CH28
A. HYPOXIA
B. HYPERCAPNIA
C. DYSPNEA
D. HYPOXEMIA
The nurse points out that nonelectrolyte products of metabolism are as important to health as electrolytes. Nonelectrolytes include:
a. magnesium.
b. amino acids.
c. calcium.
d. phosphates.
b. amino acids.
The nonelectrolytes that are products of metabolism and serve to promote health in the body are amino acids, glucose, and fatty acids.
The nurse is aware that small ions such as glucose, oxygen, and carbon dioxide redistribute themselves through semipermeable membranes by a process called:
a. diffusion.
b. osmosis.
c. blood pressure.
d. rehydration.
A
Glucose, oxygen, carbon dioxide, and other small ions diffuse through membranes until they are evenly distributed.
An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to:
a. sit up.
b. lie down.
c. breathe through a re-breather mask.
d. pant with mouth open.
C.
Anxiety can lead to hyperventilation, causing respiratory alkalosis; the treatment is to have the patient breathe through a re-breather mask. In the home setting, the patient can be asked to breathe into a paper bag.
A patient drank a cup of coffee, a half glass of orange juice, and half a carton of milk with breakfast. Using common equivalents of food containers as a guide, the nurse notes on the intake column of the intake and output sheet that the patient consumed:
a. 360 mL.
b. 400 mL.
c. 420 mL.
d. 600 mL.
C
A coffee cup is generally equivalent to 240 mL, a half glass of juice is 60 mL, and half a carton of milk is 120 mL
A 10-month old infant has had watery green stool for 2 days and refuses the bottle. The nurse is aware that the primary concern for this baby is?
A. metabolic acidosis.
b. metabolic alkalosis.
c. weight loss.
d. diaper rash.
A. metabolic acidosis.
Loss of bowel contents leads to metabolic acidosis. The child will lose weight and will probably have diaper rash, but the primary concern is the electrolyte imbalance.
The nurse assesses that the patient has developed abdominal pain, urinary retention, and confusion. The nurse concludes these signs are the results of an inadequate supply of:
a. calcium (Ca2+).
b. sodium (NA+).
c. phosphates (PO43).
d. potassium (K+).
d. potassium (K+).
The symptoms of a potassium level below 3.5 mEq/L are abdominal pain, urinary retention, confusion, decreased reflexes, and ECG changes.
A patient with healthy kidneys experiences metabolic alkalosis resulting from episodes of vomiting. The nurse takes into consideration that the kidneys can clear the alkaline substances and fully stabilize the patient’s pH in approximately:
a. 3 to 5 minutes.
b. 12 to 24 hours.
c. 3 days.
d. 1 week.
C
The compensatory ability of the kidneys takes more time to work than does the compensatory action of the lungs; 3 days are needed for the kidneys to stabilize pH within normal range.
The nurse is aware that a more dynamic process that moves molecules into cells regardless of their electrical charge or concentration in the cell is:
a. filtration.
b. osmosis.
c. active transport.
d. hydrostatic pressures.
C
Active transport can move molecules into cells regardless of their electrical charge or concentration already in the cell.
At the beginning of the shift, a patient’s IV bag has 960 mL remaining. The IV fluid is running at 75 mL/hr. In 8 hours, there should be how many milliliters remaining in the IV bag?
a. 150
b. 360
c. 450
d. 600
B
5 mL/hr 0´ 8 hours = 600; 960 - 600 = 360.
The patient who was admitted after vomiting for 3 days would show an abnormally low blood pressure because of a fluid shift from:
a. intracellular to the extracellular.
b. interstitial to intravascular.
c. intravascular to the interstitial.
d. interstitial to the intracellular.
c. intravascular to the interstitial.
If intravascular fluid, a type of extracellular fluid within the blood vessels, shifts from the plasma in the vascular space out to the interstitial space, a drop in blood volume occurs.
A nurse gets a positive Chvostek sign on a young woman with bulimia who has been giving herself frequent enemas containing phosphate. The nurse anticipates a laboratory finding of:
a. sodium 140 mEq/L.
b. potassium 4.5 mEq/L.
c. magnesium 1.6 mEq/L.
d. calcium 6.5 mEq/L.
d. calcium 6.5 mEq/L.
The low level of calcium is responsible for the sign. The positive Chvostek sign is an indicator of a reduced calcium level.
A patient with a history of severe chronic obstructive pulmonary disease (COPD) is most likely to have:
a. respiratory alkalosis.
b. respiratory acidosis.
c. metabolic alkalosis.
d. metabolic acidosis.
B
People with COPD are prone to chronic respiratory acidosis because of the retained CO2.
For the accurate measurement to detect fluid retention, the nurse instructs the nursing assistants to measure the weight with the same scale:
a. each morning before breakfast after the patient has voided.
b. each day at noon before lunch, dressed in light clothing.
c. in between meals, dressed in light clothing after voiding.
d. just before bedtime, while the patient is in a hospital gown or pajamas.
A
Weight is measured at the same time every morning on the same scale, after the patient has voided and before eating.
The primary care provider orders fluid restriction for a patient with severe fluid volume excess. When a patient is placed on a fluid restriction, the allowance of fluids should be:
a. greatest during the day shift.
b. greatest during the evening shift.
c. greatest during the night shift.
d. spaced in equal increments for all shifts
A.
The greatest amount of fluid is given during the day shift, followed by the evening shift. The least amount of fluid is given at night, when the patient should be sleeping.
An isotonic state exists within a patient’s body fluids when the solute concentration of:
a. interstitial fluid is less than the transcellular.
b. intracellular and extracellular fluid is equal.
c. intracellular fluid is greater than extracellular fluid.
d. extracellular fluid is lesser than intracellular fluid.
b. intracellular and extracellular fluid is equal
When the intracellular and extracellular fluid has the same concentration of particles, the solution is called isotonic (equal solute concentration)
patient has been identified as having a dietary deficiency of vitamin D. The nurse understands that this patient is also at risk for having a deficiency of:
a. calcium.
b. magnesium.
c. sodium.
d. potassium.
a. calcium.
Nutritional deficiency of vitamin D can result in hypocalcemia because of the patient’s inability to absorb calcium.
A patient with heart failure has gained 1.1 pounds over the last 24 hours. The nurse is aware that this weight gain represents a fluid retention of:
a. 0.25 L.
b. 0.5 L.
c. 1.0 L.
d. 2.0 L.
B
Each 2.2 pounds of weight equals 1 kg, which in turn equals 1.0 L of fluid. Therefore 1.1 pounds equals 0.5 kg and is equal to 0.5 L of fluid.
The nurse is aware that the patient who suffered a brain injury with cerebral edema will most likely receive a fluid that is:
a. isotonic.
b. hypertonic.
c. hypotonic.
d. enhanced with vitamin B.
B
Hypertonic fluids draw fluid from the intracellular space and reduce edema
The nurse is aware that an infant is more at risk for dehydration because the infant:
a. has kidneys that reabsorb water from the intravascular space.
b. has a larger body surface compared with body weight.
c. urinates more frequently.
d. has fat that absorbs water.
b. has a larger body surface compared with body weight.
Infants are more at risk for dehydration because they have a larger body surface compared with body weight. Their immature kidneys cannot reabsorb water as well as an adult, and fat does not absorb water.
The nurse explains that the dehydrated patient’s urine is concentrated because:
a. renal tubules reabsorb more water and reduce urine output.
b. kidneys cease to function.
c. blood pressure drops.
d. the colon retains more fluid from the fecal waste.
a. renal tubules reabsorb more water and reduce urine output.
When dehydration occurs, the renal tubules of the kidney reabsorb more water to be returned to the circulating volume, making the urine concentrated.
A patient who is experiencing severe diarrhea is losing excessive bicarbonate ions. This patient is at risk for developing:
a. respiratory alkalosis.
b. respiratory acidosis.
c. metabolic alkalosis.
d. metabolic acidosis.
D
Metabolic acidosis can be caused by either an excessive loss of bicarbonate ions or an excessive retention of hydrogen ions.
The nurse is comparing sitting and standing vital signs for a patient who has been diagnosed with dehydration. The pulse rate has increased by 10 beats/min at 1 minute. The nurse then anticipates the blood pressure to show a(n):
a. increase of 5 mm Hg.
b. drop of 40 mm Hg.
c. drop of 20 mm Hg.
d. increase of 10 mm Hg.
C
A drop in systolic blood pressure by at least 20 mm Hg accompanied by a pulse rate increase of at least 10 beats/min at 1 minute following position change is suggestive of fluid volume deficit.
The patient who is prescribed a diuretic for fluid volume excess is discharged home. The patient verbalizes understanding of his disease process when he says:
a. “I can put catsup on my scrambled eggs.”
b. “I can snack on salted popcorn.”
c. “I will snack on raisins.”
d. “I will avoid apricots.”
C
The patient will lose electrolytes, especially potassium, because he is on a diuretic; snacks such as raisins and apricots are rich in potassium