OXYGEN, FLUID BALANCE AND ELECTROLYTES EXAM
ALL QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES|AGRADE
The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with
severe pneumonia. What ABG results are most consistent with this diagnosis?
pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L
pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L
pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L - ANSWER: pH: 7.20, PaCO2: 65 mm
Hg, HCO3-: 26 mEq/L
Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the
PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3-
occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg,
HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm
Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2:
45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.
When caring for a patient who has risk factors for fluid and electrolyte imbalances,
which of the following assessment findings is the highest priority for the nurse to
follow up?
Mild confusion
Irregular heart rate
Blood pressure 96/53 mm Hg Weight loss of 4 lb - ANSWER: 2.
Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia.
Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight
loss is a good indicator of the amount of fluid lost, but following up on potential
cardiac dysrhythmias is a higher priority. Confusion may occur with dehydration and
hyponatremia, but following up on potential cardiac dysrhythmias is a higher
priority. The blood pressure is slightly lower than normal but is not life threatening.
Following up on potential cardiac dysrhythmias is a higher priority.
Patients diagnosed with hypervolemia should avoid sweet or dry food because
it increases the patient's desire to consume fluid.
it can cause dehydration.
it can lead to weight gain.
it obstructs water elimination. - ANSWER: it increases the patient's desire to
consume fluid.
Which of the following may occur with respiratory acidosis?
Decreased blood pressure
Third spacing Increased intracranial pressure (ICP) Decreased pulse - ANSWER: 3.
If respiratory acidosis is severe, intracranial pressure may increase, resulting in
papilledema and dilated conjunctival blood vessels. Increased blood pressure,
,increased pulse, and decreased mental alertness occur with respiratory acidosis.
Respiratory acidosis does not result in the fluid shifts known as third spacing.
Which of the following statements accurately reflects a rule of thumb upon which
the nurse may rely in assessing the patient's fluid balance?
Minimal urine output of 10 mL per hour
Minimal intake of 1.5 liters per day Minimal intake of 2 liters per day Minimal urine
output of 50 mL per hour - ANSWER: Minimal intake of 1.5 liters per day
The nurse is conducting a lecture on the difference between hypovolemia and
dehydration. When completing a verbal comparison, which point needs clarified?
Hypovolemia contains only low blood volume.
In dehydration, only extracellular is depleted.
Similar causes are present in both conditions.
Both conditions result in abnormal laboratory studies. - ANSWER: In dehydration,
only extracellular is depleted.
In clients diagnosed with dehydration, all fluid compartments including the
intracellular and extracellular compartment are reduced. The other options are
correct. Both states can be from similar disease process such as vomiting, fever,
diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that
hypovolemia relates to low blood volume.
Upon shift report, the nurse learns the following laboratory values: pH, 7.44; PCO2,
30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which
acid-base imbalance is the client most likely experiencing?
Compensated metabolic alkalosis Compensated metabolic acidosis Compensated
respiratory alkalosis Uncompensated respiratory alkalosis - ANSWER: Compensated
respiratory alkalosis
The question states that the client has a history of acid-base disturbance. The nurse
would first note that the pH has returned to close to normal indicating
compensation. The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3
(normal: 22 to 27mEq/L) levels. *In a respiratory condition, the pH and the PCO2
move in opposite direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice
versa (acidosis)*. *In a metabolic condition, the pH and the bicarbonate move in the
same direction*; if the pH is low, the bicarbonate level will be low, also. In this client,
the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2
is low, indicating a respiratory condition (opposite direction of the pH).
Which of the following electrolyte imbalances occur with adrenal insufficiency?
Hyperkalemia
Hypernatremia
, Hypokalemia
Hyponatremia - ANSWER: *Hyperkalemia occurs with adrenal insufficiency*.
*Hypokalemia occurs with gastrointestinal and renal losses*. *Hyponatremia occurs
with increased thirst and antidiuretic hormone* (ADH) release. *Hypernatremia
results from increased insensible losses and diabetes insipidus*.
Which of the following would be appropriate nursing interventions for a client with
hypokalemia? Select all that apply.
Administer the ordered Furosemide (lasix) 60 mg po.
Offer a diet with fruit juices and citrus fruits.
Administer the ordered potassium 40 mg IV push.
Administer the ordered Kayexalate enema.
Monitor intake and output every shift. - ANSWER: Monitor intake and output every
shift.
Offer a diet with fruit juices and citrus fruits.
The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater
near-drowning event. The client is restless, lethargic, and demonstrating tremors.
Additional assessment findings include swollen dry tongue, flushed skin, and
peripheral edema. The nurse anticipated that the patient's serum sodium value
would be which of the following?
135 mEq/L
125 mEq/L
145 mEq/L
155 mEq/L - ANSWER: 155.
The patient is experiencing signs and symptoms (S/S) of hypernatremia.
Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A
cause of hypernatremia is near drowning in seawater (which contains a sodium
concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst,
elevated body temperature, swollen dry tongue and sticky mucous membranes,
hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic
seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia,
elevated pulse, and elevated blood pressure.
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the
client is at risk for developing which of the following acid-base imbalances?
Respiratory alkalosis
Metabolic acidosis
Respiratory acidosis
Metabolic alkalosis - ANSWER: Metabolic acidosis.
The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by
diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal
insufficiency; excessive administration of chloride; and the administration of
ALL QUESTIONS AND CORRECT DETAILED ANSWERS
WITH RATIONALES|AGRADE
The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with
severe pneumonia. What ABG results are most consistent with this diagnosis?
pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L
pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L
pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L - ANSWER: pH: 7.20, PaCO2: 65 mm
Hg, HCO3-: 26 mEq/L
Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the
PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3-
occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg,
HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm
Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2:
45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.
When caring for a patient who has risk factors for fluid and electrolyte imbalances,
which of the following assessment findings is the highest priority for the nurse to
follow up?
Mild confusion
Irregular heart rate
Blood pressure 96/53 mm Hg Weight loss of 4 lb - ANSWER: 2.
Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia.
Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight
loss is a good indicator of the amount of fluid lost, but following up on potential
cardiac dysrhythmias is a higher priority. Confusion may occur with dehydration and
hyponatremia, but following up on potential cardiac dysrhythmias is a higher
priority. The blood pressure is slightly lower than normal but is not life threatening.
Following up on potential cardiac dysrhythmias is a higher priority.
Patients diagnosed with hypervolemia should avoid sweet or dry food because
it increases the patient's desire to consume fluid.
it can cause dehydration.
it can lead to weight gain.
it obstructs water elimination. - ANSWER: it increases the patient's desire to
consume fluid.
Which of the following may occur with respiratory acidosis?
Decreased blood pressure
Third spacing Increased intracranial pressure (ICP) Decreased pulse - ANSWER: 3.
If respiratory acidosis is severe, intracranial pressure may increase, resulting in
papilledema and dilated conjunctival blood vessels. Increased blood pressure,
,increased pulse, and decreased mental alertness occur with respiratory acidosis.
Respiratory acidosis does not result in the fluid shifts known as third spacing.
Which of the following statements accurately reflects a rule of thumb upon which
the nurse may rely in assessing the patient's fluid balance?
Minimal urine output of 10 mL per hour
Minimal intake of 1.5 liters per day Minimal intake of 2 liters per day Minimal urine
output of 50 mL per hour - ANSWER: Minimal intake of 1.5 liters per day
The nurse is conducting a lecture on the difference between hypovolemia and
dehydration. When completing a verbal comparison, which point needs clarified?
Hypovolemia contains only low blood volume.
In dehydration, only extracellular is depleted.
Similar causes are present in both conditions.
Both conditions result in abnormal laboratory studies. - ANSWER: In dehydration,
only extracellular is depleted.
In clients diagnosed with dehydration, all fluid compartments including the
intracellular and extracellular compartment are reduced. The other options are
correct. Both states can be from similar disease process such as vomiting, fever,
diarrhea and difficulty swallowing and also have abnormal lab work. It is correct that
hypovolemia relates to low blood volume.
Upon shift report, the nurse learns the following laboratory values: pH, 7.44; PCO2,
30mmHg; and HCO3,21 mEq/L for a client with noted acid-base disturbances. Which
acid-base imbalance is the client most likely experiencing?
Compensated metabolic alkalosis Compensated metabolic acidosis Compensated
respiratory alkalosis Uncompensated respiratory alkalosis - ANSWER: Compensated
respiratory alkalosis
The question states that the client has a history of acid-base disturbance. The nurse
would first note that the pH has returned to close to normal indicating
compensation. The nurse then assess the PCO2 (normal: 35 to 45 mm Hg) and HCO3
(normal: 22 to 27mEq/L) levels. *In a respiratory condition, the pH and the PCO2
move in opposite direction; thus, the pH rises and the PCO2 drops (alkalosis) or vice
versa (acidosis)*. *In a metabolic condition, the pH and the bicarbonate move in the
same direction*; if the pH is low, the bicarbonate level will be low, also. In this client,
the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2
is low, indicating a respiratory condition (opposite direction of the pH).
Which of the following electrolyte imbalances occur with adrenal insufficiency?
Hyperkalemia
Hypernatremia
, Hypokalemia
Hyponatremia - ANSWER: *Hyperkalemia occurs with adrenal insufficiency*.
*Hypokalemia occurs with gastrointestinal and renal losses*. *Hyponatremia occurs
with increased thirst and antidiuretic hormone* (ADH) release. *Hypernatremia
results from increased insensible losses and diabetes insipidus*.
Which of the following would be appropriate nursing interventions for a client with
hypokalemia? Select all that apply.
Administer the ordered Furosemide (lasix) 60 mg po.
Offer a diet with fruit juices and citrus fruits.
Administer the ordered potassium 40 mg IV push.
Administer the ordered Kayexalate enema.
Monitor intake and output every shift. - ANSWER: Monitor intake and output every
shift.
Offer a diet with fruit juices and citrus fruits.
The nurse is caring for a patient in the intensive care unit (ICU) following a saltwater
near-drowning event. The client is restless, lethargic, and demonstrating tremors.
Additional assessment findings include swollen dry tongue, flushed skin, and
peripheral edema. The nurse anticipated that the patient's serum sodium value
would be which of the following?
135 mEq/L
125 mEq/L
145 mEq/L
155 mEq/L - ANSWER: 155.
The patient is experiencing signs and symptoms (S/S) of hypernatremia.
Hypernatremia is a serum sodium level higher than 145 mEq/L (145 mmol/L). A
cause of hypernatremia is near drowning in seawater (which contains a sodium
concentration of approximately 500 mEq/L). S/S of hypernatremia include thirst,
elevated body temperature, swollen dry tongue and sticky mucous membranes,
hallucinations, lethargy, restlessness, irritability, simple partial or tonic-clonic
seizures, pulmonary edema, hyperreflexia, twitching, nausea, vomiting, anorexia,
elevated pulse, and elevated blood pressure.
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the
client is at risk for developing which of the following acid-base imbalances?
Respiratory alkalosis
Metabolic acidosis
Respiratory acidosis
Metabolic alkalosis - ANSWER: Metabolic acidosis.
The client is at risk for developing metabolic acidosis. Metabolic acidosis is caused by
diarrhea, lower intestinal fistulas, ureterostomies, and use of diuretics; early renal
insufficiency; excessive administration of chloride; and the administration of
