 3.5 to 5.5 mEq/L.

The nurse is caring for a client who has been in good health up to the present and is admitted with cellulitis of the hand.  The client's serum potassium level was 4.5 mEq/L yesterday.  Today the level is 7 mEq/L.  Which of the following is the next appropriate nursing action?

1. Call the physician and report the results

2. Question the results and redraw the specimen

3. Encourage the client to increase the intake of bananas

4. Initiate seizure precautions

2. Question the results and redraw the specimen

Rationale:  A client who has been healthy up to the present is admitted for cellulitis of the hand.  When the serum potassium goes from 4.5 to 7.0 mEq/L with no risk factors for hyperkalemia, false high results should be suspected because of the hemolysis of the specimen.  The physician would likely question the results as well.

Bananas are a food high in potassium.  Seizures are not a clinical manifestation of hyperkalemia.

A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L.  Which of the following assessments would alert the nurse to immediately stop the infusion?

1. Absent patellar reflex

2. Diarrhea

3. Premature ventricular contractions

4. Increased blood pressure

1. Absent patellar reflex

Rationale:  An intravenous magnesium infusion may be used to treat a low serum magnesium level.  Normal serum magnesium is 1.5 to 2.5 mEq/L.  Clinical manifestations of hypermagnesemia are the result of depressed neuromuscular transmission.  Absent reflexes indicate a magnesium level around 7 mEq/L.  

Diarrhea and PVCs are not clinical manifestations of high magnesium levels.  Hypermagnesemia causes hypotension.

A client with chronic renal failure reports a 10 lb weight loss over 3 months and has had difficulty taking calcium supplements.  The total calcium is 6.9 mg/dL.  Which of the following would be the first nursing action?

1. Assess for depressed deep tendon reflexes.

2. Call the physician to report calcium level

3. Place and intravenous catheter in anticipation of administering calcium gluconate

4. Check to see if a serum albumin level is available

4. Check to see if a serum albumin level is available.

Rationale:  A client with chronic renal failure who reports a 10lb weight loss over 3 months and has had difficulty taking calcium supplements is poorly nourished and likely to have hypoalbuminemia.  A drop in serum albumin will result in a false low total calcium level.  

Placing and IV is not a priority action.  Depressed reflexes are a sign of hypercalcemia or hypermagnesemia.  

Normal serum calcium is 9 to 11 mg/dL.

A client with heart failure is complaining of nausea.  The client has received IV furosemide (Lasix) and the urine output has been 2500 ml over the past 12 hours.  The client's home drugs include metoprolol (Lopressor), digoxin (Lanoxin), furosemide, and multivitamins.  Which of the following are the appropriate nursing actions before administering the digoxin?

Select all that apply.

1. Administer an antiemetic prior to giving the digoxin

2. encourage the client ot increase fluid intake

3. call the physician

4. Report the urine output

5. report indications of nausea

6. monitor continuous ECG for peaked T waves and widened QRS

3. Call the physician

4. Report the urine output

5. Report indications of nausea

Rationale:  Potassium is lost during diuresis wiht a loop diuretic such as furosemide.  Hypokalemia can cause digitalis toxicity, which often results in nausea.  The physician should be notified, and digoxin should be held until potassium levels and digoxin levels are checked.  

Peaked T waves and widened QRS are manifestations of hyperkalemia.

Normal serum potassium levels are 3.5 to 5.5 mEq/L.

The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dL.  Which of the following is the most appropriate nursing action?

1. Provide passive ROM exercises and encourage fluids.

2. Teach the client to increase intake of whole grains and nuts

3. Place tracheostomy tray at the bedside

4. Administer calcium gluconate IM as ordered.

1. Provide passive ROM exercises and encourage fluids.

Rationale:  A client who has a serum calcium of 13 mg/dL has hypercalcemia.  Normal serum calcium is 9 to 11 mg/dL.  Fluid intake promotes renal excretion of excess calcium.  ROM exercises promote reabsorption of calcium into bone.  

Placing a tracheostomy at the bedside is a nursing intervention for hypocalcemia.  Although calcium gluconate may be administered in hypocalcemia, it is never administered IM.

An older client admitted with heart failure and a sodium level of 113 mEq/L is behaving agressively toward staff and does not recognize family members.  When the family expresses concern about the client's behavior, the nurse would respond most appropriately by stating

1. "The client may be suffering from dementia, and the hospitalization has worsened the confusion."

2. "Most older adults get confused in the hospital."

3. "The sodium level is low, and the confusion will resolve as the levels normalize."

4. The sodium level is high and the behavior is a result of dehydration."

3. "The sodium level is low, and the confusion will resolve as the levels normalize."

Rationale:  Normal serum sodium is 135 to 145 mEq/L.  Neurological symptoms occur when sodium levels fall below 120 mEq/L.  The confusion is an acute condition that will go away as the sodium levels normalize.  

Dementia is an irreversible condition.

A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours.  This morning the client feels tired and short of breath.  Which of the following interventions is a priority?

1. Turn down the infusion.

2. Check the latest sodium level

3. Assess for signs of fluid overload

4. Place a call to the physician

3. Assess for signs of fluid overload.

Rationale:  A complication of hypertonic sodium solution administration is fluid overload.  

While turning down the infusion, checking the latest sodium level and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload.  

Assessment is always the priority to determine what action to take next.

A client with chronic renal failure receiving dialysis complains of frequent constipation.  When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home?

1. Biscodyl (Dulcolax) suppository

2. Fiber supplements

3. Docusate sodium

4. Milk of magnesia

4. Milk of Magnesia

Rationale:  Milk of magnesia contains magnesium, an electrolyte that is excreted by kidneys.  Clients with renal failure are at risk for hypermagnesemia, since their bodies cannot excrete the excess magnesium.  The client should avoid magnesium-containing laxatives.

A client is receiving intravenous potassium supplementation in addition to maintenance fluids.  The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due.  Before administering the next potassium dose, which of the following is the priority nursing action?

1. Encourage the client to increase fluid intake

2. Administer the dose as ordered

3. Draw a potassium level and administer the dose if the level is low or normal.

4. Notify the physician of the urine output and hold the dose.

4. Notify the physician of the urine output and hold the dose

Rationale:  Urine output is an indication of renal function.  Normal urine output is at least 30 ml/hr.  

Clients with impaired renal function are at risk for hyperkalemia.  Initiating a lab draw requires a physician's order.

The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients?

1. A client with osteoporosis taking vitamin D and calcium supplements.

2. A client who is alcoholic receiving total parenteral nutrition.

3. A client with chronic renal failure awaiting the first dialysis run.

4. A client with hypoparathyroidism secondary to thyroid surgery.

2. A client who is alcoholic receiving total parenteral nutrition.

Rationale:  Alcoholics and clients receiving TPN are at risk for low phosphorus levels due to poor intestinal absorption and shifting of phosphorus into cells along with insulin and glucose.

A client with osteoporosis taking vitamin and calcium supplements, a client with chronic renal failure awaiting dialysis and a client wiht hypoparathyroidism secondary to thyroid surgery are at risk for hyperphosphatemia.

A client admitted with squamous cell carcinoma of the lung has a serum calcium level of 14 mg/dL.  The nurse should instruct the client to avoid which of the following foods upon discharge?

Select all that apply.

1. Fish

2. Eggs

3. Broccoli

4. Organ meats

5. Nuts

6. Canned Salmon

3. Broccoli

5. Nuts

6. Canned Salmon

Rationale:  Fish, eggs and organ meats are high in phosphorus.  Broccoli, nuts and canned salmon are high in calcium.  Clients with lung or breast cancer often have elevated calcium levels due to tumor-induced hyperparathyroidism.

A client with pancreatitis has been receiving potassium supplementation for four days since being admitted with a serum potassium of 3.0 mEq/L.  Today the potassium level is 3.1 mEq/L.  Which of the following laboratory values should the nurse check before notifying the physician of the client's failure to respond to treatment?

1. Sodium

2. Phosphorus

3. Calcium

4. Magnesium

4. Magnesium

Rationale:  Low serum magnesium levels can inhibit potassium ions from crossing cell membranes, resulting in potassium loss through the urine.  Generally, low magnesium levels must be corrected before potassium replacement is effective.

The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure?

1. Increase intake of dairy products and nuts

2. take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals.

3. Reduce intake of chocolate, meats, and whole grains.

4. Avoid calcium supplements

2. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals.

Rationale:  Aluminum-based antacids are often prescribed in the treatment of renal failure to bind with phosphate and increase elimination through the GI tract.

Dairy products and nuts are foods high in phosphorus.  Chocolate, meats and whole grains are foods high in magnesium.  Clients with renal failure often require calcium supplements as a result of poor vitamin D metabolism and in order to prevent hyperphosphatemia.

A client with pneumonia presents with the following arterial blood gases:  pH of 7.28, PaCO₂ of 74, HCO₃ of 28 mEq/L, and PO₂ of 45. Which of the following is the most appropriate nursing intervention?

1. Administer a sedative

2. Place client in left lateral position

3. Place client in high-Fowler's position

4. Assist the client to breathe into a paper bag.

3. Place the client in a high-Fowler's position.

Rationale:  The client with a pH of 7.28, PaCO₂ of 74, HCO₃ of 28 mEq/L, and PO₂ of 45 is in a state of respiratory acidosis.  Placing the client in high-Fowler's position will facilitate the expansion of the lungs and help th eclient blow off the excess CO₂. 

Sedatives would impede respirations.  The question does not indicate which is the affected lung, so left lateral position would not be a first choice.  Breathing into a paper bag will cause the PCO₂ to rise higher.

A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen via nasal cannula.  The morning's ABGs were pH of 7.36, PaCO₂ of 62, HCO₃ of 35 mEq/L, O₂ at 88% on 2 liters.  Which of the following should be the nurse's first intervention?

1. Call the physician and report the change in client's condition.

2. Turn the client's O₂ up to 4 liters via nasal cannula

3. Encourage the client to sit down and to take deep breaths

4. Encourage the client to rest and to use pursed-lip breathing technique.

4. Encourage the client to rest and to use pursed-lip breathing technique.

Rationale: Clients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations.

 Deep breaths are not helpful, because clients with COPD have difficulty with air trapping in alveoli.  There is no need to call the physician, since this client is presently most likely at baseline.

A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140.  The nurse hangs which of the following IV fluids to correct this condition?

1. D5.45 NS at 50 ml/hr

2. 0.9 NS at an open rate

3. D₅W at 125 ml/hr

4. 0.45 NS at open rate

2. 0.9 NS at an open rate

Rationale:  A client who recently had surgery is vomiting, becomes dizzy when standing up, has a bp of 55/30 and has a pulse of 140 is hypovolemic and requires plasma volume expansion.  Isotonic fluids such as 0.9 NS will expand volume.  

Hypotonic fluids such as 0.45 NS will leave the intravascular space.  D₅W will metabolize into free water and leave the intravascular space.  D5.45 NS is a good maintenance fluid but a rate of 50 ml per hour is not sufficient to expand the vascular volume quickly.

A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town.  Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?

1. pH of 7.43, PCO₂ of 36, HCO₃ of 26

2. pH of 7.41, PCO₂ of 49, HCO₃ of 30

3. pH of 7.33, PCO₂ of 35, HCO₃ of 17

4. pH of 7.25, PCO₂ of 56, HCO₃ of 28

3. pH of 7.33, PCO₂ of 35, HCO₃ of 17

Rationale:  A pH of 7.33, PCO₂ of 35, and HCO₃ of 17 and a pH of 7.25, PCO₂ of 56, and HCO₃ of 28 both indicate acidosis.  The pH of 7.25 is a respiratory acidosis.  

A pH of 7.41, PCO₂ of 49, and HCO₃ of 30 is a compensated metabolic alkalosis.  A pH of 7.43, PCO₂ of 36, and HCO₃ of 26 is normal.

A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder?

1. Respiratory alkalosis

2. Respiratory acidosis

3. Metabolic alkalosis

4. Metabolic acidosis

3. Metabolic alkalosis

Rationale:  Clients on gastric suctioning can lose hydrogen ions, resulting in a metabolic alkalosis.

A client who suffers from an anxiety disorder is very upset, has a respiratory rate of 32, and is complaining of lightheadedness and tingling in the fingers.  ABG values are pH of 7.48, PaCO₂ of 29, HCO₃ of 24, and O₂ is at 93% on room air.  The nurse performs which of the following as a priority nursing intervention?

1. Monitor intake and output

2. encourage the client to increase activity

3. institute deep breathing exercises every hour

4. provide reassurance to the client and administer sedatives

4. Provide reassurance to the client and administer sedative

Rationale:  A client who is anxious and upset, gets lightheaded, and has tingling in the fingers and the indicated ABGs is in respiratory alkalosis.  Administering a sedative will help the client to breathe slowly and retain more CO2, thus bringing the pH back into normal range.  

Deep breathing exercises may worsen the client's condition.  Encouraging the client to increase activity is contraindicated because clients are often exhausted and require rest after expending so much energy breathing.  Monitoring intake and output is not a priority.

Which of the following assissment findings would indicate to the nurse that a client's diabetic ketoacidosis is deteriorating?

1. Deep tendon reflexes decreasing from +2 to +1

2. Bicarbonate rising from 20 mEq/L to 22 mEq/L

3. Urine pH of less than 6

4. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L

1. Deep tendon reflexes decreasing from +2 to +1

Rationale:  A decrease in deep tendon reflexes is a sign that pH is dropping and that metabolic acidosis is worsening in diabetic ketoacidosis.  

An increase in bicarbonate would indicate that the acidosis is being corrected.  A urine pH less than 6 indicates the kidneys are excreting acid.  Serum potassium levels are expected to fall because acidosis is corrected and potassium moves back into the intracellular spaces.

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema.  The client asks the nurse for an explanation for the edema.  Which of the following is the most appropriate response by the nurse?

1. "The fluid is an adverse reaction ot the chemotherapy."

2. "A decrease in activity has allowed extra fluid to accumulate in the tissues."

3. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues."

4. "Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues."

3. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues."

Rationale:  Generalized edema, or anasarca, is often seen in clients with low albumin levels secondary to poor nutrition.  Decreased oncotic pressure within the blood vessels allows fluid to move from the intravascular space to the interstitial space.

A client with a recent thyroidectomy complains of numbness and tingling around the mouth.  Which of the following findings indicates that serum calcium is low?

1. bone pain

2. depressed deep tendon reflexes

3. positive Chvostek's sign

4. nausea

3. positive Chvostek's sign

Rationale:  Numbness and tingling around the mouth indicates hypocalcemia, which results in neuromuscular irritability.  A positive Chvostek's sign is the contraction of facial muscles when the facial nerve in front of the ear is tapped.

Bone pain, nausea and depressed deep tendon reflexes are signs of hypercalcemia.

A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea.  Which of the following is an appropriate nursing diagnosis for this client?

1. Deficient fluid volume related to decreased fluid intake.

2. Excess fluid volume related to increased water retention.

3. Deficient fluid volume related to excessive fluid loss.

4. Risk for injury related to fluid volume loss.

2. Excess fluid volume related to increased water retention.

Rationale:  The client exhibits signs of excess fluid volume.  SIADH is the release of excess ADH by the pituitary gland, which results in hypervolemic hyponatremia and clinical manifestations of headache, weight gain, and nausea.

A registered nurse is delegating nursing tasks for the day.  Which of the following tasks may the nurse delegate to a licensed practical nurse?

1. Assess a client for metabolic acidosis

2. Evaluate the blood gases of a client with respiratory alkalosis

3. Obtain glucose level on a client admitted with diabetes mellitus

4. Perform a neurological assessment on a client suspected of having hypocalcemia.

3. Obtain glucose level on a client admitted with diabetes mellitus

Rationale:  A licensed practical nurse may obtain a finger stick glucose on a client with diabetes mellitus.  

A licensed practical nurse may not assess a client for metabolic acidosis, evaluate blood gases on a client with respiratory alkalosis, or perform a neurological ssessment on a client suspected of hypocalcemia.

A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L.  Based on the assessment data, which of the following is the priority intervention?

1. withhold furosemide (Lasix)

2. Notify the physician

3. Administer the prescribed potassium supplement

4. Instruct the client on foods high in potassium

2. Notify the physician

Rationale:  The priority intervention for this client would be to notify the physician of the low potassium level.  

After this, the furosemide may be withheld and a potassium supplement administered as prescribed and may even be increased after talking with the physician.  The client may also be instructed on foods high in potassium.  These are all appropriate interventions, but not the priority.

The nurse is admitting a client with a potassium level of 6.0 mEq/L.  The nurse reports this finding as a result of 

1. acute renal failure

2. malabsorption syndrome

3. nasogastric drainage

4. laxative abuse

1. acute renal failure

Rationale:  A serum potassium level of 6.0 mEq/L is indicative of acute renal failure.

Malabsorption syndome, nasogastric drainage, and laxative abuse may result in low serum potassium levels because output may be greater than input. Diarrhea results from malabsorption syndrome and can come from laxative abuse.  Fluids and electrolytes may be lost in the nasogastric drainage.  

Normal serum potassium is 3.5 to 5.5 mEq/L.

Which of the following should the nurse include in the diet teaching for a client with a sodium level of 158 mEq/L?

Select all that apply

1. Peanut butter sandwich

2. Pretzels

3. Baked chicken

4. Chicken bouillon

5. Baked potato

6. Baked ham

3. Baked chicken

5. Baked potato

Rationale:  Normal serum sodium is between 135 and 145 mEq/L.  A sodium level of 158 mEq/L is elevated and a low sodium diet including baked chicken and backed potatoes should be prescribed.  

A peanut butter sandwich, pretzels, chicken bouillon, and baked ham are all foods high in sodium.  

The nurse assesses a client to be experiencing muscle cramps, numbness and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped.  The nurse reports this assessment as consistent with which of the following?

1. Hypokalemia

2. Hypernatremia

3. Hypermagnesemia

4. Hypocalcemia

4. Hypocalcemia

Rationale:  Normal serum calcium is 9 to 11 mg/dL.  A client who has hypocalcemia would experience muscle cramps, numbess, and twitching of the facial muscles and eyelid when the facial nerve is tapped.  Hypocalcemia may result from renal failure, hypoparathyroidism, acute pancreatitis, liver disease, malabsorption syndrome, and vitamin D deficiency. 

Normal serum potassium level is 3.5 to 5.5 mEq/L.

Normal serum sodium is 135 to 145 mEq/L.

Normal serum magnesium is 1.5 to 2.5 mEq/L.

Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes?

1. Sodium is essential to maintain intracellular fluid water balance

2. Magnesium is essential to the function of muscle, red blood cells, and nervous system.

3. Less calcium is excreted with aging.

4. Chloride is lost in hydrochloride acid.

4. Chloride is lost through hydrochloride acid.

Rationale:  Chloride is lost through hydrochloride acid.

Sodium is essential to maintain extracellular fluid water balance.  Phosphate is the major anion in intracellular fluid water balance that is essential in function of muscle, red blood cells, and nervous system.  A person tends to excrete more calcium as they age.  

The nurse assists a client with a serum potassium of 3.2 mEq/L to make which of the following menu selections?

Select all that apply

1. Baked cod

2. Ham and cheese omelet

3. Fried eggs

4. Baked potato

5. whole grain muffin

6. spinach

1. Baked cod

4. Baked potato

6. spinach

Rationale:  Normal serum potassium is 3.5 to 5.5 mEq/L. A client who has a potassium of 3.2 mEq/L would benefit from a diet high in potassium.  Baked cod, baked potato, and spinach are all food selections high in potassium.

A ham and cheese omelet is high in sodium.  Fried eggs are high in cholesterol.  A whole grain muffin is high in grains.

the nurse evaluates which of the following clients to have hypermagnesemia?

1. A client who has chronic alcholism and a magnesium level of 1.3 mEq/L.

2. A client who has hyperthyroidism and a magnesium level of 1.6 mEq/L.

3. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L.

4. A client who has CHF, takes a diuretic, and has a magnesium level of 2.3 mEq/L.

3. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L.

Rationale:  A normal serum magnesium level is 1.5 to 2.5 mEq/L.

Clients who have chronic alcoholism and hyperthyroidism are prone to hypomagnesemia.  A client who has CHF, takes a diuretic, and has a magnesium level of 2.3 mEq/L falls within normal range.

The nurse is evaluating the serum laboratory results on the following four clients.  Which of the following laboratory results is a priority for the nurse to report first?

1. A client with osteoporosis and a calcium level of 10.6 mg/dL.

2. A client with renal failure and a magnesium level of 2.5 mEq/L.

3. A client with bulimia and a potassium level of 3.6 mEq/L.

4. A client with dehydration and a sodium level of 149 mEq/L.

4. A client with dehydration and a sodium level of 149 mEq/L.

Rationale:  Normal serum sodium is 135 to 145 mEq/L.  The sodium level generally goes up with dehydration. A sodium level of 149 mEq/L is elevated. 

Although a client with acute osteoporosis may have a high serum calcium, a level of 10.6 mg/dL is normal.  Normal serum calcium is 9 to 11 mg/dL.  Normal serum magnesium is 1.5 to 2.5 mEq/L.  A client who has renal failure is prone to hypermagnesemia, but a level of 2.5 mEq/L is at the upper limit of normal.  A client who has bulimia generally vomits enough to result in a low potassium level, but a potassium level of 3.6 mEq/L is low normal.  Normal serum potassium is 3.5 to 5.5 mEq/L.

The registered nurse is delegating client assignments to unlicensed assistive personnel.  Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel?

1. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L.

2. A client with renal failure who has a serum magnesium level of 3.0 mEq/L.

3. A client who has experienced a fracture of the femur and has a serum phosphate level of 5.0 mg/dL.

4. A client with dehydration who has a serum sodium level of 128 mEq/L.

1. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L.

Rationale:  Normal serum chloride is 95 to 105 mEq/L.  A client with diarrhea may experience low chloride levels, but 100 mEq/L is within the normal range and may be delegated to unlicensed assistive personnel.

Normal serum magnesium is 1.5 to 2.5 mEq/L.  A magnesium level of 3.0 mEq/L is elevated and may occur in renal failure.  Phosphate levels may be elevated with healing fractures.  A phosphate level of 5.0 mg/dL is elevated.  Normal serum phosphate level is 2.8 to 4.5 mg/dL.  A sodium level of 128 mEq/L is decreased and may be found with dehydration.  Normal serum sodium level is 135 to 145 mEq/L.

The Renin-Angiotensin System

Renin is released from the kidneys, facilitating the production of angiotensin II (a powerful vasoconstrictor), which stimulates the production of aldosterone.

Aldosterone is a mineralocorticoid released by the adrenal cortex which acts on the distal renal tubule to increase reabsorption of sodium and water and excretion of potassium and hydrogen.

An increase in aldosterone increases intravascular fluid volume.

Aldosterone is increased by increased renin and potassium, decreased sodium, and the release of adrenocorticotropic hormone (ACTH) through stress or trauma.

The distal tubule and the collecting duct.

The result is reabsorption of water (and sodium), increasing intravascular fluid volume and stimulating vasoconstriction.

Increased serum osmolality

Decreased circulating volume as sensed by baroreceptors

Atrial natriuretic hormone is a cardiac hormone stored in the atria of the heart.

It dilates the arteries and veins and increases the glomerular filtration rate, resulting in a decrease in blood pressure.

It is released in response to increased return and increased atrial pressure.

Which fluids have the same tonicity as body fluids and tend to stay in the intravascular space?

1. Isotonic

2. Hypotonic

3. Hypertonic

Which fluids have a tonicity that is less than that of body fluids and are drawn from the intravascular space into intracellular and interstitial spaces?

1. Isotonic

2. Hypertonic

3. Hypotonic

A patient is experiencing nausea with severe vomiting.  The nurse realizes that this patient is at risk for which of the following?

1. Interstitial fluid volume deficit

2. Extracellular fluid volume deficit

3. Intracellular fluid volume deficit

4. Interstitial fluid volume deficit

2. Extracellular fluid volume deficit

A male patient's hematocrit is 56% with serum sodium of 150 mEq/L and potassium of 5.8 mEq/L.  Which of the following would be indicated for this patient?

1. Prepare to administer a hypertonic intravenous solution

2. Prepare to administer a hypotonic intravenous solution

3. Implement a fluid and sodium restriction for the patient.

4. Prepare to administer an isotonic intravenous solution.

2. Prepare to administer a hypotonic intraveous solution

Rationale:  This patient is dehydrated, as evidenced by the elevated hemoglobin and serum sodium and potassium levels.  The nurse would prepare to administer a hypotonic solution, which has a lower osmolality to hydrate the patient.

A hypertonic solution would exacerbate the dehydration and would not be indicated. An isotonic intravenous solution has the osmolality of blood and would most likely not serve to rehydrate the patient very effectively.  This patient is dehydrated, so a sodium and fluid restriction would be detrimental to this patient's care.

The nurse is caring for a patient and has just received the laboratory data report.  Which of the following results would cause the most concern to the nurse?

1. Magnesium of 2.0 mg/dL

2. Potassium of 4.0 mEq/L

3. Calcium of 9 mg/dL

4. Sodium of 115 mEq/L

4. Sodium of 115 mEq/L

Rationale:  Of the four electrolytes presented, the sodium is out of range.  Normal values for sodium are 135-145 mEq/L.  

Normal values for potassium are 3.5 to 5.5 mEq/L

Normal values for calcium are 9 to 11 mg/dL

Normal values for magnesium are 1.5 to 2.5 mEq/L

The nurse is caring for a patient with severe vomiting and diarrhea and a NG tube to low wall suction.  The nurse realizes that this patient is at risk for which of the following electrolyte imbalances?

1. Hypokalemia

2. Hypophosphatemia

3. Hypercalcemia

4. Hypermagnesemia

1. Hypokalemia

Rationale:  Diarrhea may increase excretion of potassium  to 200 mEq/day.  Vomiting/NG tube suction can increase the loss through GI fluids removed.  

Typical circumstances leading to hypocalcemia include primary hyperparathyroidism, bone malignancy, and drug toxicity.  Hypermagnesemia is often associated with renal failure.  Hypeophosphatemia is caused by vitamin D deficiency, bowel disorders that lead to malabsorption, excessive use of phosphate-binding antacids, alcoholism, or diabetic ketoacidosis.

A patient is admitted to the hospital with a fluid volume excess.  Which of the following will the nurse most likely assess for this patient?

1. Depedent edema

2. Heart rate 86 bpm without ectopy

3. Respiratory rate 14 breaths per minute and unlabored

4. Blood pressure - 92/55

1. Dependent edema

Rationale:  With fluid volume excess, the patient would likely show dependent edema, an increased blood pressure, decreased urine output, shortness of breath, and adventitious sounds.  An example of this condition would be a patient with CHF.

The nurse is caring for a patient in renal failure with a serum potassium level of 7.1 mEq/L.  Which of the following should the nurse do first to assist this patient?

1. Have ABGs drawn

2. Assess level of consciousness

3. Measure urine output hourly

4. Obtain electrocardiogram

4. Obtain electrocardiogram

Rationale:  Obtaining an electrocardiogram is of priority, as serum potassium levels greater than 6.0 mEq/L can be life-threatening due to a decreased ability of the heart to repolarize, as evidenced by tented T-wave, loss of P-wave, and wide, bizarre QRS with a depressed ST segment.  

Evaluating the level of consciousness would be associated with hyponatremia; measuring urine output hourly would be fruitless for a patient with renal failure, and the ABGs, although likely abnormal, would not serve as a priority intervention.

The nurse is providing discharge instructions to a patient with hypokalemia.  Whcih of the following should the nurse include in these instructions?

1. Eat a balanced diet, including tomato juice and potatoes

2. Take oral Kaexylate as prescribed

3. Limit the intake of spinach and carrots

4. Expect muscle cramps and weakness for at least six weeks

1. Eat a balanced diet, including tomato juice and potatoes

Rationale:  Discharge teaching of patient/family in regard to hypokalemia includes properly taking potassium supplements such as K-Dur.  In addition, increasing potassium rich foods in the diet and recognizing/reporting increased muscle weakness are critical teaching points.  

Kaexylate enemas are used for hyperkalemia, thus would not be an appropriate measure.

Sodium

135-145 mEq/L

It inhibits the resorption of calcium by bone.

It inhibits the renal excretion of calcium.

It mobilizes calcium from the bone.

It increases kidney reabsorption of calcium.

Lethargy, headache, personality changes, seizures.

Permanent brain damage below 115 mEq/L

A patient's blood pH is decreasing.  The nurse realizes that this patient's hydrogen ion concentration is

1. Decreasing

2. Stabilizing

3. Increasing

4. Being affected by oxygen concentration

3. Increasing

Rationale:  Blood pH is inversely proportional to hydrogen ion concentration.  The hydrogen ion is the smallest ionic particle and it is extremely reactive.  The hydrogen ion combines with alkali/bases or other negatively charged ions at low concentrations.

A patient is admitted with the diagnosis of diabetic ketoacidosis.  The nurse realizes that this patient's body will attempt to attain acid-base balance by:

1. Decreasing the reabsorption of bicarbonate

2. Increasing the secretion of hydrogen ions

3. Decreasing its respiratory rate

4. Increasing the reabsorption of hydrogen gas

2. Increasing the secretion of hydrogen ions

Rationale:  The main metabolic acids are lactic acid, pyruvic acid, ketoacids seen in diabetic acidosis, acetoacetic acid, and beta-hydroxybutyric acid.  These acids are eliminated by the kidneys or are metabolized by the liver.  The capacity for elimination of these metabolic acids is much lower than that of the lungs.  In respiratory acidosis and most cases of metabolic acidosis, the kidneys excrete hydrogen ion and conserve bicarbonate to correct the pH.

A patient has a respiratory rate of 20.  The nurse calculates this patient's minute ventilation to be:

1. 10 L/min

2. 5 L/min

3. 2 L/min

4. 1 L/min

1. 10 L/min

Rationale:  The amount of ventilation is generally quantified by how much air the lungs move in one minute, referred to as the minute ventilation.  Minute ventilation is the product of respiratory rate and depth, referred to as the tidal volume.  Normal resting respiratory rate is about 12 breaths per minute.  Normal resting tidal volume is about 500 mL.  This yields a normal minute ventilation of 6 L/min:  12 breaths/min x 500mL = 6,000 mL or 6 L.  This patient's respiratory rate is 20 breaths per minute.  The minute ventilation would be 10 L/min.

The nurse, admitting a patient with diabetes, believes the patient is attempting to correct an acidotic condition.  Which of the following did this nurse most likely observe while assessing this patient?

1. Intact extraocular movements

2. Change in level of consciousness

3. Slow methodical respirations

4. Deep, rapid respirations

4. Deep, rapid respirations

Rationale:  In a state of metabolic acidosis, such as that which exists during diabetic ketoacidosis, the medullary centers will stimulate the lungs to increase the minute ventilation to blow off CO2, even if that level is normal.  These rapid, deep respirations, referred to as Kussmaul's respirations, are an attempt to correct the arterial pH by decreasing respiratory acid.  This process is referred to as compensation.

The nurse is caring for a patient with metabolic acidosis. The nurse realizes that which of the following laboratory values might be altered for this patient?

1. Prothrombin

2. Creatinine

3. Ammonia

4. Blood-urea-nitrogen

3. Ammonia

Rationale:  In the face of a high load of metabolic acids, the kidneys also increase their production of the urinary buffer, ammonia.  Under normal circumstances, ammonia excretion is about 30 mmol/day, or about 0.5 mmol/kg.  this excretion can increase to about 280 mmol/day, but this response takes several days to be completed.

The nurse is reviewing a patient's arterial blood gas results.  Which of the following values should the nurse study first?

1. pH

2. PaCO₂

3. compensation

4. HCO₃

1. pH

Rationale:  The steps to analyze an ABG result are as follows:

Step 1: Assess the pH

Step 2: Assess the PaCO₂

Step 3: Assess the bicarbonate and the base excess

Step 4: Evaluate compensation

The nurse is caring for a patient with pneumonia who has ABG values of:  pH 7.20, PaCO₂ 75, PaO₂ 44.  Which of the following would be a priority for this patient?

1. Placement of the patient in high-Fowler's position

2. Assisting the patient to breathe into a paper bag

3. Preparing to administer Sodium Bicarbonate IV

4. Administration of the prn sedative available

1. Placement of the patient in high-Fowler's position

Rationale:  The patient is in respiratory acidosis.  The main treatment for respiratory acidosis is correction of the underlying disorder that led to its development.  for a patient with pneumonia, this would include antibiotic therapy, improving oxygenation, and management of fever.  Placing the patient in high-Fowler's position will improve air flow.  Breathing into a paper bag and/or giving a sedative are indications for respiratory alkalosis.  Sodium bicarbonate administered intravenously is a controversial treatment for metabolic acidosis.

A patient is admitted in respiratory acidosis secondary to barbituate overdose.  Which of the following will the nurse most likely assess in this patient?

1. Kussmaul's respirations

2. Slow, shallow respirations

3. Increased deep tendon reflexes

4. Seizures

2. Slow, shallow respirations

Rationale:  Whenever excretion of CO2 via the lungs fails to keep up with the body's CO2 production, such as with drug overdose, respiratory acidosis will occur.  

Kussmaul respirations (rapid, deep breaths) occur with metabolic acidosis, seizures are associated wtih respiratory alkalosis, and hyperreflexia is a symptom of metabolic alkalosis.

The nurse is providing discharge instructions to a patient with respiratory alkalosis.  Which of the following statements indicates the patient understands the instructions?

1. "I will call my MD the next time I have diarrhea for a few days."

2. "I will not use Mylanta 5-6 times a day like I used to."

3. "I will not take my Lasix without a potassium supplement."

4. "I will take a stress management class or seek counseling."

4. "I will take a stress management class or seek counseling."

Rationale:  Respiratory alkalosis is characterized by a lower than normal PaCO₂ accompanied by an elevated pH.  Respiratory rate is a major determinate of the PACO₂ level.  Excessively fast or deep ventilation "blows off" the carbon dioxide, decreasing the level and increasing the pH causing alkalosis.  Psychological conditions such as anxiety and panic or severe pain can also cause overventilation.  Patients with psychological hyperventilation syndromes should benefit from reassurance and methods to decrease stress.

The amount of tidal volume taken in that remains in the trachea and bronchi without participating in gas exchange is called:

1. Base excess

2. Compensation

3. Anatomic dead space

4. Minute ventilation

3. Anatomic dead space

Lactic acid

Pyruvic acid

Ketoacids

Acetoacetic acid

Beta-hydroxybuyric acid

In the medulla.

It controls the rate and depth of ventilation.  Chemoreceptors respond to changes in PaCO₂ levels.

A patient, being discharged, will need to receive antibiotic therapy for an additional three weeks.  The peripheral vascular access device that would be the best for this patient would be.

1. A PICC line

2. A peripheral short catheter

3. A winged steel infusion set

4. A midline catheter

4. A midline catheter

Rationale:  A midline catheter is the best peripheral vascular access device for parenteral therapy up to 4 weeks.  

A peripheral short catheter is for infusions that last between 72 to 96 hours.  A winged steel infusion set is for infusions of less than 4 hours in duration.  A PICC line is a central venous access device and not a peripheral vascular access device.

A patient receiving parenteral fluids is prescribed an intravenous medication to be infused every 6 hours.  Which of the following infusion devices should the nurse use for this medication?

1. Elastomeric balloon

2. Stop cock

3. Secondary administration set

4. Extension set

4. Secondary administration set

Rationale:  The secondary administration set is the device used to administer an intravenous medication when the patient is already receiving parenteral therapy. This administration set is piggybacked inot the main infusion line.

A stop cock and extension set are add-on devices which might not be necessary for the infusion of the medication.  An elastomeric balloon is a one-time use device seen most frequently in home care.

The staff development department is planning an annual skills review day for the basics of intravenous therapy.  If the Infusion Nursing Standards of Practice are being followed, the purpose of this skills day would be to:

 1. Ensure that the nurses are in compliance with all regulatory agencies.

2. Ensure that the nurse's skill levels are adequate

3. Ensure that all nurses follow Standard Precautions

4. Preserve the patient's right to safe quality care and protect the nurse who administers infusion therapy.

4. Preserve the patient's right to safe quality care and protect the nurse who administers infusion therapy.

Rationale:  The primary goal of the Infusion Nursing Standards of Practice is to preserve the patient's right to safe, quality care and protect the nurse who administers infusion therapy.  Even though it is important for nurses to follow Standard Precautions, be in compliance with all regulatory agencies, and have adequate skill levels, these are not Standards of Practice of the Infusion Nursing organization.

A patient is prescribed parenteral fluid therapy.  Which of the following should the nurse do first?

1. Review the procedure with the patient and obtain consent.

2. Prepare the flush to use once the peripheral access device is in place. 

3. Gather the equipment to insert the peripheral access device.

4. Wash hands

1. Review the procedure with the patient and obtain consent.

Rationale:  The first thing the nurse should do is review the procedure wiht the patient or conduct education, and then obtain the patient's consent to have the access device inserted.  Once this has been done, the nurse can then gather equipment and prepare flushes all using Standard Precautions.

A patient receiving parenteral fluid therapy complains of the arm "feeling cold" and the dressing "feeling tight".  What should the nurse do?

1. Turn off the infusion, reposition the catheter

2. Stop the infusion and remove the catheter

3. Change the dressing and observe the site

4. Check for a blood return in the catheter

2. Stop the infusion and remove the catheter

Rationale: This patient is complaining of an infiltration of the parenteral fluids.  The nurse should discontinue the infusion immediately and remove the catheter.  The nurse should then elevate the affected extremity to relieve patient discomfort and assist in absorption of excess fluids and improving circulation.  The nurse should not take the time to check for a blood return, reposition the catheter, or change the dressing and observe the site.