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Adult Health Exam 1-Fluid & Electrolyte Balance, Acid-Base Balance, Care of the Older Adult, Diabetes/Hypoglycemia,Ethical Reasoning, Skin Integrity & Burns, Acute Pain, & Perioperative Care
Review Questions & Answers
Fluid & Electrolyte Balance
1. You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients
most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize
assessment for which of the following health problems?
A. Diminished deep tendon reflexes
B. Tachycardia
C. Cool, clammy skin
D. Acute flank pain
Ans: A. To gauge a patients magnesium status, the nurse should check deep tendon reflexes. If the reflex is absent, this
may indicate high serum magnesium. Tachycardia, flank pain, and cool, clammy skin are not typically associated with
hypermagnesemia.
2. You are working on a burns unit and one of your acutely ill patients is exhibiting signs and symptoms of third
spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what
imbalance?
A. Metabolic alkalosis
B. Hypermagnesemia
C. Hypercalcemia
D. Hypovolemia
Ans: D. Third-spacing fluid shift, which occurs when fluid moves out of the intravascular space but not into the
intracellular space, can cause hypovolemia. Increased calcium and magnesium levels are not indicators of third-spacing
fluid shift. Burns typically cause acidosis, not alkalosis.
3. A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial
pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for
fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as
which of the following?
A. Hydrostatic pressure
B. Osmosis and osmolality
C. Diffusion
D. Active transport
Ans: B. Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute
concentration across a semipermeable membrane. Hydrostatic pressure refers to changes in water or volume related to
water pressure. 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 normally should not be taking place. Active transport
is the movement of molecules against the concentration gradient and requires adenosine triphosphate (ATP) as an
energy source; this process typically takes place at the cellular level and is not involved in vascular volume changes.
4. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a
thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells
you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What
electrolyte imbalance should you first suspect?
A. Hypophosphatemia
B. Hypocalcemia
C. Hypermagnesemia
D. Hyperkalemia
Ans: B. 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. Hypophosphatemia creates central
nervous dysfunction, resulting in seizures and coma. Hypermagnesemia creates hypoactive reflexes and somnolence.
Signs of hyperkalemia include paresthesias and anxiety.
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,Adult Health Exam 1
5. A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in
renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability?
A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
B. The kidneys buffer acids through electrolyte changes.
C. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.
Ans: C. 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. The lungs regulate and reabsorb carbonic acid to
change and maintain pH. The kidneys do not buffer acids through electrolyte changes; buffering occurs in reaction to
changes in pH. Carbonic acid works as the chemical medium to exchange O2 and CO2 in the lungs to maintain a stable
pH whereas the kidneys use bicarbonate as the chemical medium to maintain a stable pH by moving and eliminating H+.
6. When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body,
water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?
A. Active transport of hydrogen ions across the capillary walls
B. Pressure of the blood in the renal capillaries
C. Action of the dissolved particles contained in a unit of blood
D. Hydrostatic pressure resulting from the pumping action of the heart
Ans: D. An example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial
fluid; in this instance, the hydrostatic pressure results from the pumping action of the heart. Active transport does not
move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of
dissolved particles in a unit of blood is concerned with osmolality. The pressure in the renal capillaries causes renal
filtration.
7. The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the
circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine
activities. Sympathetic stimulation constricts renal arterioles, causing what effect?
A. Decrease in the release of aldosterone
B. Increase of filtration in the Loop of Henle
C. Decrease in the reabsorption of sodium
D. Decrease in glomerular filtration
Ans: D. Sympathetic stimulation constricts renal arterioles; this decreases glomerular filtration, increases the release of
aldosterone, and increases sodium and water reabsorption. None of the other listed options occurs with increased
sympathetic stimulation.
8. The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. Your
assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What
other sign or symptom would you expect this patient to exhibit?
A. Diarrhea
B. Dilute urine
C. Increased muscle tone
D. Joint pain
Ans: B. Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps,
decreased bowel motility, paresthesias (numbness and tingling), and dysrhythmias. If prolonged, hypokalemia can lead
to an inability of the kidneys to concentrate urine, causing dilute urine (resulting in polyuria, nocturia) and excessive
thirst. Potassium depletion suppresses the release of insulin and results in glucose intolerance. Decreased muscle
strength and DTRs can be found on physical assessment. You would expect decreased, not increased, muscle strength
with hypokalemia. The patient would not have diarrhea following bowel surgery, and increased bowel motility is
inconsistent with hypokalemia.
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,Adult Health Exam 1
9. You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone
metastases. During your assessment, you note the patient complains of a new onset of weakness with
abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should
recognize that this patient may be experiencing what electrolyte imbalance?
A. Hypernatremia
B. Hypomagnesemia
C. Hypophosphatemia
D. Hypercalcemia
Ans: D. The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea,
vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting,
anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary
manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the
most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The patients
presentation is inconsistent with hypophosphatemia.
10. You are called to your patients room by a family member who voices concern about the patients status. On
assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You
also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and
symptoms?
A. Hypocalcemia
B. Hyponatremia
C. Hyperchloremia
D. Hypophosphatemia
Ans: C. The signs and symptoms of hyperchloremia are the same as those of metabolic acidosis: hypervolemia and
hypernatremia. Tachypnea; weakness; lethargy; deep, rapid respirations; diminished cognitive ability; and hypertension
occur. If untreated, hyperchloremia can lead to a decrease in cardiac output, dysrhythmias, and coma. A high chloride
level is accompanied by a high sodium level and fluid retention. With hypocalcemia, you would expect tetany. There
would not be edema with hyponatremia. Signs or symptoms of hypophosphatemia are mainly neurologic.
11. The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a
positive Chvosteks sign indicate?
A. Hypermagnesemia
B. Hyponatremia
C. Hypocalcemia
D. Hyperkalemia
Ans: C. You can induce Chvosteks sign by tapping the patients facial nerve adjacent to the ear. A brief contraction of the
upper lip, nose, or side of the face indicates Chvosteks sign. Both hypomagnesemia and hypocalcemia may be tested
using the Chvosteks sign.
12. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and
crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client
if excess fluid volume is present?
A. Weight loss and dry skin
B. Flat neck and hand veins and decreased urinary output
C. An increase in blood pressure and increased respirations
D. Weakness and decreased central venous pressure (CVP)
Ans: C. A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid
retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough,
dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema,
neck and hand vein distention, altered level of consciousness, and decreased hematocrit. Dry skin, flat neck and hand
veins, decreased urinary output, and decreased CVP are noted in fluid volume deficit. Weakness can be present in either
fluid volume excess or deficit.
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, Adult Health Exam 1
13. The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and
determines that the client is at risk for developing the potassium deficit because of which situation?
A. Sustained tissue damage
B. Requires nasogastric suction
C. Has a history of Addison's disease
D. A high uric acid level
Ans: B. The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A potassium deficit is known
as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk
for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for
hyperkalemia. The normal uric acid level for a female is 2.7 to 7.3 mg/dL (16 to 0.43 mmol/L) and for a male is 4.0 to 8.5
mg/dL (0.24 to 0.51 mmol/L). Hyperuricemia is a cause of hyperkalemia.
14. The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L (2.5
mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory
value? Select all that apply.
A. U waves
B. Absent P waves
C. Inverted T waves
D. Depressed ST segment
E. Widened QRS complex
Ans: A, C, E. The normal serum potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A serum potassium level lower
than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Potassium deficit is an electrolyte imbalance that can be potentially
life-threatening. Electrocardiographic changes include shallow, flat, or inverted T waves; ST segment depression; and
prominent U waves. Absent P waves are not a characteristic of hypokalemia but may be noted in a client with atrial
fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and in
hypermagnesemia.
15. The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium
and tells the client to consume which foods? Select all that apply.
A. Peas
B. Raisins
C. Potatoes
D. Cantaloupe
E. Strawberries
Ans: B,C, D, E. The normal potassium level is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). Common food sources of potassium
include avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach,
strawberries, and tomatoes. Peas and cauliflower are high in magnesium.
16. The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would
the nurse expect to note in the client?
A. Twitching
B. Hypoactive bowel sounds
C. Negative Trousseau’s sign
D. Hypoactive deep tendon reflexes
Ans: A. The normal serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A serum calcium level lower than 9
mg/dL (2.25 mmol/L) indicates hypocalcemia. Signs of hypocalcemia include paresthesias followed by numbness,
hyperactive deep tendon reflexes, and a positive Trousseau's or Chvostek's sign. Additional signs of hypocalcemia include
increased neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, and anxiety. Gastrointestinal
symptoms include increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea.
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