Question 1

Which electrolyte imbalance contributes to edema?

Accepted Answer

Answer reason: Hyponatremia lowers serum osmolality, causing water to shift from the intravascular space into the interstitial tissues. This fluid shift promotes swelling and contributes directly to edema formation. It is one of the most common electrolyte abnormalities associated with generalized edema.

Question 2

Which of the following assessments would the nurse be aware of as indicative of hypocalcemia?

Accepted Answer

Answer reason: Hypocalcemia increases neuromuscular excitability, producing tetany and a positive Trousseau sign. Constipation, depressed reflexes, and muscle weakness are more consistent with hypercalcemia.

Question 3

A nurse is caring for a group of clients. Which client is at risk for developing a fluid volume deficit?

Accepted Answer

Answer reason: An ostomy, especially a high-output stoma, can cause significant fluid and electrolyte losses, putting the client at risk for fluid volume deficit. Heart failure and long-term corticosteroid therapy predispose to fluid volume excess, and wound irrigation does not typically cause systemic fluid deficit.

Question 4

What are the earliest symptoms of hyponatremia?

Accepted Answer

Answer reason: Early hyponatremia presents with nonspecific malaise and fatigue; thirst is typical of hypernatremia; ataxia occurs later with severe neurologic involvement; weakness may occur, but fatigue is an earlier nonspecific sign.

Question 5

The nurse is caring for a client who was admitted to the burn unit four hours after the injury with second-degree burns to the trunk and head. Which finding would the nurse least expect to find during this time period?

Accepted Answer

Answer reason: In the emergent phase of major burns (first 24–48 hours), capillary leak causes hypovolemia; cellular destruction leads to hyperkalemia; and sodium shifts into the interstitial space, producing hyponatremia. Laryngeal edema is also common with head and neck burns. Hypernatremia is least expected at 4 hours postburn.

Question 6

A client with acute alcohol intoxication is being treated for hypomagnesemia. During assessment, the nurse would expect to find?

Accepted Answer

Answer reason: Hypomagnesemia (common in alcoholism) increases neuromuscular excitability and can mimic hypocalcemia, producing a positive Trousseau's (and Chvostek's) sign. Bradycardia and a negative Chvostek's sign are inconsistent; hypertension is less specific.

Question 7

What is the primary acid–base disturbance indicated by ABG results showing a pH of 7.50, PaCO2 of 25 mmHg, and HCO3− of 18 mEq/L?

Accepted Answer

Answer reason: pH > 7.45 indicates alkalemia; PaCO2 is low (25 mm Hg), pointing to a primary respiratory alkalosis. The decreased HCO3− reflects renal compensation.

Question 8

The nurse is caring for a client in the acute care unit. Initial laboratory values reveal a serum sodium level of 156 mEq/L. What behavioral changes would the nurse expect the client to exhibit?

Accepted Answer

Answer reason: A serum sodium of 156 mEq/L indicates hypernatremia, which causes cellular dehydration of the brain, leading to restlessness, irritability, and agitated or manic-like behavior. Hyporeflexia and muscle cramps are more typical of other electrolyte deficits, and depression is not characteristic.

Question 9

A nurse is caring for a client with diarrhea. In which clinical indicator would the nurse anticipate a decrease?

Accepted Answer

Answer reason: Diarrhea causes a fluid volume deficit (dehydration), which reduces skin elasticity (decreased tissue turgor). Heart rate and urine specific gravity typically increase; temperature is not expected to decrease.

Question 10

The nurse is obtaining a history from a 74-year-old client. Which statement made by the client would alert the nurse to a possible fluid and electrolyte imbalance?

Accepted Answer

Answer reason: Chronic laxative use can cause diarrhea, dehydration, and potassium loss, making it a key historical clue to fluid and electrolyte imbalance in older adults.

Question 11

A burn client is in the acute phase of burn care. The nurse assesses jugular vein distention, edema, a urine output of 20 cc in 2 hours, and crackles on auscultation. Which order would the nurse anticipate from the physician?

Accepted Answer

Answer reason: JVD, crackles, and edema indicate fluid volume overload in the acute/diuretic phase of burn care. The appropriate anticipated order is a loop diuretic to remove excess fluid. Increasing IV fluids, irrigating the Foley, or placing the patient in Trendelenburg would not treat the overload and could worsen it.

Question 12

Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials 911 because Anne is unconscious, has depressed ventilation (shallow and slow respirations), a rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Anne at risk for if medical attention is not provided?

Accepted Answer

Answer reason: A head injury with hypoventilation (shallow, slow respirations) leads to CO2 retention, causing a primary respiratory acidosis.

Question 13

The nurse is caring for a client who has sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

Accepted Answer

Answer reason: In the emergent phase after burns, plasma loss and capillary leakage cause hypovolemia and hemoconcentration, leading to elevated hematocrit. Patients typically have tachycardia, hypotension, and decreased urine output.

Question 14

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess?

Accepted Answer

Answer reason: Extracellular fluid volume excess causes venous congestion and bounding pulses, manifested by distended neck (jugular) veins. Hematocrit typically decreases due to hemodilution; rapid thready pulse and hypernatremia are not expected findings.

Question 15

A nurse is triaging in the emergency room when a client enters complaining of muscle cramps and a feeling of exhaustion after a running competition. Which of the following would the nurse suspect?

Accepted Answer

Answer reason: Endurance athletes can develop exercise-associated hyponatremia from sodium loss in sweat and replacement with hypotonic fluids, causing muscle cramps and fatigue.

Question 16

A patient is post-operative from knee surgery and receiving Morphine 4 mg IV every 2 hours; the patient is extremely drowsy with a respiratory rate of 8; which condition is the patient at risk for?

Accepted Answer

Answer reason: Opioids like morphine depress respirations, causing hypoventilation and CO2 retention, which leads to respiratory acidosis.

Question 17

Which assessment finding would the nurse note in a client receiving IV diuretics who is experiencing a fluid volume deficit?

Accepted Answer

Answer reason: Fluid volume deficit from diuretics presents with dehydration signs such as weight loss and poor skin turgor. Other options reflect fluid excess (lung congestion, increased BP) or incorrect lab trends (decreased hematocrit).

Question 18

A client arrives in the emergency department after a motor vehicle accident with BP 68/34, pulse 130, and respirations 18; what is the most appropriate priority nursing diagnosis?

Accepted Answer

Answer reason: Profound hypotension with tachycardia after trauma indicates hypovolemic/hemorrhagic shock; the priority nursing diagnosis is deficient fluid volume. Airway is adequate (RR 18), and other options are less immediate.

Question 19

What is the recommended rate of fluid replacement in a child with moderate dehydration?

Accepted Answer

Answer reason: Moderate dehydration in children is treated with oral rehydration at about 50–75 mL/kg over 4 hours; option C (40–60 mL/kg over 4 hours) reflects this recommendation.

Question 20

What additional signs would the nurse expect to note in a client with hyponatremia?

Accepted Answer

Answer reason: Hyponatremia increases GI motility, producing hyperactive bowel sounds, cramping, and diarrhea. Muscle twitching is more typical of hypernatremia or hypocalcemia, and urine output/specific gravity vary with volume status and are not reliable hallmark signs.

Question 21

Which assessment should a nurse perform to obtain the most accurate determination of fluid balance in a child with hydronephrosis?

Accepted Answer

Answer reason: Daily weight is the most accurate indicator of fluid balance; small changes reflect fluid gain/loss (about 1 kg ≈ 1 L). I&O can be inaccurate, edema is a late/subjective sign, and electrolytes do not directly quantify volume status.

Question 22

Which client is most likely at risk for fluid volume deficit?

Accepted Answer

Answer reason: An ileostomy produces large amounts of liquid stool rich in water and electrolytes, placing the client at high risk for dehydration (fluid volume deficit). Heart failure and corticosteroids are associated with fluid excess, and wound irrigations are topical and do not typically cause systemic fluid loss.

Question 23

Which client is at risk for fluid volume excess?

Accepted Answer

Answer reason: Renal disease impairs excretion of water and sodium, predisposing to fluid volume excess. The other options (diuretics with skin tenting, ileostomy, GI suctioning) are associated with fluid volume deficit.

Question 24

Which client is at risk for the development of a potassium level of 5.5 mEq/L?

Accepted Answer

Answer reason: Hyperkalemia (K+ 5.5 mEq/L) occurs with massive tissue breakdown; burns cause potassium to shift out of cells. Colitis and laxative abuse cause GI losses leading to hypokalemia, and Cushing’s syndrome is associated with hypokalemia.

Question 25

What is an essential nursing action when caring for a small child with severe diarrhea?

Accepted Answer

Answer reason: Severe diarrhea places a child at high risk for dehydration. Daily weight is the most sensitive indicator of fluid balance and guides therapy. Forcing fluids is unsafe, calories are secondary to hydration, and temperature control is not the priority.

Question 26

What is the emergency management of hyperkalemia admitted in a tertiary care hospital?

Accepted Answer

Answer reason: In severe hyperkalemia, IV insulin with dextrose rapidly shifts potassium intracellularly, lowering serum K+. Kayexalate acts slowly, and calcium gluconate stabilizes myocardium but does not lower potassium. The specified 25% dextrose prevents hypoglycemia with insulin, making it the best emergency management choice listed.

Question 27

The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is?

Accepted Answer

Answer reason: An ileostomy produces large amounts of liquid effluent, placing the client at highest risk for dehydration and electrolyte loss; therefore fluid volume deficit is the priority over body image or elimination concerns.

Question 28

The most appropriate means of rehydration of a 7-month-old with diarrhea and mild dehydration is?

Accepted Answer

Answer reason: For infants with mild dehydration from diarrhea, first-line therapy is oral rehydration solution (ORS). IV fluids are reserved for moderate to severe dehydration, lactose-free formula does not address acute rehydration, and the BRAT-type diet is not recommended as primary therapy.

Question 29

A client has had diarrhea for the past 3 days. Which acid/base imbalance would the nurse expect the client to have?

Accepted Answer

Answer reason: Prolonged diarrhea causes loss of bicarbonate-rich intestinal fluids, leading to decreased HCO3− and a primary metabolic acidosis.

Question 30

The client with a history of diabetes insipidus is admitted with polyuria, polydipsia, and mental confusion. The priority intervention for this client is?

Accepted Answer

Answer reason: Diabetes insipidus can cause severe dehydration and hypernatremia; mental confusion signals possible hemodynamic instability. The immediate priority is to assess vital signs to identify hypotension/tachycardia and ensure circulatory stability before other monitoring or measures.

Question 31

The client with hyperemesis gravidarum is at risk for developing?

Accepted Answer

Answer reason: Severe vomiting in hyperemesis gravidarum causes loss of gastric H+ and Cl−, producing metabolic alkalosis, and leads to volume depletion/dehydration.

Question 32

A 25-year-old male is admitted in sickle cell crisis. Which intervention is the highest priority?

Accepted Answer

Answer reason: During sickle cell crisis, dehydration increases blood viscosity and promotes further sickling. Aggressive hydration reduces sickling, improves circulation, and prevents vaso-occlusive complications. Pain control is important, but restoring adequate hydration is the physiologic priority.

Question 33

In the oliguric phase of renal failure, what is the most appropriate nursing diagnosis?

Accepted Answer

Answer reason: Oliguric renal failure decreases urine output, causing fluid retention and edema; the priority nursing diagnosis is fluid volume excess.

Question 34

Which of the following clients is at risk for developing potassium deficit (hypokalemia)?

Accepted Answer

Answer reason: Nasogastric suction causes gastrointestinal potassium loss leading to hypokalemia. Crush injury, Addison’s disease, and potassium-sparing diuretics are associated with hyperkalemia, not potassium deficit.

Question 35

Which of the following clients is at high risk for developing hyperkalemia?

Accepted Answer

Answer reason: Extensive burns cause cellular destruction and a shift of potassium from cells into the bloodstream, leading to hyperkalemia. Colitis and laxative overuse cause GI potassium losses (hypokalemia), and Cushing's syndrome increases mineralocorticoid effect causing potassium loss (hypokalemia).

Question 36

A nurse is assessing a client with suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to find in the client?

Accepted Answer

Answer reason: Hypocalcemia causes increased neuromuscular excitability, leading to muscle cramps and twitching with positive Chvostek’s and Trousseau’s signs and often hyperactive (not hypoactive) bowel sounds.

Question 37

The nurse is caring for a client who's sodium level is 125 mEq/L (hyponatremia). The nurse understands that hyponatremia may be caused by?

Accepted Answer

Answer reason: Thiazide and other diuretics can cause sodium loss leading to hyponatremia. Cushing’s syndrome, hyperaldosteronism, and corticosteroid use tend to increase sodium retention, not decrease it.

Question 38

A client is receiving diuretics; the nurse suspects that the client is experiencing fluid volume deficit. Which assessment finding would the nurse note in a client with fluid volume deficit?

Accepted Answer

Answer reason: Diuretics can cause hypovolemia. Fluid volume deficit reduces preload, resulting in low central venous pressure. Lung congestion and increased blood pressure indicate fluid excess, and hematocrit typically increases due to hemoconcentration.

Question 39

Which client would the nurse consider at risk for fluid volume excess?

Accepted Answer

Answer reason: Renal failure impairs excretion of water and sodium, leading to fluid retention and volume excess. The other options are associated with fluid loss (diuretics, ileostomy output, GI suction), increasing risk for deficit rather than excess.

Question 40

The nurse understands that a client with ileostomy loose large amount of bicarbonate ions. So this client would be at risk for which acid base disorder?

Accepted Answer

Answer reason: Loss of bicarbonate-rich intestinal fluids from an ileostomy reduces base, producing a non-respiratory (metabolic) acidosis.

Question 41

A nurse is caring for a client with nasogastric tube placed on low suction. The nurse understands that the client is at risk for which acid base disorder?

Accepted Answer

Answer reason: NG suction removes gastric hydrochloric acid, causing loss of hydrogen ions and chloride, leading to metabolic alkalosis.

Question 42

A nurse is caring for a client who's blood gas results indicate a pH of 7.5 and a Pco2 of 30 mm Hg. The nurse understands that the patient is in alkalosis. Which condition is expected to be present with alkalosis?

Accepted Answer

Answer reason: Alkalosis drives potassium into cells via H+/K+ shift, decreasing serum potassium and causing hypokalemia. The other listed electrolyte changes are not typically expected with alkalosis.

Question 43

The nurse is caring for a client with diabetes insipidus. The nurse understands that the client may develop fluid volume deficit because in diabetes insipidus?

Accepted Answer

Answer reason: Diabetes insipidus is due to deficient ADH action, leading to an inability to concentrate urine and marked polyuria. Excess renal water loss causes fluid volume deficit.

Question 44

All of the following are the risk factors for fluid volume deficit except?

Accepted Answer

Answer reason: Diarrhea, vomiting, and adrenal insufficiency cause sodium and water loss leading to fluid volume deficit. Hyperaldosteronism causes sodium and water retention, leading to fluid volume excess, not deficit.

Question 45

While caring for the patient with hyperkalemia which of the following findings would the nurse do not expect?

Accepted Answer

Answer reason: Hyperkalemia is commonly associated with metabolic acidosis and can cause muscle weakness/paralysis and cardiac dysrhythmias. Metabolic alkalosis is not expected with hyperkalemia, making it the exception.

Question 46

The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is?

Accepted Answer

Answer reason: Adequate burn resuscitation in children is assessed by urine output; the goal is about 1 mL/kg/hr. For a 10-year-old, ~30 mL/hr indicates sufficient perfusion and hydration. Increased hematocrit suggests dehydration, and thirst or local skin turgor are unreliable.

Question 47

The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding?

Accepted Answer

Answer reason: With extracellular fluid volume deficit, kidneys conserve water, leading to decreased urine output (oliguria). Bounding pulse and distended neck veins indicate fluid volume excess; tachypnea may occur but oliguria is the expected, more specific finding.

Question 48

Skin pinch test is done in case of which condition?

Accepted Answer

Answer reason: The skin pinch (skin turgor) test assesses hydration status; skin tenting indicates dehydration.

Question 49

A client develops volume overload from an IV that has infused too rapidly. What assessments would the nurse expect to find?

Accepted Answer

Answer reason: Fluid volume overload (early CHF) produces an S3 gallop due to rapid ventricular filling. Overload typically causes bounding pulse and distended neck veins, not thready pulse or flattened veins; hypoventilation is unrelated.

Question 50

An eighteen month-old has been brought to the emergency room with irritability, lethargy over two days, dry skin and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional signs/symptoms of?

Accepted Answer

Answer reason: Lethargy, irritability, dry skin, and tachycardia are classic pediatric signs of dehydration; further assessment should focus on fluid deficit.

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