Electrolytes
A client is admitted with a serum potassium level of 6.5 mEq/L. Which of the following orders should the nurse question?
Answer: B. Administer potassium chloride IV push. (This would worsen the hyperkalemia.)
A patient with chronic respiratory disease has the following ABG: pH 7.36, PaCO2 52 mmHg, HCO3 28 mEq/L. What does this indicate?
B. Compensated respiratory acidosis (The pH is normal but on the acidic side, PaCO2 is high, and HCO3 is elevated, indicating compensation.)
Which clinical manifestation would the nurse expect to see in a client with hypervolemia?
B. Crackles in the lungs and edema. (These are classic signs of fluid overload.)
Which of the following patients is most likely experiencing chronic pain?
A. A patient with a fractured arm from a fall this morning
B. A patient with lower back pain that has lasted for 8 months
C. A patient experiencing chest pain with shortness of breath
D. A post-op patient reporting incisional pain 1 day after surgery
Correct Answer: B
Rationale:
Pain lasting longer than 3–6 months is considered chronic. The other examples describe acute pain, which is sudden and short-term.
Which of the following are classified as isotonic IV fluids? SATA
A. Normal Saline (0.9% NaCl)
B. Lactated Ringer’s (LR) are both isotonic solutions because they have a similar osmolarity to the blood, and they don't cause fluid shifts between compartments.
C. D5W (5% Dextrose in Water) is initially isotonic but becomes hypotonic once the dextrose is metabolized, which is why it is often debated for classification. However, it's commonly used as an isotonic fluid for initial administration before metabolism.
The nurse is caring for a client with hypermagnesemia. Which of the following symptoms would the nurse expect?
A client’s ABG results are: pH 7.35, PaCO2 48 mmHg, HCO3 30 mEq/L. What does this indicate?
Answer:
A client with a sodium level of 156 mEq/L is confused and thirsty. What is the priority nursing action?
A nurse is assessing pain in a patient who just had abdominal surgery. Which question is the most appropriate to determine the intensity of the patient’s pain?
A. "Can you describe what your pain feels like?"
B. "On a scale of 0 to 10, how would you rate your pain?"
C. "What makes your pain worse?"
D. "Does your pain radiate anywhere else?"
Correct Answer: B
Rationale:
This question uses the numeric rating scale (NRS) to assess pain intensity, which is standard in nursing practice. Other options assess quality, aggravating factors, or pain location, not intensity.
A patient with hyponatremia is ordered 3% NaCl IV. What is the most important nursing action?
A. Monitor for signs of dehydration
B. Check hourly urine output
C. Infuse rapidly to raise sodium quickly
D. Monitor for fluid overload and neurological changes
Correct Answer: D. Monitor for fluid overload and neurological changes
Rationale:
Hypertonic fluids like 3% NaCl pull water out of cells. They must be given slowly and carefully, often in critical care, and require close monitoring to prevent fluid overload or cerebral demyelination.
A nurse is caring for a client with hypernatremia. Which of the following would the nurse prioritize in the care plan?
Answer: B. Providing oral fluids and monitoring intake and output.
(The primary treatment for hypernatremia is restoring fluid balance.)
A client is admitted with a respiratory rate of 28 breaths per minute due to anxiety. What intervention should the nurse implement first?
Answer:
A client is admitted with a heart rate of 115 bpm, low blood pressure, and dry mucous membranes. What is the priority intervention?
Answer:
An older adult client recovering from abdominal surgery is hesitant to take pain medication, stating, “I don’t want to get addicted.” What is the nurse’s best response?
A. “You should take it anyway so you don’t bother the staff.”
B. “Addiction isn’t common when medications are used properly for acute pain.”
C. “I’ll remove the medication from your chart if you don’t want it.”
D. “Maybe just try non-pharmacologic methods and avoid medication completely.”
Correct Answer: B.
Rationale: Education about appropriate pain management is important. Reassuring the client that addiction is unlikely when pain medication is used short-term and as prescribed helps reduce fear and encourages comfort.
A client’s IV rate is set to deliver 1,000 mL over 8 hours with tubing that has a drip factor of 15 gtt/mL. What is the drip rate in drops per minute (gtt/min)?
Answer: B. 31 gtt/min. (1,000 ÷ 480 × 15 = 31.25, rounded to 31.)
A client with a sodium level of 118 mEq/L is being treated with hypertonic saline (3%). Which of the following symptoms would indicate rapid correction of hyponatremia?
Answer: D. Neurological symptoms such as seizures.
(Rapid correction of sodium levels can lead to osmotic demyelination syndrome.)
A client with COPD is admitted with ABGs showing pH 7.31, PaCO2 60 mmHg, and HCO3 24 mEq/L. What is the priority intervention?
Answer:
Which finding is the most reliable indicator of a client’s hydration status?
Answer:
A nurse is assessing a nonverbal older adult for signs of pain. Which of the following are nonverbal indicators of pain?
Select all that apply.
A. Grimacing
B. Increased heart rate
C. Laughing
D. Guarding a body part
E. Restlessness
F. Refusing to eat
Correct Answers:
A. Grimacing
B. Increased heart rate
D. Guarding a body part
E. Restlessness
F. Refusing to eat
Rationale:
Nonverbal signs of pain include facial expressions like grimacing, physiological changes (e.g., increased heart rate), behavioral changes (guarding, restlessness), and decreased appetite. Laughing is not a typical indicator of pain.
A nurse notices that a patient has a red, swollen, and warm IV insertion site. What is the most likely cause?
Correct Answer: B. Phlebitis
Rationale:
A 45-year-old client with chronic kidney disease presents with muscle weakness and an irregular heartbeat. Their potassium level is 6.8 mEq/L. Which nursing interventions are appropriate? (Select all that apply.)
(Explanation: Hyperkalemia requires urgent interventions like cardiac monitoring, insulin with dextrose to shift potassium intracellularly, Kayexalate to remove potassium, and dietary restrictions. IV potassium chloride would worsen the hyperkalemia.)
A nurse is caring for a client with COPD. Which findings are consistent with respiratory acidosis? (Select all that apply.)
Answers:
An 82-year-old client is admitted with dehydration and reports dizziness and fatigue. Which assessment findings are consistent with fluid volume deficit? (Select all that apply.)
Answer:
(Explanation: Dehydration causes delayed capillary refill, flattened neck veins, hypotension, and dry oral mucosa. Bounding pulses are associated with fluid volume excess.)
A nurse is assessing a client who is experiencing acute pain. Which of the following are expected physiological responses to acute pain?
Select all that apply.
A. Increased heart rate
B. Decreased respiratory rate
C. Diaphoresis
D. Hypertension
E. Pupil constriction
F. Increased blood glucose
A. Increased heart rate
C. Diaphoresis
D. Hypertension
F. Increased blood glucose
Rationale:
Acute pain activates the sympathetic nervous system, causing increased HR, BP, diaphoresis, and elevated blood glucose. Respiratory rate typically increases, and pupils dilate—not constrict.
Fluid Type | Match to Use Case
0.9% NS | A. Cellular dehydration (e.g., DKA)
0.45% NaCl | B. Hypovolemia or blood loss
D5W (initially) | C. Hypernatremia
3% NaCl | D. Symptomatic hyponatremia
Answers:
0.9% NS → B
0.45% NaCl → A
D5W → C
3% NaCl → D
0.9% NS → B. Hypovolemia or blood loss
Rationale:
0.9% Normal Saline is isotonic, meaning it stays in the intravascular and interstitial space and expands extracellular volume without shifting fluid into or out of cells. It's commonly used for hypovolemia, dehydration, blood loss, and during blood transfusions because it won’t cause hemolysis of red blood cells.
0.45% NaCl → A. Cellular dehydration (e.g., DKA)
Rationale:
0.45% Normal Saline is a hypotonic solution. It shifts water into the cells, making it ideal for treating cellular dehydration, such as in diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic states (HHS), where intracellular fluid is depleted.
D5W (initially isotonic, then hypotonic) → C. Hypernatremia
Rationale:
D5W (5% dextrose in water) is isotonic in the bag but becomes hypotonic once the dextrose is metabolized. It leaves behind free water that moves into cells, helping dilute high sodium levels. It's useful in treating hypernatremia, but caution is needed in patients at risk of increased intracranial pressure.
3% NaCl → D. Symptomatic hyponatremia
Rationale:
3% Normal Saline is hypertonic and pulls water out of cells into the extracellular space. It is used cautiously in severe or symptomatic hyponatremia (e.g., with seizures or confusion) to raise serum sodium. Frequent monitoring of sodium levels and neurologic status is critical to avoid complications like osmotic demyelination syndrome.