Brunner: Medical-Surgical Nursing, 11th Edition

Test Bank

Chapter 14 : Fluid and Electrolytes: Balance and Disturbance

Multiple Choice

1. A nurse is caring for a patient who requires measurement of specific gravity every 4 hours.
What does this test detect?
A) Nutritional deficit
B) Hyperkalemia
C) Hypercalcemia
D) Fluid volume status

Ans: D
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Patient Needs: D-4
Feedback: A specific gravity will detect if the patient has a fluid volume deficit or fluid volume
excess. This will not detect hyperkalemia, hypercalcemia, or nutritional deficits.

2. Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?
A) Diminished deep tendon reflexes
B) Tachycardia
C) Cool clammy skin
D) Increased serum magnesium

Ans: A
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-4
Feedback: To gauge a patient's magnesium status, the nurse should check deep tendon reflexes.
If the reflex is absent, this may indicate high serum magnesium.

3. A patient is receiving furosemide (Lasix) 40 mg/d IV. What electrolyte value should be
monitored when a patient is receiving a loop diuretic?
A) Calcium levels
B) Phosphorous levels
C) Potassium levels
D) Magnesium levels

Ans: C
Chapter: 14
Cognitive Level: Analysis
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-2
Feedback: The diuretics act on the ascending loop of Henle to prevent re-absorption of water,
potassium, and sodium. Because of this, potassium and sodium levels should be monitored when
a patient is receiving diuretics.

4. The nurse is evaluating a patient's laboratory results. Based upon the laboratory findings, what
results will cause the release of an antidiuretic hormone (ADH)?
A) Increased serum sodium
B) Decreased serum sodium
C) Decrease in serum osmolality
D) Decrease in thirst

Ans: A
Chapter: 14
Cognitive Level: Analysis
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Patient Needs: D-4
Feedback: Increased serum sodium causes increased thirst and the release of ADH by the
posterior pituitary gland. When serum osmolality decreases and thirst and ADH secretions are
suppressed, the kidney excretes more water to restore normal osmolality.
5. Third spacing occurs when fluid moves out of the intravascular space but not into the
intracellular space. Based upon this fluid shift, the nurse will expect the patient to demonstrate:
A) Hypertension
B) Bradycardia
C) Hypervolemia
D) Hypovolemia

Ans: D
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-4
Feedback: Third-spacing fluid shift, which occurs when fluid moves out of the intravascular
space but not into the intracellular space, can cause hypovolemia.

6. The nurse working in the PACU is aware that which of the following procedures may
contribute to extracellular losses?
A) Removal of an ingrown toenail
B) Tooth extraction
C) Abdominal surgery
D) Cataract surgery

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-1
Feedback: Fluid loss from the extracellular compartment can be caused by abdominal surgery.

7. The renin and angiotensin systems help to maintain the balance of sodium and water in the
body. What other functions do these systems serve?
A) Regulating hemoglobin levels
B) Maintaining a healthy blood volume
C) Releasing platelets when tissues are injured
D) Lowering blood volumes

Ans: B
Chapter: 14
Cognitive Level: Comprehension
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-4
Feedback: The renin and angiotensin systems help to maintain the balance of sodium and water
in the body and maintain healthy blood volumes.

8. A patient's lab results show a slight decrease in potassium. The physician has declined to treat
with drug therapy but has suggested increasing the potassium through diet. Which of the
following would be a good source of potassium?
A) Apples
B) Asparagus
C) Carrots
D) Bananas

Ans: D
Chapter: 14
Cognitive Level: Application
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-1
Feedback: Bananas are high in potassium. Apples, carrots, and asparagus are not high in
potassium.

9. Your patient has alcoholism, and you may suspect during your assessment that his serum
magnesium is low. What will the nurse potentially expect to assess related to hypomagnesemia?
A) Tremor
B) Pruritus
C) Edema
D) Decreased blood pressure

Ans: A
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-4
Feedback: Chronic alcoholics are at risk for hypomagnesemia because they tend to eat a poor
diet. Signs and symptoms of hypomagnesemia are largely confined to the neuromuscular system
and include confusion, tremor, tetany, laryngeal stridor, and ataxia.

10. The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte
imbalance does a positive Chvostek's sign indicate?
A) Hypermagnesemia
B) Hypomagnesemia
C) Hypocalcemia
D) Hyperkalemia

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-1
Feedback: You can induce Chvostek's sign by tapping the patient's facial nerve adjacent to the
ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek's sign. Both
hypomagnesemia and hypocalcemia may be tested using the Chvostek's sign.

11. A patient with hypokalemia and heart failure is admitted to the telemetry unit. The nurse is
aware that hypokalemia could cause which of the following abnormalities on an
electrocardiogram (ECG)?
A) Shortened P-R interval
B) Inverted T wave
C) Depressed U wave
D) Elevated U wave

Ans: D
Chapter: 14
Cognitive Level: Analysis
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-4
Feedback: An elevated U wave is specific to hypokalemia.

12. A patient is in the hospital with heart failure. The nurse notes during the evening assessment
that the patient's neck veins are distended and the patient has dyspnea. What action should the
nurse take?
A) Place the patient in low Fowler's and notify the physician.
B) Increase the patient's IV fluid and auscultate the lungs.
C) Place the patient in semi-Fowler's and prepare to give the PRN diuretic as ordered.
D) Discontinue the patient's IV.

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-4
Feedback: The patient is exhibiting signs of fluid overload and should be placed in a semi-
Fowler's position; diuretics should be given as ordered.

13. A nurse sees a variety of patients in the community health clinic. Which of the following
patients would be at the greatest risk of dehydration?
A) An 18-year-old basketball player with a stress fracture of the right foot
B) An infant with diarrhea
C) A 45-year-old with stomach flu
D) An elderly patient living alone

Ans: B
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-3
Feedback: Infants are particularly vulnerable for dehydration. They cannot drink on their own,
and their kidneys are immature so they cannot concentrate urine efficiently. The elderly are also
at risk, for dehydration, but the infant is at greater risk.
14. A patient with diabetes insipidus is admitted to the intensive care unit after a motor vehicle
accident that resulted in head trauma and damage to the pituitary gland. Diabetes insipidus can
occur when there is a decreased production of which of the following?
A) ADH
B) Estrogen
C) Aldosterone
D) Renin

Ans: A
Chapter: 14
Cognitive Level: Comprehension
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Patient Needs: D-4
Feedback: In diabetes insipidus, the brain fails to secrete ADH, and the patient experiences
increased thirst, fluid intake, and urine production.

15. The nurse is caring for a patient who is diaphoretic from a fever. The amount of sodium
excreted in the urine will:
A) Decrease
B) Increase
C) Remain unchanged
D) Fluctuate

Ans: A
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-4
Feedback: When a patient is sweating, the body will compensate by secreting less sodium in the
urine.

16. The triage nurse notes upon assessment in the emergency room that the patient with anxiety
is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which
acid-base imbalance?
A) Respiratory acidosis
B) Respiratory alkalosis
C) Increased PaCO2
D) Central nervous system (CNS) disturbances

Ans: B
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 8
Patient Needs: D-4
Feedback: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme
anxiety can lead to hyperventilation.

17. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11
mEq/L. How would the nurse interpret the results?
A) Respiratory acidosis with no compensation
B) Metabolic alkalosis with a compensatory alkalosis
C) Metabolic acidosis with no compensation
D) Metabolic acidosis with a compensatory respiratory alkalosis

Ans: D
Chapter: 14
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 9
Patient Needs: D-4
Feedback: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO3 is also low,
which causes alkalosis. The bicarb is low, which causes acidosis. The pH bicarb more closely
corresponds with a decrease in pH, making the metabolic component the primary problem.

18. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion
site will document which complication related to IV therapy?
A) Air emboli
B) Phlebitis
C) Infiltration
D) Fluid overload
Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Easy
Integrated Process: Communication/Documentation
Objective: 11
Patient Needs: A-2
Feedback: Infiltration is the administration of nonvesicant solution or medication into the
surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the
vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the
insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the
flow rate.

19. What would be the best initial nursing actions prior to inserting an IV?
A) Have the patient wash the hands.
B) Prepare the IV insertion site with povidone iodine.
C) Verify the order for IV therapy.
D) Identify a suitable vein.

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 11
Patient Needs: A-2
Feedback: Prior to initiating an IV, the nurse should verify the physician's order for IV therapy.

20. The patient asks the nurse if he will die if air bubbles get into the IV tubing. What is the
nurse's best response?
A) “The system is closed and that is impossible.”
B) “Only relatively large volumes of air administered rapidly are dangerous.”
C) “There is a risk of complication with IV administration.”
D) “You watch too many movies.”

Ans: B
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 11
Patient Needs: D-2
Feedback: An air emboli is more often associated with central vein access. Usually only
relatively large volumes of air administered rapidly are dangerous. It is more often a concern
when air enters a central venous access line.

21. A patient admitted with a gastrointestinal bleed and anemia is receiving a blood transfusion.
Based upon the patient's hypotensive blood pressure, the nurse anticipates an order for IV fluids
from the physician. Which of the following IV solutions may be administered with blood
products?
A) D5 and .45% Normal Saline
B) Lactated Ringer's
C) 5% dextrose in water
D) 0.9% NaCl

Ans: D
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 11
Patient Needs: D-2
Feedback: The only IV solution that may be administered with blood products is normal saline.

22. The nurse preparing a site for the insertion of an IV catheter should treat excess hair at the
site by:
A) Leaving the hair intact
B) Shaving the area
C) Clipping the hair in the area
D) Removing the hair with a depilatory

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 11
Patient Needs: D-3
Feedback: Hair can be a source of infection and should be removed by clipping. Shaving the
area can cause skin abrasions, and depilatories can irritate the skin.

23. The nurse assessing skin turgor in an elderly patient should remember that:
A) Overhydration causes the skin to tent.
B) Dehydration causes the skin to appear edematous and spongy.
C) Inelastic skin turgor is a normal part of aging.
D) Normal skin turgor is moist and boggy.

Ans: C
Chapter: 14
Cognitive Level: Knowledge
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 3
Patient Needs: D-4
Feedback: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes
inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous
and spongy. Normal skin turgor is dry and firm.

24. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:
A) Choose a proximal site.
B) Choose a distal site.
C) Have the patient hold his arm over his head.
D) Leave the tourniquet on for at least 5 minutes.

Ans: B
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 10
Patient Needs: D-3
Feedback: When selecting a site for insertion of an IV catheter, the nurse should choose a distal
site, not a proximal site. Selection of a distal site leaves the upper veins available for subsequent
cannulations. Instruct the patient to hold his arm in a dependent position to increase blood flow.
Never leave a tourniquet in place longer than 2 minutes.
25. The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive
indicator of body fluid balance is:
A) Daily weight
B) Serum sodium levels
C) Measured intake and output
D) Blood pressure

Ans: A
Chapter: 14
Cognitive Level: Application
Difficulty: Easy
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-1
Feedback: Daily weights show trends and can assist medical management by indicating if
interventions and medications are effective. Laboratory data are objective data that indicate
whether electrolyte levels are within normal limits for the patient with fluid balance problems.
However, if a patient is dehydrated, some laboratory data can show false elevations. Intake and
output is extremely important, but matching the two is difficult because fluid is also lost through
breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because
heart rate and blood pressure can be elevated by either depletion or excess of fluids in some
situations.

26. A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum
potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:
A) Neuromuscular function
B) Bowel sounds
C) Respiratory rate
D) Electrocardiogram (ECG) results

Ans: D
Chapter: 14
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-2
Feedback: Although changes in all these findings are seen in hyperkalemia, ECG changes can
indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate
to assess the patient's neuromuscular function, bowel sounds, or respiratory rate for effects of
hyperkalemia.
27. The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action
should the nurse take when assessing for hypocalcemia?
A) Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
B) Observe for swelling of the neck, tracheal deviation, and severe pain.
C) Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
D) Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Ans: D
Chapter: 14
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-4
Feedback: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of
hyperirritability of the nervous system due to hypocalcemia. The other options describe
complications the nurse should also be observing for; however, tetany and neurologic alterations
are primary indications of hypocalcemia.

28. A patient who is hospitalized with a possible electrolyte imbalance is disoriented and weak,
has an irregular pulse, and takes hydrochlorothiazide. He most likely suffers from:
A) Hypernatremia
B) Hyponatremia
C) Hyperkalemia
D) Hypokalemia

Ans: D
Chapter: 14
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 5
Patient Needs: D-4
Feedback: The symptoms of hypokalemia include GI, cardiac, renal, respiratory, and neurologic
disturbances. The use of potassium-wasting diuretics, such as hydrochlorothiazide, without
potassium replacement therapy is a primary cause of hypokalemia.

29. A female patient is discharged from the hospital after having an episode of heart failure.
She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later,
she tells her community health nurse that she feels weak and her heart "flutters" frequently. What
action should the nurse take?
A) Tell the patient to rest more often.
B) Tell the patient to stop taking the digoxin, and call the physician.
C) Call the physician, report the symptoms, and request to draw a blood sample to determine the
patient's potassium level.
D) Tell the patient to avoid foods that contain caffeine.

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-2
Feedback: Furosemide is a potassium-wasting diuretic. A low potassium level may cause
weakness and palpitations. Telling the patient to rest more often won't help the patient if she's
hypokalemic. Digoxin isn't causing the patient's symptoms, so she doesn't need to stop taking it.
The patient should probably avoid caffeine, but this wouldn't resolve potassium depletion.

30. A nurse in the medical-surgical unit is giving a patient with low blood pressure a hypertonic
solution, which will increase the number of dissolved particles in his blood, creating pressure for
fluids in the tissues to shift into the capillaries and increase the blood volume. Which of the
following terms is associated with this process?
A) Hydrostatic pressure
B) Osmosis and osmolality
C) Diffusion
D) Active transport

Ans: B
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Patient Needs: A-1
Feedback: Osmosis is the movement of fluid from a region of low solute concentration to a
region of high solute concentration across a semipermeable membrane. The number of dissolved
particles contained in a unit of fluid determines the osmolality of a solution, which influences the
movement of fluid between the fluid compartments. Giving a patient who has a low blood
pressure a hypertonic solution will increase the number of dissolved particles in the blood,
creating pressure for fluids in the tissues to shift into the capillaries and increase the blood
volume. Option A is incorrect; hydrostatic pressure refers to changes in water or volume related
to water pressure. Option C is incorrect; diffusion is the movement of solutes from an area of
greater concentration to lesser concentration. The solutes in an intact vascular system are unable
to move, so diffusion should not normally take place. Option D is incorrect; active transport is
the movement of molecules against the concentration gradient and requires ATP as an energy
source. This process typically takes place at the cellular level and is not involved in vascular
volume changes.

31. A 73-year-old man who slipped on a small carpet in his home and fell on his hip is alert and
oriented; PERRLA (pupils equally round and reactive to light and accommodation) is intact, and
he has come by ambulance to the emergency department (ED). Heart rate elevated, he is anxious
and thirsty. A Foley catheter is in place and 40mL of urine is present. The nurse's most likely
explanation for the urine output is:
A) The man urinated prior to his arrival in the ED and will probably not need to have the Foley
catheter kept in place.
B) The man has a brain injury, lacks ADH, and needs vasopressin.
C) The man is in heart failure and is releasing atrial natriuretic peptide, which results in
decreased urine output.
D) He is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone
system that results in diminished urine output.

Ans: D
Chapter: 14
Cognitive Level: Application
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 2
Patient Needs: A-1
Feedback: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased
renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II.
Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and
stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in
response to an increased release of renin, which decreases urine production. Based on the nursing
assessment and mechanism of injury, this is the most likely cause of the lower urine output.
Option A is incorrect; the man urinating prior to his arrival at the ED is unlikely. The fall and hip
injury would make his ability to urinate difficult. Options B and C are incorrect; there is no
assessment information that indicates he has a head injury or heart failure.

32. A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery.
The woman seems confused and has poor skin turgor, and she states that “she stops drinking
water early in the day because it is too difficult to get up during the night to go to the bathroom.”
The nurse explains to the woman that:
A) She will need to have her medications adjusted and be readmitted to the hospital for a
complete workup.
B) Limiting fluids can create imbalances in the body that can result in confusion; maybe we
need to adjust the timing of your fluids.
C) It is normal to be a little confused following surgery and it safe not to urinate at night.
D) Confusion following surgery is common in the elderly due to loss of sleep.

Ans: B
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Teaching/Learning
Objective: 3
Patient Needs: A-1
Feedback: In elderly patients, the clinical manifestations of fluid and electrolyte disturbances
may be subtle or atypical. For example, fluid deficit may cause confusion or cognitive
impairment in the elderly person. Option A is incorrect; there is no mention of medications in the
stem of the question or any specific evidence given for the need for readmission to the hospital.
Options C and D are incorrect; confusion is never normal, common, or expected in the elderly.

33. A nurse in the medical-surgical unit has a newly admitted patient who is oliguric; the acute
care nurse practitioner orders a fluid challenge of 100 to 200 mL of normal saline solution over
15 minutes. The nurse is aware this intervention will help:
A) Distinguish hyponatremia from hypernatremia
B) Evaluate pituitary gland function
C) Distinguish reduced renal blood flow from decreased renal function
D) Provide an effective treatment for hypertension-induced oliguria

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 4
Patient Needs: D-2
Feedback: If a patient is not excreting enough urine, the health care provider needs to determine
whether the depressed renal function is the result of reduced renal blood flow, which is a fluid
Volume deficit (FVD) or prerenal azotemia, or acute tubular necrosis that results in necrosis or
cellular death from prolonged FVD. A typical example of a fluid challenge involves
administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a
patient with FVD but normal renal function is increased urine output and increased blood
pressure. Option A is incorrect; laboratory exams are needed to distinguish hyponatremia from
hypernatremia. Option B is incorrect; a fluid challenge is not used to evaluate pituitary gland
function. Option D is incorrect; a fluid challenge may give you information regarding
hypertension-induced oliguria, but it is not an effective treatment.

34. A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in
renal failure; during the assessment the patient complains of tingling in her lips and fingers.
When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse
suspects:
A) Hypophosphatemia
B) Hypocalcemia
C) Hypermagnesemia
D) Hyperkalemia

Ans: B
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 5
Patient Needs: A-1
Feedback: Tetany is the most characteristic manifestation of hypocalcemia and
hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth,
and less commonly in the feet. Taking a normal blood pressure could illicit a carpal spasm if it
creates slight ischemia of the ulnar nerve. Option A is incorrect; hypophosphatemia creates
central nervous dysfunction resulting in seizures and coma. Option C is incorrect;
hypermagnesemia creates hypoactive reflexes and somnolence. Option D is incorrect;
hyperkalemia creates paresthesias and anxiety.

35. A patient who is in renal failure partially loses the ability to regulate changes in pH because
the kidneys:
A) Regulate and reabsorb carbonic acid to change and maintain pH
B) Buffer acids through electrolyte changes
C) Regenerate and reabsorb bicarbonate to maintain a stable pH
D) Combine carbonic acid and bicarbonate to maintain a stable pH

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 6
Patient Needs: A-1
Feedback: The kidneys regulate the bicarbonate level in the ECF; they can regenerate
bicarbonate ions as well as reabsorb them from the renal tubular cells. In respiratory acidosis and
most cases of metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate
ions to help restore balance. Option A is incorrect; the lungs regulate and reabsorb carbonic acid
to change and maintain pH. Option B is incorrect; the kidneys do not buffer acids through
electrolyte changes. Buffering occurs in reaction to changes in pH. Option D is incorrect;
carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a
stable pH while the kidneys use bicarbonate as the chemical medium to maintain a stable pH by
moving and eliminating H+.

36. A 65-year-old male patient was admitted to a medical-surgical unit 72 hours ago with pyloric
stenosis; a nasogastric tube was inserted upon admission and has been on low intermittent
suction since then. The nurse taking care of the patient notices that his potassium is very low and
becomes concerned that the patient may be at risk for:
A) Hypercalcemia
B) Metabolic acidosis
C) Metabolic alkalosis
D) Respiratory acidosis

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Patient Needs: A-1
Feedback: Probably the most common cause of metabolic alkalosis is vomiting or gastric
suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in
which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove
potassium and can cause hypokalemia. Option A is incorrect; this patient would not be at risk for
hypercalcemia. Hyperparathyroidism and cancer account for almost all cases of hypercalcemia.
Option B is incorrect; the nasogastric tube is removing stomach acid and will likely raise pH.
Option D is incorrect; respiratory acidosis is unlikely. There was no change reported in the
patient's respiratory status.

37. A nurse admitting a patient with a history of emphysema reviews her past lab reports and
notes that the patient's PaCO2 has been 56 to 64 mmHg. The nurse will be cautious administering
oxygen because:
A) The patient's calcium will rise dramatically due to pituitary stimulation.
B) The oxygen will increase the patient's intracranial pressure and create confusion.
C) The oxygen may cause the patient to hyperventilate and become acidotic.
D) Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

Ans: D
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 8
Patient Needs: D-4
Feedback: When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the
respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide
narcosis and hypoxemia. Option A is incorrect; there is no information that indicates the patient's
calcium will rise dramatically due to pituitary stimulation. Option B is incorrect; there is no
feedback system that oxygen stimulates that would create an increase in the patient's intracranial
pressure and create confusion. Option C is incorrect; increasing the oxygen would not stimulate
the patient to hyperventilate and become acidotic. Rather, it would cause hypoventilation and
acidosis.

38. The nurse in the intensive care unit receives arterial blood gases (ABG) with a patient who is
complaining of being “short of breath.” The ABG has the following values:
pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mm Hg. The labs reflect:
A) Respiratory acidosis
B) Metabolic alkalosis
C) Respiratory alkalosis
D) Metabolic acidosis

Ans: A
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 9
Patient Needs: A-1
Feedback: A pH of less than 7.40, a PaCO2 greater than 40, and an HCO3 of 24 are normal;
therefore, it is a respiratory acidosis. Compensation by the kidneys has not begun, which
indicates this was probably an acute event. Option B is incorrect; an HCO3 of 24 is within the
normal range, so it is not metabolic alkalosis. Option C is incorrect; a pH of 7.21 is an acidosis
not alkalosis. Option D is incorrect; a pH of 7.21 is an acidosis. The HCO3 of 24 is within the
normal range, so it is not a metabolic acidosis.
39. A nurse preparing to start an IV on a newly admitted patient teaches the patient about the
procedure and begins to prepare the site. The nurse should always start by:
A) Leaving one hand ungloved to assess the site
B) Preparing the skin with an iodine solution
C) Asking the patient if he is allergic to latex or iodine
D) Removing excessive hair at the selected site

Ans: C
Chapter: 14
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 10
Patient Needs: A-2
Feedback: Before preparing the skin, the nurse should ask the patient if he or she is allergic to
latex or iodine, which are products commonly used in setting up for IV therapy. A local reaction
could result in irritation to the IV site or, in the extreme, it could result in anaphylaxis, which can
be life threatening. Option A is incorrect; both hands should always be gloved when preparing
for IV insertion, and latex-free gloves must be used or the patient must report that he or she has
no latex allergies. Option B is incorrect; preparing the skin with an iodine solution is dependent
on the report of no allergies to iodine solutions. Iodine is the recommended solution for IV
preparation as outlined in the policy and procedures manual. Option D is incorrect; removing
excessive hair at the selected site is always secondary to allergy inquiry.