Nur 151 Exam 4

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1.

A client is admitted to the hospital with a

decreased serum osmolarity and a serum
sodium of 126 mEq/L. In further assessing the
client, which of the following assessments
would indicate that hyponatremia is caused
by fluid volume excess?
a. Distended neck veins
b. Decreased urine output
c. Rapid weight gain
d. Increased rate and depth of respirations
e. Bounding pulse
f. Gravity of urine is lower

2.

A client with a history of severe diarrhea

presents with a rapid pulse, orthostatic
hypotension, urine output of 20 mL/hr, pale
skin, and increased respiratory rate. In
evaluating the client's laboratory values, you
would expect to see which abnormality?
a.
b.
c.
d.

3.

4.

5.

a. Rehydration
c.
Administration
of an antidiarrheal

a. Increased
blood
pressure over
base
c. Crackles
auscultated in
the lung fields

Increased blood pressure over base

Urinary output of 40 mL/hr
Crackles auscultated in the lung fields
Decreased urine specific gravity

A client with gastroenteritis should be

assessed for fluid and electrolyte balance.
The nurse understands that most nutrients
and electrolytes are absorbed in the:
a.
b.
c.
d.

Which patient is at greatest risk of

hyperkalemia?
a. 65 y.o. with acute renal failure
b. 24 y.o. with excessive vomiting and
diarrhea
c. 48 y.o. who is on a potassium
supplement and uses a salt substitute
d. 84 y.o. with severe dehydration due to
vomiting and limited oral intake

a. 65 y.o. with
acute renal
failure

7.

Your patient is on Lasix & is diuresing

well. He is not a potassium supplement
and refuses to eat fruit or vegetables.
Symptoms of greatest concern?
a. Fatigue
b. Nausea & vomiting
c. Weakness
d. Irregular pulse
e. Anxiety
f. Irritability
e. Weakness of LE

d. Irregular
pulse (cardiac
arrhythmia)

8.

Diabetic patient with ketoacidosis may

first compensate by:
a. Excreting hydrogen ions
b. Hyperventilating
c. Excreting HCO3
d. Hypoventilating

b.
Hyperventilating

9.

Your patient is on Lasix & is diuresing

well. He is not a potassium supplement
and refuses to eat fruit or vegetables.
These symptoms (muscle weakness &
cramping, irregular pulse)
indicate possible:
a. Hypernatremia
b. Hypokalemia
c. Hypocalcemia
d. Hyperkalemia

b. hypokalemia

10.

Diabetic pt. c/o/ lethargy, confusion &

cramps. He has warm, flushed skin,
decreased pH & decreased HCO3, and has
not eaten for 24 hrs. This may indicate:
a. Respiratory acidosis
b. Metabolic acidosis
c. Respiratory alkalosis
d. Metabolic alkalosis

b. Metabolic
acidosis

11.

Name the acid-base imbalance: Homeless

person with sx of starvation - 7.32 pH, CO2
36, HCO3 20
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis

1. Metabolic
acidosis

12.

COPD patient - pH 7.32, CO2 50, HCO3 30

1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis

3. Respiratory
acidosis w/
partial
compensation

Re-hydration
Administration of a diuretic
Administration of an anti-diarrheal
Replacement of glucose

A client with a history of severe diarrhea

presents with a rapid pulse, orthostatic
hypotension, urine output of 20 mL/hr, cool
pale skin, and increased respiratory rate. IV
fluids are administered. Which of the
following would indicate that the client has a
negative response to fluid replacement?
a.
b.
c.
d.

6.

d. Increased
hematocrit

Decreased urine specific gravity

Increase potassium
Decreased BUN
Increased hematocrit

A client with a history of severe diarrhea

presents with a rapid pulse, orthostatic
hypotension, urine output of 20 mL/hr, pale
skin, and increased respiratory rate.
Interventions to correct this fluid volume
imbalance include:
a.
b.
c.
d.

a. Distended
neck veins
c. Rapid
weight gain
d. Increased
rate and
depth of
respirations
e. Bounding
pulse
f. Gravity of
urine is lower

The
The
The
The

colon
stomach
liver
small intestine

d. The small
intestine

13.

Someone having a panic attack and

hyperventilating. C/o numbness and tingling
to fingers. pH 7.48, CO2 32, HCO3 23
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis

4.
Respiratory
alkalosis

21.

The most reliable index of fluid volume

status when caring for a pt with a fluid
imbalance is:
a. Skin turgor
b. Presence of edema
c. Hourly urinary output
d. Daily weight patterns

d. Daily
weight
patterns

14.

Your patient has a K+ value of 3.0. You are

most concerned about:
1. Muscle weakness
2. Confusion
3. Cardiac dysrhythmias
4. Renal failure

3. Cardiac
dysrhythmias

22.

b.
Restlessness
and anxiety

15.

Patient who had neck surgery has a positive

Chvostek's and Trousseau's signs. This
indicates probable:
1. Hypocalcemia
2. Hypercalcemia
3. Hypokalemia
4. Hyperkalemia
5. Hyponatremia
6. Hypernatremia

1.
Hypocalcemia

The nurse is working on a pulmonary unit at

the local hospital. The nurse is alert to the
early signs of hypoxia in the clients, which
include:
a. Cyanosis
b. Restlessness and anxiety
c. A decreased respiratory rate
d. A decreased blood pressure

23.

d. Assess
the client's
pulse
oximetry
reading

Peripheral edema may be an indication of:

1. CHF
2. Hypokalemia
3. A protein deficiency
4. Dehydration
5. Fluid volume excess
6. Renal failure

1. CHF
3. A protein
deficiency
5. Fluid
volume
excess
6. Renal
failure

When assisting with PM care for an 82 y.o.

client who is recuperating from pneumonia,
the nurse observes that the client appears to
be uncharacteristically confused, asking
"Where am I?" Which of the following
interventions should the nurse perform first?
a. Listen for lung sounds
b. Reorient the client to place
c. Ask some simple questions to confirm the
confusion
d. Assess the client's pulse oximetry reading

24.

17.

What fluid imbalance may be present if

electrolytes & Hct. appear high?
1. Fluid volume excess
2. Fluid volume deficit
3. These labs would not be affected by fluid
volume

2. Fluid
volume deficit

If a client with COPD is complaining of

trouble breathing, the nurse should (in order)
1. call the physician
2. Start the client on oxygen as ordered
3. Instruct the client to breath slowly using
pursed lip breathing
4. Call RT for an SVN treatment
5. Place the client in semi-fowler's or tripod
position
6. Assess pulse ox and other VS

18.

What is the best determination of fluid

balance in a patient at risk?
1. Daily weights
2. Electrolyte values
3. Skin turgor
4. Presence of edema
5. Urine output

1. Daily
weights

19.

Clubbing is most common in:

1. Dehydration
2. COPD or congenital heart disease
3. Party girls
4. Renal failure
5. Peripheral vascular disease

2. COPD or
congenital
heart disease

5. Place the
client in
semi-fowler's
or tripod
position
6. Assess
pulse ox and
other VS
2. Start the
client on
oxygen as
ordered
4. Call RT for
an SVN
treatment
3. Instruct
the client to
breath slowly
using pursed
lip breathing
1. call the
physician

25.

3. On the
oral mucosa

Which 2 clients are at greatest risk for FVE

(fluid volume excess)?
1. Client w/ an ileostomy
2. Client w/CHF
3. Client taking diuretics
4. Client on IV fluids and GI suctioning
5. Client w/acute renal failure

2. Client
w/CHF
5. Client
w/acute renal
failure

Central cyanosis which indicate hypoxia is

best detected:
1. On the palms and soles of the feet
2. On the nail beds
3. On the oral mucosa
4. In the sclera of the eyes

16.

20.

26.

Cardiac dysrhythmias may occur secondary to which electrolyte imbalance:

1. Hyponatremia
2. Hypokalemia
3. Hyperkalemia
4. Hypernatremia

2. Hypokalemia (best answer) or could also be

3. Hyperkalemia

27.

Possible causes of hypercalcemia include:

a. Renal failure
b. Malnutrition
c. Prolonged immobility
d. Protein deficiency

c. Prolonged immobility

28.

Weight gain, dyspnea, orthopnea, and edema indicate probable:

1. Fluid volume deficiency
2. Fluid volume excess
3. Dehydration
4. Hypernatremia

2. Fluid volume excess