Professional Documents
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BALANCE
100 ITEMS
1. What is the nurse's primary concern
regarding fluid & electrolytes when caring for
an elderly pt who is intermittently confused?
A. risk of dehydration
B. risk of kidney damage
C. risk of stroke
D. risk of bleeding
Answer: 1
Rationale 1: As an adult ages, the thirst
mechanism declines. Adding this in a pt with
an altered level of consciousness, there is an
increased risk of dehydration & high serum
osmolality.
Rationale 2: The risks for kidney damage are
not specifically related to aging or fluid &
electrolyte issues.
Rationale 3: The risk of stroke is not
specifically related to aging or fluid &
electrolyte issues.
Rationale 4: The risk of bleeding is not
specifically related to aging or fluid &
electrolyte issues.
2. The nurse is planning care for a pt with
severe burns. Which of the following is this pt
at risk for developing?
A. intracellular fluid deficit
B. intracellular fluid overload
C. extracellular fluid deficit
D. interstitial fluid deficit
Answer: 1
Rationale 1: Because this pt was severely
burned, the fluid within the cells is
diminished, leading to an intracellular fluid
deficit.
Rationale 2: The intracellular fluid is all fluids
that exist within the cell cytoplasm &
nucleus. Because this pt was severely
burned, the fluid within the cells is
diminished, leading to an intracellular fluid
deficit.
Rationale 3: The extracellular fluid is all fluids
that exist outside the cell, including the
interstitial fluid between the cells. Because
this pt was severely burned, the fluid within
the cells is diminished, leading to an
intracellular fluid deficit.
Rationale 4: The extracellular fluid is all fluids
that exist outside the cell, including the
interstitial fluid between the cells. Because
this pt was severely burned, the fluid within
the cells is diminished, leading to an
intracellular fluid deficit.
C. 1000 mL
D. 1200 mL
Answer: 1
Rationale 1: A urine output of less than 30
mL per hour must be reported to the primary
healthcare provider. This indicates
inadequate renal perfusion, placing the pt at
increased risk for acute renal failure &
inadequate tissue perfusion. A minimum of
720 mL over a 24-hour period is desired (30
mL multiplied by 24 hours equals 720 mL per
24 hours).
6. A pt is receiving intravenous fluids
postoperatively following cardiac surgery.
Nursing assessments should focus on which
postoperative complication?
A. fluid volume excess
B. fluid volume deficit
C. seizure activity
D. liver failure
Answer: 1
Rationale 1: Antidiuretic hormone &
aldosterone levels are commonly increased
following the stress response before, during,
& immediately after surgery. This increase
leads to sodium & water retention. Adding
more fluids intravenously can cause a fluid
volume excess & stress upon the heart &
circulatory system.
Rationale 2: Adding more fluids intravenously
can cause a fluid volume excess, not fluid
volume deficit, & stress upon the heart &
circulatory system.
Rationale 3: Seizure activity would more
commonly be associated with electrolyte
imbalances.
Rationale 4: Liver failure is not anticipated
related to postoperative intravenous fluid
administration.
7. A pt is diagnosed with severe
hyponatremia. The nurse realizes this pt will
mostly likely need which of the following
precautions implemented?
A. seizure
B. infection
C. neutropenic
D. high-risk fall
Answer: 1
Rationale 1: Severe hyponatremia can lead
to seizures. Seizure precautions such as a
quiet environment, raised side rails, & having
an oral airway at the bedside would be
included.
Rationale 2: Infection precautions not
specifically indicated for a pt with
hyponatremia.
Rationale 3: Neutropenic precautions not
Answer: 1
Rationale 1: The nursing care for a pt with
hyponatremia is dependent on the cause.
Restriction of fluids to 1,000 mL/day is
usually implemented to assist sodium
increase & to prevent the sodium level from
dropping further due to dilution.
Rationale 2: The administration of
intravenous fluids would be indicated in fluid
volume deficit & hypernatremia.
Rationale 3: Kayexalate is used in pts with
hyperkalemia.
Rationale 4: The administration of normal
saline with furosemide is used to increase
calcium secretion.
11. When caring for a pt diagnosed with
hypocalcemia, which of the following should
the nurse additionally assess in the pt?
A. other electrolyte disturbances
B. hypertension
C. visual disturbances
D. drug toxicity
Answer: 1
Rationale 1: The pt diagnosed with
hypocalcemia may also have high
phosphorus or decreased magnesium levels.
Rationale 2: The pt with hypocalcemia may
exhibit hypotension, & not hypertension.
Rationale 3: Visual disturbances do not occur
with hypocalcemia.
Rationale 4: Hypercalcemia is more
commonly caused by drug toxicities.
12. A pt with a history of stomach ulcers is
diagnosed with hypophosphatemia. Which of
the following interventions should the nurse
include in this pt's plan of care?
A. Request a dietitian consult for selecting
foods high in phosphorous.
B. Provide aluminum hydroxide antacids as
prescribed.
C. Instruct pt to avoid poultry, peanuts, &
seeds.
D. Instruct to avoid the intake of sodium
phosphate.
Answer: 1
Rationale 1: Treatment of hypophosphatemia
includes treating the underlying cause &
promoting a high phosphate diet, especially
milk, if it is tolerated. Other foods high in
phosphate are dried beans & peas, eggs,
fish, organ meats, Brazil nuts & peanuts,
poultry, seeds & whole grains.
Rationale 2: Phosphate-binding antacids,
such as aluminum hydroxide, should be
avoided.
Rationale 3: Poultry, peanuts, & seeds are
part of a high phosphate diet.
Rationale 4: Mild hypophosphatemia may be
C. potassium
D. Chloride
Answer: 1
Rationale 1: Excessive serum phosphate
levels cause few specific symptoms. The
effects of high serum phosphate levels on
nerves & muscles are more likely the result
of hypocalcemia that develops secondary to
an elevated serum phosphorus level. The
phosphate in the serum combines with
ionized calcium, & the ionized serum calcium
level falls.
37. The nurse is reviewing a pt's blood pH
level. Which of the systems in the body
regulate blood pH? Select all that apply.
A. renal
B. cardiac
C. buffers
D. Respiratory
Answer: 1,3
Rationale 1: Three systems work together in
the body to maintain the pH despite
continuous acid production: buffers, the
respiratory system, & the renal system.
Rationale 2: The cardiac system is
responsible for circulating blood to the body.
It does not help maintain the body's pH.
Rationale 3: Three systems work together in
the body to maintain the pH despite
continuous acid production: buffers, the
respiratory system, & the renal system.
Rationale 4: Three systems work together in
the body to maintain the pH despite
continuous acid production: buffers, the
respiratory system, & the renal system.
38. The nurse observes a pt's respirations &
notes that the rate is 30 per minute & the
respirations are very deep. The metabolic
disorder this pt might be demonstrating is
which of the following?
A. hypernatremia
B. increasing carbon dioxide in the blood
C. hypertension
D. Pain
Answer: 2
Rationale 1: Hypernatremia is associated
with profuse sweating & diarrhea.
Rationale 2: Acute increases in either carbon
dioxide or hydrogen ions in the blood
stimulate the respiratory center in the brain.
As a result, both the rate & depth of
respiration increase. The increased rate &
depth of lung ventilation eliminates carbon
dioxide from the body, & carbonic acid levels
fall, which brings the pH to a more normal
range.
A. respiratory acidosis
B. metabolic acidosis
C. respiratory alkalosis
D. metabolic alkalosis
Answer: 1
Rationale 1: Acute respiratory acidosis occurs
due to a sudden failure of ventilation.
Overdoses of narcotic or sedative
medications can lead to this condition.
Rationale 2: The pt condition being described
is respiratory not metabolic in nature.
Rationale 3: Acute respiratory acidosis occurs
due to a sudden failure of ventilation.
Overdoses of narcotic or sedative
medications can lead to this condition.
Rationale 4: Acute respiratory acidosis occurs
due to a sudden failure of ventilation.
Overdoses of narcotic or sedative
medications can lead to this condition. The
pt condition being described is respiratory
not metabolic in nature.
42. The pt has been placed on a 1200 mL
daily fluid restriction. The pt's IV is infusing
at a keep open rate of 10 mL/hr. The pt has
no additional IV medications. How much fluid
should the pt be allowed from 0700 until
1500 daily?
A. 540 ml
B. 300 ml
C. 600 ml
D. 590 ml
Answer: 540
Rationale: Fluid allowed is calculated by
figuring the total daily IV intake (in this case
10 mL/hr 24 hours = 240 mL/day),
subtracting that total from the daily
allowance (in this case 1200mL - 240 mL =
960mL). The amount calculated is then
distributed as 50% for the traditional day
shift, 25%-35% for the traditional evening
shift, & the remainder for the traditional
night shift. In this case, 50% of 960 is 540
mL.
43. The pt is receiving intravenous potassium
(KCL). Which nursing actions are required?
Select all that apply.
A. Administer the dose IV push over 3
minutes.
B. Monitor the injection site for redness.
C. Add the ordered dose to the IV hanging.
D. Use an infusion controller for the IV.
E. Monitor fluid intake & output.
Answer: 2,4,5
44. Which pts are at risk for the development
of hypercalcemia? Select all that apply.
dependent
c. A 56-year-old new admission client with
diabetic ketoacidosis (DKA) on a n insulin
drip
d. A 38-year-old client on a ventilator with
narcotic overdose and respiratory alkalosis
13. ANSWER B The client with COPD,
although ventilator dependent, is the most
stable of this group. Clients with acid-base
imbalances often require frequent laboratory
assessment and changes in therapy to
correct their disorders. In addition, the client
with DKA is a new admission and will require
an in-depth admission assessment. All three
of these clients need care from an
experienced critical care nurse.
61.A client with respiratory failure is
receiving mechanical ventilation and
continues to produce ABG results indicating
respiratory acidosis. Which action should you
expect to correct this problem?
a. Increase the ventilator rate from 6 to 10
per minute
b. Decrease the ventilator rate from 10 to 6
per minute
c. Increase the oxygen concentration for 30%
to 40%
d. Decrease the oxygen concentration for
40% to 30%
14. ANSWER A the blood gas
component responsible for respiratory
acidosis is CO2 (Carbon dioxide). Increasing
the ventilator rate will blow off more CO2
and decrease the acidosis. Changes in the
oxygen setting may improve oxygenation but
will not affect respiratory acidosis.
62.Which action should you delegate to the
nursing assistant for the client with diabetic
ketoacidosis? (Choose all that apply.)
a. Check fingerstick glucose every hour.
b. Record intake and output every hour.
c. Check vital signs every 15 minutes.
d. Assess for indicators of fluid imbalance.
15. ANSWER B, C The nursing
assistants training and education include
how to take vital signs and record intake and
output. The need to take vital signs this
frequently indicates that the client maybe
unstable. The nurse should give the nursing
assistant reporting parameters when
delegating this action, should also check the
vital signs for indications in instability.
Performing fingerstick glucose checks and
assessing clients require additional education
and skill that are appropriate to licensed
nurses. Some facilities may train
experienced nursing assistants to perform
fingerstick glucose checks and change their
role descriptions to designate their new
skills, but this is beyond the normal scope of
practice for a nursing assistant.
63.You are admitting an elderly client to the
medical unit. Which factor indicates that this
client has a risk for acid-base imbalances?
a.
alkalosis
b.
alkalosis
c.
alkalosis
d.
alkalosis
Uncompensated metabolic
Uncompensated respiratory
Compensated respiratory
Compensated metabolic
86.
or
C. Partially Compensated
87.
88.
or
89.
90.
or
91.
92.
or
93.
94.
or
95.
96.
or
97.
98.
or
99.
100.
or
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