Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances
MULTIPLE CHOICE
1. A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest
risk for dehydration?
a. A 36-year-old who is prescribed long-term steroid therapy
b. A 55-year-old receiving hypertonic intravenous fluids
c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure
ANS: C
Older adults, because they have less total body water than younger adults, are at greater risk for
development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration.
DIF: Understanding/Comprehension REF: 168
KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
2. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should
the nurse implement first?
a. Measure intake and output every 4 hours.
b. Apply oxygen by mask or nasal cannula.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowlers position.
ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion.
Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow
rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client
too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client
in a high-Fowlers position will not address the clients problem.
DIF: Applying/Application REF: 168
KEY: Hydration
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. After teaching a client who is being treated for dehydration, a nurse assesses the clients
understanding. Which statement indicates the client correctly understood the teaching?
a. I must drink a quart of water or other liquid each day.
b. I will weigh myself each morning before I eat or drink.
c. I will use a salt substitute when making and eating my meals.
d. I will not drink liquids after 6 PM so I wont have to get up at night.
ANS: B
One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss
or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other
statements are not indicative of practices that will prevent dehydration.
DIF: Analyzing/Analysis REF: 168
KEY: Hydration
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
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4. A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting
into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic
effect should the nurse assess?
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b. Daily weight increase from 55 kg to 57 kg
c. Heart rate decrease from 100 beats/min to 82 beats/min
d. Respiratory rate increase from 12 breaths/min to 15 breaths/min
ANS: A
ACE inhibitors will disrupt the reninangiotensin II pathway and prevent the kidneys from reabsorbing
water and sodium. The kidneys will excrete more water and sodium, decreasing the clients blood
pressure.
DIF: Applying/Application REF: 178
KEY: Hydration| angiotensin-converting enzyme (ACE) inhibitor
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as
being at greatest risk for insensible water loss?
a. Client taking furosemide (Lasix)
b. Anxious client who has tachypnea
c. Client who is on fluid restrictions
d. Client who is constipated with abdominal pain
ANS: B
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water
loss include those being mechanically ventilated, those with rapid respirations, and those undergoing
continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and
fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not
insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for
fluid loss.
DIF: Applying/Application REF: 165
KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse is evaluating a client who is being treated for dehydration. Which assessment result should
the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 breaths/min to 22 breaths/min
b. Decreased skin turgor on the clients posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL d. Decreased orthostatic light-headedness
and dizziness
ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid
volumes return to normal, clients should perfuse the brain more effectively, therefore improving
confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate,
decreased skin turgor, and increased specific gravity are all manifestations of dehydration.
DIF: Applying/Application REF: 168
KEY: Hydration
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
7. After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients
understanding. Which food choice for lunch indicates the client correctly understood the teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole wheat crackers
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d. Grilled chicken breast with glazed carrots
ANS: D
Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and
those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh
produce. The ham, tomato soup, salami, and crackers are often high in sodium.
DIF: Applying/Application REF: 169
KEY: Electrolyte imbalance MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category:
Health Promotion and Maintenance
8. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess
first for potential hyponatremia?
a. A 34-year-old on NPO status who is receiving intravenous D5W
b. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
c. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin) d. A 73-year-old with
tachycardia who is receiving digoxin (Lanoxin)
ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids
by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic,
ibuprofen, and digoxin will not put a client at risk for hyponatremia.
DIF: Applying/Application REF: 173
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
9. A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse
include in this clients teaching?
a. Weigh yourself every morning and every night.
b. Check your radial pulse twice a day.
c. Read food labels to determine sodium content. d. Bake or grill the meat rather than frying it.
ANS: C
Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate
the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent
hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of
hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method
of cooking, increases the sodium content of a meal.
DIF: Applying/Application REF: 172
KEY: Electrolyte imbalance MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category:
Health Promotion and Maintenance
10. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L,
magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse
complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography
ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias,
and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should
assess the clients respiratory status first to ensure respirations are sufficient. The respiratory assessment
should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other
assessments are important but are secondary to the clients respiratory status.
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DIF: Analyzing/Analysis REF: 176
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
11. A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular
changes. Which prescription should the nurse implement first?
a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
b. Provide a heart healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. d. Prepare the client for
hemodialysis treatment.
ANS: C
A client with a high serum potassium level and cardiac changes should be treated immediately to reduce
the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by
increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and
glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate
may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be
needed, but this treatment will take much longer to implement and is not the first prescription the
nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but
will not decrease the clients current potassium level.
DIF: Applying/Application REF: 178
KEY: Electrolyte imbalance| insulin
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
12. A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia? a.
Client with pancreatitis who has continuous nasogastric suctioning
b. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
c. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
d. Client with uncontrolled diabetes and a serum pH level of 7.33
ANS: A
A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to
hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.
DIF: Understanding/Comprehension REF: 176
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
13. A nurse is assessing a client with hypokalemia, and notes that the clients handgrip strength has
diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
a. Assess the clients respiratory rate, rhythm, and depth.
b. Measure the clients pulse and blood pressure.
c. Document findings and monitor the client. d. Call the health care provider.
ANS: A
In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity
of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is
imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in
immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The clients pulse and
blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the
health care provider to obtain orders for potassium replacement. Documenting findings and continuing
to monitor the client should occur during and after potassium replacement therapy.
DIF: Applying/Application REF: 175 KEY: Electrolyte imbalance
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MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. After teaching a client to increase dietary potassium intake, a nurse assesses the clients
understanding. Which dietary meal selection indicates the client correctly understands the teaching?
a. Toasted English muffin with butter and blueberry jam, and tea with sugar
b. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
c. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk d. Bowl of oatmeal with
brown sugar, a half cup of sliced peaches, and coffee
ANS: C
Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals,
sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast,
raisins, and milk has the greatest number of items with higher potassium content.
DIF: Applying/Application REF: 175
KEY: Electrolyte imbalance MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category:
Physiological Integrity: Basic Care and Comfort
15. A client at risk for developing hyperkalemia states, I love fruit and usually eat it every day, but now I
cant because of my high potassium level. How should the nurse respond?
a. Potatoes and avocados can be substituted for fruit.
b. If you cook the fruit, the amount of potassium will be lower.
c. Berries, cherries, apples, and peaches are low in potassium. d. You are correct. Fruit is very high in
potassium.
ANS: C
Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet
include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium
include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium
content.
DIF: Applying/Application REF: 175
KEY: Electrolyte imbalance
MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Psychosocial
Integrity
16. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order
should the nurse implement first?
a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin (Calcimar).
ANS: B
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause
cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac
changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for
hypercalcemia, but are not the highest priority.
DIF: Applying/Application REF: 181
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
17. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which
intervention should the nurse implement to prevent injury while in the hospital?
a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 liter of fluids each shift.
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d. Dangle the client on the bedside before ambulating.
ANS: D
An older adult with moderate dehydration may experience orthostatic hypotension. The client should
dangle on the bedside before ambulating. Although dehydration in an older adult may cause confusion,
speaking quietly will not help the client remain calm or decrease confusion. Assessing the clients urine
may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to
drink fluids, but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms
of fluid overload, especially if the client has heart failure or renal insufficiency.
DIF: Applying/Application REF: 169
KEY: Electrolyte imbalance| safety| mobility/immobility
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations
should the nurse expect to find? (Select all that apply.)
a. Increased pulse rate
b. Distended neck veins
c. Decreased blood pressure d. Warm and pink skin
e. Skeletal muscle weakness
ANS: A, B, E
Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood
pressure, pale and cool skin, and skeletal muscle weakness.
DIF: Remembering/Knowledge REF: 171
KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for
hypophosphatemia? (Select all that apply.)
a. A 36-year-old who is malnourished
b. A 42-year-old with uncontrolled diabetes
c. A 50-year-old with hyperparathyroidism d. A 58-year-old with chronic renal failure e. A 76-year-old
who is prescribed antacids
ANS: A, B, E
Clients at risk for hypophosphatemia include those who are malnourished, those with uncontrolled
diabetes mellitus, and those who use aluminum hydroxidebased or magnesium-based antacids.
Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.
DIF: Remembering/Knowledge REF: 182
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and
release. For which potential complications should the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L
c. Urine specific gravity of 1.02 g/mL d. Serum sodium level of 128 mEq/L e. Blood osmolality of 250
mOsm/L
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ANS: B, E
Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the
reabsorption of water and sodium in the kidney at the same time that it promotes excretion of
potassium. Any drug or condition that disrupts aldosterone secretion or release increases the clients risk
for excessive water loss (increased urine output), increased potassium reabsorption, decreased blood
osmolality, and increased urine specific gravity. The client would not be at risk for sodium imbalance.
DIF: Applying/Application REF: 173
KEY: Hydration
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which
potential complications of this electrolyte imbalance should the nurse assess? (Select all that apply.)
a. Electrocardiogram changes
b. Slow, shallow respirations
c. Orthostatic hypotension d. Paralytic ileus
e. Skeletal muscle weakness
ANS: A, D, E
Electrolyte imbalances associated with acute renal failure include hyperkalemia and
hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by
decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices
are potential complications of hypokalemia.
DIF: Applying/Application REF: 164
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical
manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)
a. Hypokalemia Flaccid paralysis with respiratory depression
b. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
c. Hyponatremia Decreased level of consciousness
d. Hypercalcemia Positive Trousseaus and Chvosteks signs
e. Hypomagnesemia Bradycardia, peripheral vasodilation, and hypotension
ANS: A, C
Flaccid paralysis with respiratory depression is associated with hypokalemia. Decreased level of
consciousness is associated with hyponatremia. Paresthesia with sensations of tingling and numbness is
associated with hypophosphatemia or hypercalcemia. Positive Trousseaus and Chvosteks signs are
associated with hypocalcemia or hyperphosphatemia. Bradycardia, peripheral vasodilation, and
hypotension are associated with hypermagnesemia.
DIF: Analyzing/Analysis REF: 176
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which
manifestations indicate that treatment is improving the clients hypokalemia? (Select all that apply.) a.
Respiratory rate of 8 breaths/min
b. Absent deep tendon reflexes
c. Strong productive cough
d. Active bowel sounds
e. U waves present on the electrocardiogram (ECG)
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ANS: C, D
A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance.
Active bowel sounds also indicate treatment is working. A respiratory rate of 8 breaths/min, absent
deep tendon reflexes, and U waves present on the ECG are all manifestations of hypokalemia and do not
demonstrate that treatment is working.
DIF: Understanding/Comprehension REF: 177
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Evaluation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
7. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions
should the nurse include in this clients care plan? (Select all that apply.)
a. Encourage oral fluid intake of at least 2 L/day.
b. Use a draw sheet to reposition the client in bed.
c. Strain all urine output and assess for urinary stones.
d. Provide nonslip footwear for the client to use when out of bed. e. Rotate the client from side to side
every 2 hours.
ANS: B, D
Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a
priority. Nursing staff should use a draw sheet when repositioning the client in bed and have the client
wear nonslip footwear when out of bed to prevent fractures and falls. The other interventions would
not provide safety for this client.
DIF: Applying/Application REF: 181
KEY: Electrolyte imbalance
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
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Chapter 12: Assessment and Care of Patients with Acid-Base Imbalances
MULTIPLE CHOICE
1. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The
clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L.
Which manifestation should the nurse identify as an example of the clients compensation mechanism?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys
ANS: A
This client has metabolic acidosis. The respiratory system compensates by increasing its activity and
blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of
hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not
release acids.
DIF: Applying/Application REF: 192
KEY: Acid-base imbalance| laboratory values
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas
values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should
the nurse perform first?
a. Cardiac rate and rhythm
b. Skin and mucous membranes c. Musculoskeletal strength
d. Level of orientation
ANS: A
Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate
and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes
will be present. Central nervous system and neuromuscular system changes do not occur with mild
acidosis and should be monitored if the acidosis worsens. Skin and mucous membrane assessment is not
a priority now, but will change as acidosis worsens.
DIF: Applying/Application REF: 192
KEY: Acid-base imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
3. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base
imbalance should the nurse assess to prevent complications of this therapy?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis d. Metabolic alkalosis
ANS: D
Many diuretics, especially loop diuretics, increase the excretion of hydrogen ions, leading to excess acid
loss through the renal system. This situation is an acid deficit of metabolic origin.
DIF: Applying/Application REF: 195
KEY: Acid-base imbalance| diuretics
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should
the
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nurse take?
a. Monitor daily hemoglobin and hematocrit values. b. Administer furosemide (Lasix) intravenously.
c. Encourage the client to take deep breaths.
d. Teach the client fall prevention measures.
ANS: D
The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client
safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other
nursing interventions are not appropriate for metabolic alkalosis.
DIF: Remembering/Knowledge REF: 196
KEY: Acid-base imbalance| falls| safety
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
5. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For
which manifestation of this acid-base imbalance should the nurse assess?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvosteks sign
ANS: B
The pancreas is a major site of bicarbonate production. Pancreatitis can cause a relative metabolic
acidosis through underproduction of bicarbonate ions. Manifestations of acidosis include lethargy and
Kussmaul respirations. Agitation, seizures, and a positive Chvosteks sign are manifestations of the
electrolyte imbalances that accompany alkalosis.
DIF: Applying/Application REF: 192
KEY: Acid-base imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas
values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the
nurse take next?
a. Assess clients rate, rhythm, and depth of respiration.
b. Measure the clients pulse and blood pressure.
c. Document the findings and continue to monitor. d. Notify the physician as soon as possible.
ANS: A
Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness
can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia),
but these would best be assessed with cardiac monitoring. Findings should be documented, but simply
continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to
report.
DIF: Applying/Application REF: 192
KEY: Acid-base imbalance
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
7. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg,
PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these
values?
a. Diabetic ketoacidosis in a person with emphysema
b. Bronchial obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent d. Diarrhea for 36 hours in an older, frail woman
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ANS: B
Arterial blood gas values indicate that the client has acidosis with normal levels of bicarbonate,
suggesting that the problem is not metabolic. Arterial concentrations of oxygen and carbon dioxide are
abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from
inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute
respiratory problem rather than a chronic problem, because no renal compensation has occurred.
DIF: Analyzing/Analysis REF: 193
KEY: Acid-base imbalance| laboratory values
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
8. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients
arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which
action should the nurse take first?
a. Apply oxygen by mask or nasal cannula.
b. Apply a paper bag over the clients nose and mouth.
c. Administer 50 mL of sodium bicarbonate intravenously.
d. Administer 50 mL of 20% glucose and 20 units of regular insulin.
ANS: A
The client has experienced a combination of metabolic and acute respiratory acidosis through heavy
skeletal muscle contractions and no gas exchange. When the seizures have stopped and the client can
breathe again, the fastest way to return acid-base balance is to administer oxygen. Applying a paper bag
over the clients nose and mouth would worsen the acidosis. Sodium bicarbonate should not be
administered because the clients arterial bicarbonate level is normal. Glucose and insulin are
administered together to decrease serum potassium levels. This action is not appropriate based on the
information provided.
DIF: Applying/Application REF: 189
KEY: Acid-base imbalance| laboratory values| medical emergency
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
9. After teaching a client who was malnourished and is being discharged, a nurse assesses the clients
understanding. Which statement indicates the client correctly understood teaching to decrease risk for
the development of metabolic acidosis?
a. I will drink at least three glasses of milk each day.
b. I will eat three well-balanced meals and a snack daily.
c. I will not take pain medication and antihistamines together. d. I will avoid salting my food when
cooking or during meals.
ANS: B
Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells to switch
to using fats for fuel and by creating ketoacids as a by-product of excessive fat metabolism. Eating
sufficient calories from all food groups helps reduce this risk.
DIF: Applying/Application REF: 191
KEY: Acid-base imbalance| nutrition MSC: Integrated Process: Teaching/Learning NOT: Client Needs
Category: Health Promotion and Maintenance
10. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2
28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?
a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease (COPD) d. Diabetic ketoacidosis and emphysema
ANS: B
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The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial
pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to
hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to
respiratory acidosis, and the client with emphysema most likely would have combined metabolic
acidosis on top of a mild, chronic respiratory acidosis.
DIF: Applying/Application REF: 194
KEY: Acid-base imbalance| laboratory values
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
11. After providing discharge teaching, a nurse assesses the clients understanding regarding increased
risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?
a. I dont drink milk because it gives me gas and diarrhea.
b. I have been taking digoxin every day for the last 15 years.
c. I take sodium bicarbonate after every meal to prevent heartburn.
d. In hot weather, I sweat so much that I drink six glasses of water each day.
ANS: C
Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause
metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of
metabolic alkalosis.
DIF: Analyzing/Analysis REF: 195
KEY: Acid-base imbalance| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance
12. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas
values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order
should the nurse expect to receive?
a. Furosemide (Lasix) 40 mg intravenous push
b. Sodium bicarbonate 100 mEq diluted in 1 L of D5W c. Mechanical ventilation
d. Indwelling urinary catheter
ANS: B
This clients arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions
from diarrhea. The bicarbonate should be replaced to help restore this clients acid-base balance.
Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this
may improve the clients pH, the client has excessive diarrhea and cannot afford to lose more fluid.
Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their oxygen
saturation at 90%, or who have respirator muscle fatigue. Mechanical ventilation and an indwelling
urinary catheter would not be prescribed for this client.
DIF: Applying/Application REF: 191
KEY: Acid-base imbalance| laboratory values| elimination
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
13. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm
Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
a. Assess the airway.
b. Administer prescribed bronchodilators.
c. Provide oxygen.
d. Administer prescribed mucolytics.
ANS: A
All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs.
However, the priority is assessing and maintaining an airway. Without a patent airway, other
interventions will not be
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helpful.
DIF: Applying/Application REF: 191
KEY: Acid-base imbalance| laboratory values
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
14. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are
pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask
when developing this clients plan of care?
a. Do you take any over-the-counter medications?
b. You appear anxious. What is causing your distress?
c. Do you have a history of anxiety attacks?
d. You are breathing fast. Is this causing you to feel light-headed?
ANS: B
The nurse should assist the client who is experiencing anxiety-induced respiratory alkalosis to identify
causes of the anxiety. The other questions will not identify the cause of the acid-base imbalance.
DIF: Applying/Application REF: 195
KEY: Acid-base imbalance| laboratory values
MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Psychosocial
Integrity
15. A nurse is caring for a client who has chronic emphysema and is receiving oxygen therapy at 6 L/min
via nasal cannula. The following clinical data are available:
Arterial Blood Gases Vital Signs
pH = 7.28 Pulse rate = 96 beats/min
PaO2 = 85 mm Hg Blood pressure = 135/45
PaCO2 = 55 mm Hg Respiratory rate = 6 breaths/min
HCO3 = 26 mEq/L O2 saturation = 88%
Which action should the nurse take first?
a. Notify the Rapid Response Team and provide ventilation support. b. Change the nasal cannula to a
mask and reassess in 10 minutes.
c. Place the client in Fowlers position if he or she is able to tolerate it. d. Decrease the flow rate of
oxygen to 2 to 4 L/min, and reassess.
ANS: A
The primary trigger for respiration in a client with chronic respiratory acidosis is a decreased arterial
oxygen level (hypoxic drive). Oxygen therapy can inhibit respiratory efforts in this case, eventually
causing respiratory arrest and death. The nurse could decrease the oxygen flow rate; eventually, this
might improve the clients respiratory rate, but the priority action would be to call the Rapid Response
Team whenever a client with chronic carbon dioxide retention has a respiratory rate less than 10
breaths/min. Changing the cannula to a mask does nothing to improve the clients hypoxic drive, nor
would it address the clients most pressing need. Positioning will not help the client breathe at a normal
rate or maintain client safety.
DIF: Applying/Application REF: 194
KEY: Acid-base imbalance| laboratory values
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. A nurse is planning interventions that regulate acid-base balance to ensure the pH of a clients blood
remains within the normal range. Which abnormal physiologic functions may occur if the client
experiences an acid- base imbalance? (Select all that apply.)
a. Reduction in the function of hormones
b. Fluid and electrolyte imbalances
c. Increase in the function of selected enzymes
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d. Excitable cardiac muscle membranes
e. Increase in the effectiveness of many drugs
ANS: A, B, E
Acid-base imbalances interfere with normal physiology, including reducing the function of hormones
and enzymes, causing fluid and electrolyte imbalances, making heart membranes more excitable, and
decreasing the effectiveness of many drugs.
DIF: Remembering/Knowledge REF: 185
KEY: Acid-base imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
2. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas
values are pH 7.32, PaO2 94 mm Hg, PaCO2 34 mm Hg, and HCO3 18 mEq/L. For which clinical
manifestations should the nurse assess? (Select all that apply.)
a. Reduced deep tendon reflexes
b. Drowsiness
c. Increased respiratory rate d. Decreased urinary output e. Positive Trousseaus sign
ANS: A, B, C
Metabolic acidosis causes neuromuscular changes, including reduced muscle tone and deep tendon
reflexes. Clients usually present with lethargy and drowsiness. The respiratory system will attempt to
compensate for the metabolic acidosis; therefore, respirations will increase rate and depth. A positive
Trousseaus sign is associated with alkalosis. Decreased urine output is not a manifestation of metabolic
acidosis.
DIF: Understanding/Comprehension REF: 192
KEY: Acid-base imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
3. A nurse is assessing clients who are at risk for acid-base imbalance. Which clients are correctly paired
with the acid-base imbalance? (Select all that apply.)
a. Metabolic alkalosis Young adult who is prescribed intravenous morphine sulfate for pain
b. Metabolic acidosis Older adult who is following a carbohydrate-free diet
c. Respiratory alkalosis Client on mechanical ventilation at a rate of 28 breaths/min
d. Respiratory acidosis Postoperative client who received 6 units of packed red blood cells e. Metabolic
alkalosis Older client prescribed antacids for gastroesophageal reflux disease
ANS: B, C, E
Respiratory acidosis often occurs as the result of underventilation. The client who is taking opioids,
especially IV opioids, is at risk for respiratory depression and respiratory acidosis. One cause of
metabolic acidosis is a strict low-calorie diet or one that is low in carbohydrate content. Such a diet
increases the rate of fat catabolism and results in the formation of excessive ketoacids. A ventilator set
at a high respiratory rate or tidal volume will cause the client to lose too much carbon dioxide, leading to
an acid deficit and respiratory alkalosis. Citrate is a substance used as a preservative in blood products.
It is not only a base, it is also a precursor for bicarbonate. Multiple units of packed red blood cells could
cause metabolic alkalosis. Sodium bicarbonate antacids may increase the risk of metabolic alkalosis.
DIF: Analyzing/Analysis REF: 192
KEY: Acid-base imbalance
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
4. A nurse assesses a client who is receiving total parenteral nutrition. For which adverse effects related
to an acid-base imbalance should the nurse assess? (Select all that apply.)
a. Positive Chvosteks sign
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b. Elevated blood pressure c. Bradycardia
d. Increased muscle strength e. Anxiety and irritability
ANS: A, E
A client receiving total parenteral nutrition is at risk for metabolic alkalosis. Manifestations of metabolic
alkalosis include positive Chvosteks sign, normal or low blood pressure, increased heart rate, skeletal
muscle weakness, and anxiety and irritability.
DIF: Applying/Application REF: 194
KEY: Acid-base imbalance| nutrition
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
5. A nurse is planning care for a client who is anxious and irritable. The clients arterial blood gas values
are pH 7.30, PaO2 96 mm Hg, PaCO2 43 mm Hg, and HCO3 19 mEq/L. Which questions should the nurse
ask the client and spouse when developing the plan of care? (Select all that apply.)
a. Are you taking any antacid medications?
b. Is your spouses current behavior typical?
c. Do you drink any alcoholic beverages?
d. Have you been experiencing any vomiting?
e. Are you experiencing any shortness of breath?
ANS: B, C
This clients symptoms of anxiety and irritability are related to a state of metabolic acidosis. The nurse
should ask the clients spouse or family members if the clients behavior is typical for him or her, and
establish a baseline for comparison with later assessment findings. The nurse should also assess for
alcohol intake because alcohol can change a clients personality and cause metabolic acidosis. The other
options are not causes of metabolic acidosis.
DIF: Applying/Application REF: 193
KEY: Acid-base imbalance| laboratory values
MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Psychosocial
Integrity
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