242

243

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FLUIDS AND ELECTROLYTE IMBALANCES
1. Mama Alats latest electrolyte level reveals acute sodium depletion and remaining 110 mEq/L
sodium level. The medical regimen ordered is to infuse Mama Alat with highly hypertonic sodium
solution of 5% NaCl. The nurse understands that this regimen is essential to
a. promote aldosterone release to reabsorb sodium and water
b. allow sodium ions to enter the cells
c. correct the acute sodium depletion
d. relieve the acute manifestations of cerebral edema
2. A client is diagnosed with severe anemia after many episodes of syncope and extreme
fatigability. Blood transfusion is ordered. Prior to the administration of the blood, the serum
potassium level of the client and the storage time of the blood are determined. The scientific
rationale for this is:
a. aged blood has high serum potassium concentration that can lead to hyperkalemia
b. prolonged blood storage causes cellular lysis that can lead to hypokalemia
c. blood components have high potassium level causing hyperkalemia
d. blood administration and potassium level is indirectly proportional
3. A nurse is conducting a review class to nursing students about the functions of the different
cations and anions in the body. Chloride, the major anion of the extracellular fluid, primarily
maintains central nervous system function. Which is accurately stated?
a. Chloride, together with sodium, attracts water to form the liquid portion of the CSF.
b. Chloride, making up the composition of the intravascular fluid, assists in determining osmotic
pressure in the brain.
c. Chloride is affected by aldosterone release, which also affects sodium level for neural
functioning.
d. Chloride shift aids in hydrogen ions depression, which releases oxygen from hemoglobin for
cerebral perfusion.
4. Prior to administering the physicians order of intravenous infusion that contains potassium, it
is of utmost importance for the nurse to
a. get baseline blood pressure
b. check input and output table
c. assess the skin turgor of the abdomen
d. determine presence of edema
5. The nurse is developing a plan of care for a client with heart failure, who is at risk for excess
fluid volume. Which physiological change ensuing from heart failure corroborations this nursing
diagnosis?
a. rapid sodium excretion
b. Improved cardiac output
c. elevated antidiuretic hormone production
d. increased glomerular filtration rate
6. The nurse is preparing to start the IV of Mr. Flow, a 70-year-old client, with order of 125 ml per
hour of continuous fluid replacement. What are the equipments the nurse should prepare at the
bedside before IV insertion?
a. 1-inch cannula, gauge 18 lumen, to be inserted in the left arm, antecubital region
b. 1-inch cannula, gauge 22 lumen, to be inserted in the top vein of the left hand
c. 3-inch cannula, gauge 18 lumen, to be inserted in the left hand
d. 3-inch cannula, gauge 22 lumen, to be inserted in the right arm, antecubital region

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7. A client with liver problem developed ascites. Because of continuous increase in abdominal
girth, paracentesis will be done to the client. After the first fluid aspiration, total of 1800 ml of
fluid is removed. Following the procedure, the immediate action of the nurse is to watch out for
a. Symptoms of decreased peristalsis.
b. Complaints of respiratory difficulty and congestion.
c. Fever and chills.
d. Signs of vascular collapse.
8. Upon auscultation of the lungs, crackles was noted on the base of both lungs of a client with
cirrhosis. The client was also observed with dyspnea. The nurse suspects fluid volume excess.
The nurse will also anticipate which of the following signs that the client may elicit?
a. blood pressure of 150/90
b. urine output of 100 for the passed 3 hours
c. pulse of grade 1+
d. negative jugular vein distention
9. Nurse Dylan is monitoring a client who is hypotensive. The nurse is aware that the body will
compensate when this condition persists by activating the renin-angiotensin mechanism. The
nurse will expect which of the following electrolytes will be affected in this mechanism?
a. Potassium, sodium, and magnesium
b. Chloride, calcium and sodium
c. Calcium, magnesium and phosphate
d. Sodium, chloride, and potassium
10. Fluid volume deficit is suspected on a client who has been taking diuretics on a long-term
basis. The nurse assigned on the client should monitor for what diagnostic abnormality related to
the clients condition?
a. hematocrit of 30%
b. potassium level of 3.6 mEq/L
c. urine specific gravity of 1.035
d. central venous pressure 11 cm H20
11. Among the body functions below, osmosis can accomplish
a. Ventilation and perfusion
b. Urine production
c. Sweat production
d. Blood coagulation
12. A patient who has a history of chronic alcoholism goes to the hospital with his latest
laboratory result of decreased magnesium level. When performing the initial assessment, the
nurse should give emphasis on assessing the
a. Musculoskeletal system
b. Renal system
c. Respiratory system
d. Cardiovascular system
13. As a knowledgeable nurse, you are aware that calcium level of 8.5 mg/dl is related to which
of the following conditions?
a. Hyperparathyroidism that elevates the level of parathormone to attract calcium back to the
circulation

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b. Multiple myeloma that increases bone breakdown leading to the exit of calcium from the bone
to the blood
c. Comatose state will signal osteoclastic activity and bone resorption
d. Chronic renal failure leading to inability to metabolize Vitamin D that promotes calcium
absorption
14. Sodium polystyrene sulfonate (Kayexalate) enema will be administered by Nurse Azin to a
client with a potassium level of 6.0 mEq/L. Nurse Azin is correct when she instructs the client to
do what activity and expect which of the following side effects?
a. retain the enema for 30 minutes to allow for glucose exchange; afterward,
have diarrhea
b. retain the enema for 60 minutes to allow for glucose exchange; diarrhea is
reduce the potassium level
c. retain the enema for 30 minutes to allow for sodium exchange; afterward,
have diarrhea.
d. retain the enema for 60 minutes to allow for sodium exchange; diarrhea is
reduce the potassium level.

the client should

not necessary to
the client should
not necessary to

15. After 1 week of hospitalization, the patient develops hypokalemia. Which of the following are
significant symptoms of his disorder?
1.
2.
3.
4.
5.
6.
7.

Muscle weakness
Leg cramps
Hypertension and tachycardia
Decreased bowel motility
U wave on ECG
Inverted T wave on ECG
Muscle irritability

a. all except 4 and 5

b. all except 3 and 7
c. 1, 2, 3, 5
d. 1, 2, 4, 5
16. Nurse Electra is reviewing the health care providers orders for a client who was transferred
from surgery following aortic aneurysm repair. The orders are maintain client on NPO, keep
nasogastric tube in place, vital signs q 1 hour, and an order that the nurse thinks he should
clarify with the physician. The order that is pertained in the situation that needs physicians
clarification is
a. 50 ml D5W with Cefoxitin (Mefoxin) 1gm IV over 30 minutes.
b. 40 mEq potassium diluted in 1L D5W over 8 hours
c. 25 mEq potassium IV push.
d. 10 mEq in 250 ml D5W to run over 3 hours
17. A client developed hypermagnesemia due to untreated diabetic ketoacidosis. The nurse
assigned to the client most likely expect all of the manifestation except
a. facial flushing, drowsiness, and dysarthria
b. muscle weakness, shallow breathing, and hypotension
c. urine output of 20 cc/hour, nausea and vomiting
d. absent patellar reflex, muscle rigidity and spasm
18. A client is now transferred back to the surgical floor after abdominal surgery. His IV is ordered
to run at 125 ml per hour. The client is also on an NPO status while a nasogastric tube is placed
for decompression. The nurse in the surgical floor will most likely expect the administration of

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a. 0.9% sodium chloride
b. Dextrose 10% in water
c. Dextrose 5% in water
d. Lactated Ringers solution
19. An IV running at 180 mL/hr via an IV pump is given to the patient following exploratory
laparotomy. A nasogastric tube is also place to decompress the abdomen. While assessing the
client, the nurse should notify the physician if which is observed?
a. Rales in all lung fields are noted upon auscultation
b. Increasing level of consciousness and negative pedal edema
c. Pump alarming that means a high pressure has been reached
d. Nasogastric tube output is 550 mL, urine output of 900 mL, and intake of 1800 mL
20. Nurse Rose is performing a dressing change on Mr. Pipin with an abdominal wound inserted
with a Penrose drain. Nurse Rose should give focus in documenting the
a. Character of drainage, clients tolerance of procedure, type of dressing used.
b. Type of dressing used, description of the wound, presence of drains with character of
drainage.
c. Description of the wound, presence and character of drainage, time and date of dressing
change.
d. Status of wound healing, amount of drainage, how client tolerated the procedure.
21. The client had a colon resection this morning. In the post-operative period, the client is given
with 0.9% NaCI at 125 ml per hour, inserted with a nasogastric tube under low-pressure suction
and was created with ileostomy. The nurse noted that the client is progressively becoming
restless. Upon reviewing the clients laboratory studies post-operatively, the nurse should be
alerted with
a. Sodium level 152 mEq/L.
b. H and H count 14.2 and 39%.
c. Blood urea nitrogen 29 mg/dl.
d. Capillary blood glucose 175 mg/dl.
22. The latest potassium level of a client with acute renal failure is 6.0 mEq/L. The priority action
of the nurse is to
a. Increase fluid intake to dilute the electrolyte concentration.
b. Request laboratory check for sodium level.
c. Add more fiber in the diet.
d. Place the client on a cardiac monitor.
23. Due to 2 days of constant fever with unknown origin, the client is for monitoring in the
hospital. Physical assessment of Nurse Chiyo reveals sticky mucous membranes and profuse
diaphoresis. Weakness and disorientation were also noted while Nurse Chiyo is interviewing the
client. The neurologic assessment shows a decreasing level of consciousness. With these
manifestations, Nurse Chiyo suspects the presence of
a. Hypermagnesemia.
b. Hypernatremia.
c. Hyperkalemia.
d. Hypercalcemia.
24. Mr. Azukal is started on low-dose intravenous insulin therapy. The nurse assigned to Mr.
Azukal is aware of the important nursing assessments in accordance to the possible
complications of this therapy, except frequent

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a. evaluation of blood glucose levels, because glucose levels should decline as insulin levels
increase
b. elevation of serum ketones to monitor the course of ketosis.
c. blood pressure measurements to monitor the degree of hypotension.
d. estimates of serum potassium, because increased blood glucose levels are correlated with
elevated potassium levels.
25. A nurse is assigned to clients with fluid imbalances. The nurse is knowledgeable to conclude
that the kidneys control the output of fluids and the input of fluid is being controlled by
a. Antidiuretic hormone
b. Thirst sensation
c. Aldosterone release
d. Renin-angiotensin mechanism
ACID-BASE IMBALANCES
26. Mr. Allen was rushed in the emergency room after overdosing with sedatives. His arterial
blood gas result reveals respiratory acidosis. He is placed on a cardiac monitor for possible
ventricullar fibrillation. The nurse is aware that this cardiac complication is related to
a. Stimulation of the medulla oblongata.
b. Depression of the SA node.
c. Sedative effect to myocardium.
d. Hyperkalemia.
27. In case Mr. Allen developed ventricullar fibrillation, what should the nurse get from the crash
cart as a preliminary emergency drug?
a. Epinephrine IM
b. Lidocaine IV push
c. Sodium bicarbonate IV
d. Potassium chloride side drip
28. A client is for monitoring in the emergency floor while waiting for the result of his arterial
blood gas. As a knowledgeable nurse, you should know what breathing pattern is most
appropriate in any of the blood gas result. Which of the following is suitably stated?
a. Pursed lip breathing is most appropriate to compensate for respiratory alkalosis
b. Purse lip breathing is most effective for respiratory acidosis
c. Ventilation with brown paper bag is suitable for respiratory acidosis
d. Ventilation with brown paper bag is least functional for respiratory alkalosis.
29. Mr. Guillermo was diagnosed of Guillain-Barr syndrome and recently develops respiratory
acidosis as a result of reduced alveolar ventilation. As the nurse caring for Mr. Guillermo, you
know that the kidneys play a major role in the compensatory mechanism of respiratory acidosis
by
a. increased GFR of acid and stimulation of serum bicarbonate secretion
b. decreased GFR of acid and suppression of serum bicarbonate secretion
c. hyperventilation and suppression of serum bicarbonate secretion
d. hyperventilation and decreased GFR of acid
30. Due to pulmonary embolism confirmed on chest x-ray, the patient is starting to manifest
symptoms of respiratory alkalosis. Other than the arterial blood gas analysis, the nurse should
also monitor for which laboratory studies?
a. hyperkalemia, hypercalcemia, hypophosphatemia

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b. hypokalemia, hypocalcemia, hyperphosphatemia
c. hyperkalemia, hypercalcemia, hyperphosphatemia
d. hypokalemia, hypocalcemia, hypophosphatemia
31. Radial arterial blood gas analysis is ordered to be performed on a client with chronic lung
infection. Before drawing the sample, the nurse performs the Allens test correctly by
1.
2.
3.
4.
5.
6.

Open the hand in a relaxed, slightly flexed position

Release the pressure on the ulnar artery
Manually occlude the ulnar artery
Flushing of hands in about 3 to 5 seconds
Asking the patient to make a fist
Observing for pallor of the palms

a. 5, 3, 1, 6, 2, 4
b. 1, 6, 3, 4, 5, 2
c. 3, 5, 6, 1, 2, 4
d. 6, 1, 3, 5, 4, 2
32. Severe diarrhea can lead to metabolic acidosis due to excessive loss of bicarbonate. The
nurse must therapeutically adhere to the collaborative management for this case. Which should
the nurse anticipate to be prescribed for metabolic acidosis?
a. Fluid replacement
b. Administration of bronchodilators
c. Breath into a brown paper bag
d. Perform postural drainage
33. The physician ordered acetazolamide (Diamox) administration for a client with metabolic
alkalosis after 24 hours of intermittent projectile vomiting. The main action of this drug in
relation to acid-base imbalance is
a. it inhibits the combination of hydrogen ions and carbonate.
b. it increases excretion of bicarbonate by the kidneys.
c. it hastens the peristalsis to excrete bicarbonate in the feces.
d. it increases carbonic acid retention in the lungs.
34. Respiratory and metabolic acidosis may result to systemic manifestation. The nurse should
monitor for
1.
2.
3.
4.
5.
6.
7.

cerebral vasoconstriction
increased blood pressure
CNS depression
hypokalemia
coma
peripheral vasodilation
increased intracranial pressure

a. 1, 2, 3, 4
b. 2, 3, 5, 7
c. 1, 3, 5, 6
d. 2, 4, 6, 7
35. Hypovolemic shock has the tendency to cause acidosis. What is the physiologic basis of this
acid-base imbalance?
a. Decreased blood volume compensates with enhancing the rate and depth of ventilation and
increased sensitivity of the central chemoreceptors.

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b. Decreased blood volume is associated with hydrogen ion excess, poor respiratory and skeletal
muscle weakness.
c. Decreased blood volume is associated with decreased blood supply, oxygenation and
increased anaerobic metabolism.
d. Decreased blood volume is associated with failure of the kidneys to excrete hydrogen ions and
reabsorb bicarbonate ions.
36. A client with diabetes mellitus type I diagnosed 10 years ago advances to a complication
called Diabetic ketoacidosis. The nurse notices this client to be breathing deeply and rapidly. The
nurse correctly documented this as Kussmauls respirations. The scientific rationale for this kind
of breathing pattern is
a. The shallow and slow respirations will increase the HCO3 in the serum.
b. The kidneys produce excess urine and the lungs try to compensate.
c. The respirations increase the amount of carbon dioxide in the bloodstream.
d. The lungs speed up to release carbon dioxide and increase the pH.
37. Nurse Vent is assigned to a 65-year-old patient, who is being weaned from a ventilator. Prior
to extubation, the latest arterial blood gases are analyzed from the following results: pH of 7.33,
PaO2 of 74mmHg, PaCO2 of 51mmHg and HCO3 of 25 mEq/L. Immediate physician notifications
is necessary because the client is in a state of
a. Respiratory alkalosis
b. Respiratory acidosis
c. Metabolic alkalosis
d. Metabolic acidosis
38. A male clients findings on arterial blood gas analysis are pH 7.31, PaCO2 39 mm Hg, and
HCO3 19 mEq/L. The nurse is aware that the effectivity of the medical regimen will be reflected if
the next result will reveal
a. pH 7.40 and PaCO2 31 mm Hg
b. pH 7.47 and PaCO2 50 mm Hg
c. pH 7.42 and PaCO2 47 mm Hg
d. pH 7.33 and PaCO2 29 mm Hg
39. Upon interview for the clients medical history, the nurse is alerted that chronic lung disease
belongs to the past diagnosis of the client. The nurse is aware that the client has an increased
risk of developing respiratory acidosis and should watch out for which manifestations?
a. Restlessness, lethargy, inability to focus
b. Paresthesia, confusion, and bradypnea
c. Shallow and slowed breathing
d. Hyperactivity and bradycardia
40. One of the morning shift nurse is assigned to four patients in the ward. Which of the following
patients handled by the nurse will most likely progress to metabolic alkalosis?
a. A 12-year old boy receiving isotonic sodium chloride IV solution
b. A 61-year old with who is unable to access water freely
c. A 36-year old post surgical patient who has continuous nasogastric suction
d. A 58-year-old who just experienced a stroke

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ANSWERS AND CONCEPT ILLUMINATIONS

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FLUIDS AND ELECTROLYTE IMBALANCES
1. ANSWER: D.
CONCEPT ILLUMINATION
Acute hyponatremia could yield complications like cerebral edema. As the intravascular sodium level
decreases, the intravascular fluid becomes diluted while the intracellular fluid is concentrated. This
promotes osmosis or the move of fluid from the intravascular that is diluted, to the intracellular which is
concentrated. This mechanism will develop cerebral edema as evidenced by altered mental status,
obtunded state that may progress to coma. Highly hypertonic sodium solutions like 3% NaCl and 5% NaCl
are used to relieve the manifestations of cerebral edema, not to correct the acute sodium depletion. These
solutions does not affect the aldosterone release by the adrenal cortex and definitely not allow sodium ions
to enter the cell, because sodium is normal retained extracellularly.
2. ANSWER: A.
CONCEPT ILLUMINATION
The potassium level and duration of blood storage are directly proportional, meaning as the storage time of
the blood increases, known as aged blood, the potassium concentration also increases. Potassium
concentration is related to the deterioration of red blood cell when the blood is stored for a longer time prior
to its use. When the potassium level of the client is already elevated, extreme precaution should be done
when the client is for blood transfusion.
3. ANSWER: A.
CONCEPT ILLUMINATION
The choroid plexus, where the cerebrospinal fluid or CSF is formed, depends on chloride combined with
sodium to attract water to form the fluid portion of the CSF. Cerebrospinal fluid functions to cushion the
brain and prevent friction from the skull, provides nourishment to brain cells, removes metabolites and
regulates intracranial pressure. Option B is incorrect because chloride is present in the extracellular fluid
particularly in the interstitial space and lymphatic compartments than in blood or intravascularly. Option C
is not related to chloride function since aldosterone release affects sodium and water, while chloride only
follows sodium. Option D is also incorrect because chloride aids in hydrogen ions formation, not depression,
which releases oxygen from hemoglobin for cerebral perfusion.
4. ANSWER: B.
CONCEPT ILLUMINATION
Potassium administration is very dangerous to clients with impaired renal function because of the change of
decreased ability to excrete potassium. Serum potassium has a narrow therapeutic window, which is only
from 3.5 to 5.0 mEq/L. When potassium can accumulate in the body and exceed the therapeutic level of 5.0
mEq/L, it can cause cardiac dysrhythmias and arrest. Regarding the vital signs, the complication of
potassium excess is reflected by the apical pulse rate, instead of the blood pressure making option A not
the priority. Assessment of skin turgor is more related for clients who are at risk for dehydration and not
directly related to IV fluids containing potassium, thus option C is also unnecessary. Edema monitoring is
for clients who are at risk for fluid volume excess in dependent position.
5. ANSWER: C.
CONCEPT ILLUMINATION
In response to changes in fluid level in the body, the posterior pituitary gland will secrete antidiuretic
hormone. This hormone binds to membrane bound receptors and increases water reabsorption by kidney
tubules. This mechanism will result in less water loss as urine. When less fluid is loss in the urine, more fluid
remains in the intravascular space, which will return to the heart. When the heart is not that effective in
pumping out blood to the circulation, this will result to congestion and fluid volume excess. Rapid sodium
excretion will be followed by increased fluid output and would not place the client at risk for excess fluid
volume. Improved cardiac output will allow more renal perfusion, resulting in increased urine output and
does not place the client at risk for excess fluid volume. An increase in GFR would not also put the client at
risk for excess fluid volume.
6. ANSWER: B.
CONCEPT ILLUMINATION
A small gauge or lumen catheter is preferred for continuous fluid replacement. Gauge 22 is a small gauge
catheter used to prevent sudden fluid overload. On the other hand, gauge 18 is the standard gauge for
clients who will undergo blood transfusion. This gauge has larger lumen diameter to prevent blood
coagulation. In terms of the insertion site, IV catheter insertion should be started in the most distal part of
the extremity, using the lowest vein possible and progress upward. The antecubital area is not a preferred
area.
7. ANSWER: D.

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CONCEPT ILLUMINATION
Paracentesis is done to remove the fluid situated in the peritoneal cavity. The nurse should make sure that
the client listens attentively to instructions such as remaining still during the procedure so as not to
puncture proximal organs. After paracentesis, since large amount of fluid is aspirated, the body could
develop into vascular collapse or sudden and rapid decreased of fluid volume. The nurse should monitor the
vital signs for signs of hypovolemic shock as evidenced by hypotension, tachycardia, and tachypnea. The
temperature is not usually altered after paracentesis, unless there is the development of infection.
Peristalsis will be affected prior to paracentesis because the enlarging abdomen compresses the colon.
Respiratory difficulty and congestion are common also before the procedure because the diaphragm has
limited expansion.
8. ANSWER: A.
CONCEPT ILLUMINATION
When there is elevated blood volume in the body, the pressure of the blood will also increase. For clients
with liver cirrhosis, the liver is not functioning normally and cannot adequately produce the most abundant
protein, which is albumin. Albumin maintains the colloid osmotic pressure in the intravascular space.
Hypoalbuminemia or decreased albumin level will lead to inadequate pulling of blood back to the blood
vessels. One of the risks of this condition is pulmonary congestion as evidenced by dyspnea and crackles
auscultated due to presence of fluid.
9. ANSWER: D.
CONCEPT ILLUMINATION
In response to decreased blood volume and perfusion to the kidneys, the juxtaglomerular apparatus will
release the enzyme called renin into the circulation. Renin acts on the protein angiotensinogen, which will
be converted to angiotensin I. As blood flows with angiotensin I and goes to the lungs, the angiotensinconverting-enzyme will convert angiotensin I to angiotensin II. This last enzyme is a potent vasoconstrictor
and will also act on the adrenal cortex to produce more aldosterone. Aldosterone increases sodium
reabsorption and will be followed by fluid that will now elevate the blood volume. Aldosterone also leads to
potassium excretion, resulting in an increase in chloride. Sodium, potassium, and chloride are the main
electrolytes affected on this mechanism. Calcium level is related to the action of the parathyroid gland,
thyrocalcitonin, and vitamin D produced by the kidneys. On the other hand, calcium balance influences
phosphorus and magnesium regulation by the kidneys.
10. ANSWER: C.
CONCEPT ILLUMINATION
Long-term intake of diuretics may lead to dehydration and fluid volume deficit. When the body has less
blood volume, the compensatory mechanism is decreased glomerular filtration to decrease urine output. If
the body is conserving the remaining fluid, the urine specific gravity will be elevated. Urine specific gravity
is the measure of the concentration of the particles or solutes in the urine. A high specific gravity indicates
concentrated urine. Normal urine specific gravity is 1.010 to 1.030. The hematocrit level in option A is
decreased, which means hemodilution due to excessive fluid volume not deficit. The normal hematocrit
level is 37% to 47%. Potassium level in option B is normal, indicating that there is no problem with regards
to the effect of most diuretics which is hypokalemia. Central venous pressure is the pressure of the right
side of the heart and the normal level is 0 to 14 cm H 2O, therefore option D means that there is no problem
in the fluid level of the body.
11. ANSWER: B.
CONCEPT ILLUMINATION
Osmosis is the passage or movement of solvent from a less concentrated to a more concentrated solution
through a semi-permeable membrane. This tends to equalize the concentrations of the two solutions. Urine
production is achieved through osmosis. The mechanism starts with filtration to form a filtrate, a less
concentrated area, in the Bowmans capsule. Then the reabsorption phase takes place when solutes move
from a more concentrated area to a less concentrated area, which is the filtrate. On the other hand, water
is reabsorbed across the wall of the nephrons by osmosis. Ventilation and perfusion work best using
diffusion, or the movement of solute, that is the oxygen, from an area of more oxygen to an area of less
oxygen. Example is the movement of oxygen from alveoli to the blood and then perfusion when oxygen
moves from the blood to the cells. Sweat production is more on excretion of sodium ions. Blood coagulation
is aided by platelets and clotting factors, not by osmosis.
12. ANSWER: D.
CONCEPT ILLUMINATION
Magnesium primarily aids in bone formation and for the maintenance of nerve and muscle functions.
Magnesium naturally works as a sedative of the muscles. When there is magnesium toxicity, the body
becomes weak and the reflexes become hypoactive. In case of magnesium deficiency, since sedative effect
is lessened, the body will become irritable causing arrthythmias, vasodilation, and hyperactive reflexes of

254
the nervous system. Normal magnesium level is 1.5 to 2.5 mEq/L. Cardiovascular function should be
monitored closely because hypomagnesemia can cause life-threatening arrhythmias, resulting in
cardiovascular failure and arrest. The musculoskeletal system may also be affected in magnesium
deficiency but this is not the priority of the nurse, as well as the renal system. The respiratory system could
become hyperactive in case of magnesium deficiency; therefore, this system will only be the priority if
there is risk of respiratory failure, which commonly happens in hypermagnesemia.
13. ANSWER: D.
CONCEPT ILLUMINATION
The calcium level in the situation indicates hypocalcemia. The normal level of calcium is 4.5 to 5.5 mEq/L or
9 to 11 mg/dl. The kidneys are responsible in metabolizing Vitamin D, which main function is to promote
calcium absorption in the intestines. When the kidneys fail, the vitamin D level will be insufficient for
calcium absorption leading to hypocalcemia. Hyperparathyroidism causes hypercalcemia because of the
increased level of parathormone that promotes bone tissue breakdown leading to the movement of calcium
back to the circulation. Multiple myeloma is abnormal proliferation of plasma cells in the bone. Since the
bone structures are saturated with the plasma cells, the bone will break down leading to the exit of calcium
from the bone going to the blood that again causes hypercalcemia. Comatose clients have prolonged bed
rest and due to immobility or non-usage of the bones, osteoclastic activity will be trigger leading to bone
resorption and demineralization.
14. ANSWER: C.
CONCEPT ILLUMINATION
Potassium and sodium in the body is inversely proportional due to the sodium-potassium pump. In case of
hyperkalemia, kayexalate is given since it is a sodium exchange resin. This composition of enema will allow
the body to gain sodium, as potassium is lost in the bowel. For the exchange to occur, Kayexalate must be
in contact with the bowel for at least 30 minutes, therefore the nurse should instruct the client to retain the
solution in the area. Sorbitol in the Kayexalate enema causes diarrhea, which increases potassium loss and
decreases the potential for Kayexalate retention.
15. ANSWER: D.
CONCEPT ILLUMINATION
Potassium is the major intracellular electrolyte. The influence of potassium is direct to cardiac and skeletal
muscles. Under the mechanism of the sodium-potassium pump, potassium goes in and out of the cell. In
cases of hypokalemia, direct irritability to the cardiac and skeletal muscles will be decreased causing
muscle weakness, leg cramps, decreased bowel motility, anorexia, nausea, vomiting, paresthesias and
dysrhythmias like presence of U wave, short T wave, and depressed ST segment. Hypertension,
tachycardia, and muscle irritability are more related to hyperkalemia. Inverted T wave will be seen on
clients with myocardial infarction due to ischemic regions in the myocardium.
16. ANSWER: C.
CONCEPT ILLUMINATION
Lethal effects will happen if potassium is given IV push. This route allows rapid accumulation of potassium
that can lead to cardiac arrest. It is also extremely irritating and painful at the catheter site. The therapeutic
way of giving potassium is to dilute it in an IV solution and run over the time of the total infusion. Examples
of therapeutic potassium administration are 40 mEq potassium diluted in 1L D 5W over 8 hours or potassium
10 mEq in 250 ml D 5W to run over 3 hours. The other orders listed are all within acceptable limits for a
postoperative client.
17. ANSWER: B.
CONCEPT ILLUMINATION
Hypermagnesemia is a complication of untreated diabetic ketoacidosis when catabolism releases cellular
magnesium that cannot be excreted due to decreased GFR in an attempt to alleviate fluid volume
depletion. Magnesium acts like a sedative, that when the level of it in the body is increased, body
neuromuscular functions are depressed. Manifestations include muscle weakness that can lead to paralysis,
nausea and vomiting, facial flushing, drowsiness and difficulty speaking or dysarthria, respiratory
depression leading to shallow slowed breathing, hypotension, decreased urinary reflex leading to oliguria
and hypoactive to absent deep tendon reflexes. Option D is incorrect in terms of muscle rigidity and spasm
because both of these symptoms can be seen in hypomagnesemia, where the sedative effects are
decreased leading to hyperactivity of muscles.
18. ANSWER: D.
CONCEPT ILLUMINATION
Lactated Ringers solution is an isotonic solution that contains multiple electrolytes with closely the same
concentration with plasma. It is used for clients with risk of fluid and electrolyte imbalance after abdominal
surgery, burns, fluid lost as bile or diarrhea, or for acute blood loss replacement.

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19. ANSWER: A.
CONCEPT ILLUMINATION
One of the complications of intravenous fluid replacement is pulmonary congestion as evidenced by rales or
crackles auscultated in all lung fields. This should be brought to the HCPs attention. Increasing level of
consciousness indicates that oxygenation in the lungs and cerebral perfusion is normal. Negative pedal
edema conveys not fluid retention.
20. ANSWER: C.
CONCEPT ILLUMINATION
The status of the wound, characteristics of the drainage, and time and date of dressing change are the
most critical data to record. How well the client tolerated the procedure may be charted if the client had
untoward response, but other information is more critical. Type of dressing used is not necessary.
21. ANSWER: A.
CONCEPT ILLUMINATION
The client is placed on suction plus ileostomy excretes fluid output. Both of these means that the client is
losing fluids, but the only replacement fluid used is 0.9% NaCl, which only contains sodium and not enough
to compensate with the losing electrolytes. The laboratory value of sodium level 152 mEq/L indicates that
the client has hypernatremia. Sodium is followed by water in the kidneys, therefore there will be increased
venous return and cardiac workload. The hemoglobin and hematocrit values are within the normal range.
The blood urea nitrogen (BUN) level is elevated, and this needs to be investigated and correlated with the
serum creatinine level. It is not alarmingly high and could be indication of decreased fluids, but it is not the
priority concern. The glucose level is expected to be elevated due to the stress brought by the surgical
procedure.
22. ANSWER: D.
CONCEPT ILLUMINATION
The complication of hyperkalemia is increased stimulation of the heart which may cause cardiac
dysrhythmias that can lead to cardiac arrest. Because of this, the client should be placed on a cardiac
monitor. Fluid intake is not increased because it contributes to fluid overload and would not affect the
serum potassium level significantly. The nurse also may assess the sodium level because sodium is another
electrolyte commonly measured with the potassium level. However, this is not a priority action of the nurse.
Vegetables are a natural source of potassium in the diet, and their use would not be increased.
23. ANSWER: B.
CONCEPT ILLUMINATION
Due to water loss in profuse diaphoresis, sodium is retained in high concentration in the body known as
hypernatremia. Manifestations of hypernatremia are sticky mucous membranes, musculoskeletal affectation
evidenced by weakness, and neurologic involvement as a sign of disorientation and decreased level of
consciousness. Only weakness and decreasing level of consciousness are affected by hypermagnesemia,
hyperkalemia, and hypercalcemia. The other manifestations are uncommon to these 3 options.
24. ANSWER: D.
CONCEPT ILLUMINATION
It is true that when the blood glucose level increases, potassium level will most likely increase because
potassium ions are attached to glucose. However, the situation pertains to the assessment that the nurse
should not do frequently. When a client is receiving insulin, regular glucose monitoring is necessary, but not
potassium level unless the client has other associated disorders that potassium could aggravate. The nurse
should include only the monitoring of glucose for possible hypoglycemia due to the insulin therapy. In
addition is the monitoring for serum ketones since insulin is given to diabetes mellitus Type I which is also
related to the development of ketosis. Clients receiving insulin are also at risk for hypotension because of
diluted blood with less glucose.
25. ANSWER: B.
CONCEPT ILLUMINATION
Intake and output mechanism should work collaboratively to maintain the fluid status of the body on
equilibrium. The kidneys play a major role in the excretion or output of body fluids. On the other hand, thirst
sensation acts as the major control of fluid intake or input. Unless the body is triggered by the oral cavity
for the presence of dryness and thirst, fluid input will not be achieved. Antidiuretic hormone controls also
the output like the kidneys, since it prevents diuresis. Aldosterone is another hormone that reabsorbs water
and sodium, therefore it acts mainly on output control. Renin-angiotensin mechanism is under the kidney
control on fluid status.

ACID-BASE IMBALANCES

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26. ANSWER: D.
CONCEPT ILLUMINATION
Sedative depresses the respiratory function, slowing respiration, and retaining carbon dioxide causing
respiratory acidosis. Hyperkalemia may result as the hydrogen concentration overwhelms the
compensatory mechanisms and hydrogen ions moves into cells, causing a shift of potassium out of the cell
into the blood. Potassium has a direct effect to the myocardial contraction, therefore hyperkalemia will
rapidly and excessive stimulate the ventricular contraction causing ventricullar fibrillation. The medulla
oblongata is not directly stimulated by potassium. Depression of SA node and sedation of the myocardium
both slows down the conduction and contractility of the heart, therefore ventricullar fibrillation is not
possible in this two conditions.
27. ANSWER: C.
CONCEPT ILLUMINATION
The cause of ventricullar fibrillation is hyperkalemia secondary to respiratory acidosis. The body effectively
compensates with respiratory acidosis by increasing the bicarbonate level yielding to metabolic alkalosis.
The preliminary emergency drug in this situation is sodium bicarbonate basing on the origin of the attack.
Epinephrine and lidocaine are next to be given to stabilize the conduction. Potassium chloride will only
aggravate the fibrillation since it will further increase potassium level.
28. ANSWER: B.
CONCEPT ILLUMINATION
Breathing techniques aid in either carbon dioxide elimination or retention. In respiratory acidosis, the goal is
to eliminate carbon dioxide level because it is elevated in the circulation. The best way to eliminate carbon
dioxide is to perform pursed lip breathing because this prolongs the exhalation phase and excretes more
carbon dioxide compared to normal exhalation. On the other hand, respiratory alkalosis goal is to retain
carbon dioxide because it is insufficient in the circulation. Carbon dioxide is best retained when the client is
taught to breathe using a paper bag. This traps the carbon dioxide inside the bag, and when the client
inhales again, more carbon dioxide will likely enter back the pulmonary area. Option A is incorrect because
pursed lip is for respiratory acidosis, not alkalosis. Option C is incorrect as well, because ventilation with
paper bag is more suitable for respiratory alkalosis. Option D should be states as ventilation with brown
paper bag is more functional for respiratory alkalosis.
29. ANSWER: A.
CONCEPT ILLUMINATION
The kidneys also maintain the equilibrium of acids and bases in the body. In case of respiratory acidosis, the
function of the kidneys is to eliminate the acid. This is done by increasing the glomerular filtration rate
(GFR) of acid while stimulating bicarbonate secretion. When bicarbonate is elevated in the blood, the body
will interpret this as metabolic alkalosis in response to respiratory acidosis. Hyperventilation also aids in
respiratory acidosis, however this is effective if with stimulation of serum bicarbonate secretion.
30. ANSWER: D.
CONCEPT ILLUMINATION
Respiratory alkalosis should be monitored for electrolyte imbalance specifically hypokalemia, hypocalcemia,
hypophosphatemia. Hypokalemia results from hydrogen ions pulled out of the cell in exchange for
potassium. There will be potassium entrance into the cell leading to deficient potassium level in the blood.
On the other hand, severe alkalosis leads to inhibited ionization of calcium causing hypocalcemia.
Hypophosphatemia is from the reuptake of phosphate by the cells, thereby losing phosphate in the blood.
31. ANSWER: A.
CONCEPT ILLUMINATION
Allens test is performed prior to radial arterial blood gas analysis. The purpose of this test is to assess and
confirm for the presence of collateral circulation using the ulnar artery. The blood sample may be taken
from the radial artery safely if collateral circulation is adequate. The correct method in performing Allens
test is by:
1.
2.
3.
4.
5.
6.

Asking the patient to make a fist

Manually occlude the ulnar artery
Open the hand in a relaxed, slightly flexed position
Observing for pallor of the palms
Release the pressure on the ulnar artery
Flushing of hands in about 3 to 5 seconds

32. ANSWER: A.
CONCEPT ILLUMINATION

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The body will have the tendency to increase the rate and depth of respirator to promote respiratory
alkalosis to compensate with metabolic acidosis. This is known as hyperventilation to eliminate carbon
dioxide so as not to aggravate the acidity of the blood. Hyperventilation will lead to rapid insensible water
loss. Fluid replacement will be ordered by the physician. Bronchodilators are therapeutic for clients with
respiratory acidosis, not metabolic acidosis. Breathing into a brown paper bag is related to respiratory
alkalosis to reinhale carbon dioxide and this is not what the body wanted in the treatment of metabolic
acidosis. Postural drainage is more related to trapping of carbon dioxide in respiratory acidosis.
33. ANSWER: B.
CONCEPT ILLUMINATION
Metabolic alkalosis is due to bicarbonate excess. The goal of acetazolamide (Diamox), which is a carbonic
anhydrase inhibitor, is to increase the excretion of bicarbonate by the kidneys. The renal system is the main
organ that retains and excretes bicarbonate. Therefore, to control the bicarbonate level, the renal excretion
of bicarbonate should be triggered. The other options are not related to the action of acetazolamide.
34. ANSWER: B.
CONCEPT ILLUMINATION
Respiratory and metabolic acidosis has direct effect to the cerebral and peripheral blood vessels. Here are
the manifestations that the nurse should watch out:
1. Cerebral vasodilation is associated with acidosis. Cerebral vasoconstriction is related to alkalosis.
2. Increased blood pressure secondary to peripheral vasoconstriction.
3. CNS depression secondary to cerebral vasodilation, therefore watched out for coma.
4. Hyperkalemia due to hydrogen ions moving into cell while potassium will go out of the cell into the
serum. Hypokalemia results from alkalosis.
5. Coma secondary to cerebral vasodilation and CNS depression.
6. Peripheral vasoconstriction is associated with acidosis. Peripheral vasodilation will be seen in alkalosis.
7. Increased intracranial pressure can be seen both in acidosis and alkalosis. If acidosis is the cause, it is
because of the vasodilatory effect. If alkalosis is the cause, it is due to vasoconstriction but increased firing
effect.
35. ANSWER: C.
CONCEPT ILLUMINATION
Hypovolemic shock leads to decreased oxygen supply and perfusion. The metabolism of the cell will then
be achieved through anaerobic respiration that will result to synthesis of lactic acid. Lactic acid will produce
more hydrogen ions that are acidic causing metabolic acidosis.
36. ANSWER: D.
CONCEPT ILLUMINATION
Diabetic acidosis is one of the causes of metabolic acidosis. The main goal of the body with this specific
imbalance is to promote respiratory alkalosis. To achieve respiratory alkalosis, Kussmauls respiration is
done to decrease carbonic acid level, which is a type of acid that aggravates metabolic acidosis. When the
client breaths deeply and rapidly, carbon dioxide is largely eliminated, then stimulation for high pH or
alkalosis will be attained.
37. ANSWER: B.
CONCEPT ILLUMINATION
The first step in interpretation is to determine if pH is alkalosis or acidosis. Then evaluate PaCo2 as the
respiratory component and HCO3 as the metabolic component. The clients pH is <7.35 and PaCO2 >45
mmHg indicate a state of respiratory acidosis and indicates that the patient is not tolerating the weaning
process.
38. ANSWER: A.
CONCEPT ILLUMINATION
The interpretation of the arterial blood gas in the situation is uncompensated metabolic acidosis. It is said
to be uncompensated because the partial pressure of carbon dioxide in the situation remained to be
normal, even with the presence of acidic pH and metabolic acidosis. The treatment regimen is said to be
effective if the pH will become normal and the partial pressure of carbon dioxide will become alkalosis in
response to the metabolic acidosis. A pH level of 7.40 means full compensation and PaCO2 of 31 mm Hg
means respiratory alkalosis.
39. ANSWER: A.
CONCEPT ILLUMINATION
Chronic lung disease can lead to respiratory acidosis because of decreased oxygenation and elevated
carbon dioxide level. The effect of acidosis to the nervous system is that this condition causes cerebral

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vasodilation, which can lead to increased intracranial pressure and central nervous system depression. The
manifestations of such complication are manifested by restlessness, lethargy, and inability of the client to
focus. Contrary to acidosis is alkalosis, which may cause cerebral vasoconstriction and central nervous
system stimulation as evidenced by seizure and hyperactivity. In terms of the bodys compensatory
mechanism, when there is respiratory acidosis, the body will tend to increase and make the respiration
deep to expel carbon dioxide and accommodate oxygen. The choices that contain bradypnea, shallow and
slowed breathing, plus bradycardia are all not forms of the bodys compensatory mechanism. Paresthesia
is more related to deficient perfusion to extremities. Hyperactivity is applicable for respiratory alkalosis due
to central nervous system stimulation.
40. ANSWER: C.
CONCEPT ILLUMINATION
The physiologic disturbance of patients with metabolic alkalosis is high pH and elevated plasma
bicarbonate concentration. Patients who are vomiting, with intestinal obstruction, and are undergoing
gastric lavage are likely to progress to metabolic alkalosis with loss of hydrogen and chloride ions.