The nurse understands that cerebrospinal fluid is considered which type of fluid?
A. Intracellular
B. Interstitial
C. Transcellular
D. Plasma - ANSWER- C. Transcellular
The nurse assesses for which clinical manifestations in the patient with
dehydration? (Select all that apply.)
A. Increased urine specific gravity
B. Increased serum BUN
C. Increased serum osmolality
D. Decreased serum osmolality
E. Decreased BUN-to-creatinine ratio - ANSWER- A. Increased urine specific
gravity
B. Increased serum BUN
C. Increased serum osmolality
In the aging adult, which of the following impacts food and fluid intake?
A. Increased sensitivity to smells
B. Increased sensitivity to texture in foods
C. Decreased manual dexterity
D. Decreased olfactory function - ANSWER- D. Decreased olfactory function
The nurse assesses for which clinical manifestations in the patient with
hypervolemia?
A. Bradycardia
B. S3 heart sound
,C. Postural hypotension
D. Decreased skin turgor - ANSWER- B. S3 heart sound
The nurse identifies the patient with which electrolyte abnormality as having the
greatest risk for ventricular fibrillation?
A. Hypochloremia
B. Hyponatremia
C. Hypocalcemia
D. Hypokalemia - ANSWER- D. Hypokalemia
Which nursing action is the priority in the patient with a serum calcium of 6.0
mg/dL?
A. Prepare for placement of a nasogastric tube.
B. Place an intubation tray at the bedside.
C. Place an indwelling urinary catheter.
D. Prepare for emergency dialysis. - ANSWER- B. Place an intubation tray at the
bedside.
How does the nurse interpret an arterial pH of 7.47?
A. Acidosis
B. Alkalosis
C. Compensation
D. Homeostasis - ANSWER- B. Alkalosis
Which parameter of the ABG result correlates to the assessment of the base
component?
A. pH
B. PaO2
C. HCO3-
D. PaCO2 - ANSWER- C. HCO3-
What acid-base imbalance does the nurse suspect on the basis of these results?
pH: 7.31
PaCO2: 52 mm Hg
HCO3-: 28 mEq/L
A. Uncompensated respiratory acidosis
, B. Partially compensated respiratory acidosis
C. Uncompensated metabolic acidosis
D. Partially compensated metabolic acidosis - ANSWER- B. Partially compensated
respiratory acidosis
Which acid-base imbalance should be suspected with these ABG results?
pH: 7.47
PaCO2: 31 mm Hg
HCO3-: 24 mEq/L
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - ANSWER- B. Respiratory alkalosis
When the body is in a state of alkalosis, what is the role of the renal buffers?
A. ↑ Excretion of water
B. ↓ Excretion of water
C. ↑ Excretion of HCO3-
D. ↓ Excretion of HCO3- - ANSWER- C. ↑ Excretion of HCO3-
A patient has been diagnosed with an intestinal obstruction. The nurse inserts a
nasogastric tube and attaches the tube to low intermittent suction. For which
acid-base imbalance is the patient at greatest risk?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - ANSWER- D. Metabolic alkalosis
The patient's ABG results indicate worsening respiratory acidosis. He has rapid,
shallow breaths and decreased bilateral breath sounds. Which intervention
should be the nurse's first priority?
A. Administer an antibiotic for suspected pneumonia.
B. Administer diuretics for heart failure.
C. Encourage the patient to breathe into a brown paper bag.
D. Prepare the patient for intubation and mechanical ventilation. - ANSWER- D.
Prepare the patient for intubation and mechanical ventilation.
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