Electrolyte imbalance

. On morning assessment of your patient in room 2502 who has severe burns. You notice
that fluid is starting to accumulate in his abdominal tissue. You note that his weight has not
changed and his intake and output is equal. What do you suspect?

 A. Third spacing
 B. This is normal and expected after a burn and it is benign
 C. Document this finding as non-pitting abdominal edema. 
 D. Intravascular compartment syndrome
The answer is A. You would suspect third spacing. Third-spacing is the accumulation of trapped
extracellular fluid in a body space as a result in this case of a burn. Third spacing can occur in
body spaces such as the pericardial, pleural, peritoneal, and joint cavities, bowel, and abdomen
after a trauma or burn. It is normal not to see a change in weight or abnormal intake or output
values.

2. Which patient is at more risk for an electrolyte imbalance?

 A. An 8 month old with a fever of 102.3 'F and diarrhea

 B. A 55 year old diabetic with nausea and vomiting 
 C. A 5 year old with RSV
 D. A healthy 87 year old with intermittent episodes of gout
The answer is A. The 8 month old with a fever of 102.3 'F and diarrhea is the correct answer.
Infants (age 1 and under) and older adults are at a higher risk of fluid-related problems than any
other age group. This is because infants have the highest amount of total body fluid (80% of the
body is made up of fluid) and if any type of illness especially GI effects the body this increases
the chances of an electrolyte imbalance.

3. A patient is admitted to the ER with the following findings: heart rate of 110 (thready
upon palpation), 80/62 blood pressue, 25 ml/hr urinary output, and Sodium level of 160.
What interventions do you expect the medical doctor to order for this patient?

 A. Restrict fluid intake and monitor daily weights

 B. Administer hypertonic solution of 5% Dextrose 0.45% Sodium Chloride and
monitor urinary output
 C. Administer hypotonic IV fluid and administer sodium tablets. 
 D. No interventions are expected
The answer is B. The patient must be re-hyrdated and the sodium levels should be decreased at
the same time. So a hypertonic solution of 5% dextrose and 0.45% NA will help do this. The
solution is hypertonic because of the 5% Dextrose which will rapidly metabolize to the cells.
When the dextrose metabolizes to the cells it leaves behind 0.9% NA which acts as a isotonic
solution. This allows the 0.45% NA to act as a hypotonic solution to repair the vascular
compartment. After these fluids are infused the patient's NA level should decrease, BP increase,
HR return to normal etc. It is a complicated physiological process because the Dextrose has
unique capabilities when it is metabolized....although the solution is labeled as hypertonic it
becomes a hypotonic solution when the Dextrose is metabolized by the cells.

4. After obtaining an EKG on a patient you notice that ST depression is present along with
an inverted T wave and prominent U wave. What lab value would be the cause of this
finding?

 A. Magnesium level of 2.2

 B. Potassium level of 5.6
 C. Potassium level of 2.2 
 D. Phoshorus level of 2.0
The answer is C. Hypokalemia (normal potassium levels are 3.5 to 5.1) will present with these
type of EKG findings.

5. Which patient below would have a potassium level of 5.5?

 A. A 76 year old who reports taking Lasix four times a day

 B. A patient with Addison's disease
 C. A 55 year old woman who have been vomiting for 3 days consistently 
 D. A patient with liver failure
The answer is B. A patient with Addison disease suffers from increased potassium levels due to
adrenal insufficiency. Therefore, potassium levels higher than 5.1 may present in patients with
Addison's disease.

6. You are taking a patient's blood pressure manually. As you pump up the cuff above the
systolic pressure for a few minutes you notice that the patient develop a carpal spasm.
Which of the following is true?

 A. The patient is having a normal nervous response to an inflating blood pressure cuff
that is inflated above the systolic pressure
  B. This is known as Trousseau's Sign and is present in patients with HYPERcalcemia
 C. This is known as Chvostek's Sign 
 D. This is known as Trousseau's Sign and is present in patients with hypocalcemia
The answer is D. The correct answer is "this is known as Trousseau's Sign and is present in
patients with hypocalcemia". Patient's with hypokalemia may present with a positive Trousseau's
and Chvostek sign.

7. Which patient is at most risk for hypomagnesemia?

 A. A 55 year old chronic alcoholic

 B. A 57 year old with hyperthyroidism
 C. A patient reporting overuse of antacids and laxatives 
 D. A 25 year old suffering from hypoglycemia
The answer is A. The correct answer is a 55 year old who is a chronic alcoholic. Patients who
suffer from alcoholism have an increased secretion of magnesium and usually do not eat a proper
diet, therefore, they are at risk for lower magnesium levels.

8. In report from a transferring facility you receive information that your patient's
Magnesium level is 1.2. When the patient arrives you are ordered by the doctor to
administer Magnesium Sulfate via IV. Which of the following interventions takes priority?

 A. Set-up bedside suction

 B. Set-up IV Atropine at bedside due to the bradycardia effects of Magnesium Sulfate
 C. Monitor the patient's for reduced deep tendon reflexes and initiate seizure
precautions 
 D. None of the above are correct
The answer is C. As the nurse administering Magnesium sulfate IV, you must monitor for
reduced deep tendon reflexes because the patient could quickly develop hypermagnesemia. In
addition, seizure precautions should be initiated due to the patient's low magnesium level.

9. Which patient is at most risk for fluid volume deficient?

 A. A patient who has been vomiting and having diarrhea for 2 days. 
 B. A patient with continuous nasogastric suction.
  C. A patient with an abdominal wound vac at intermittent suction.
 D. All of the above are correct.
The answer is D. All the patients above are at risk for losing too much fluid volume. 

10. A patient is admitted with exacerbation of congestive heart failure. What would you
expect to find during your admission assessment?

 A. Flat neck and hand veins

 B. Furrowed dry tongue 
 C. Increased blood pressure and crackles throughout the lungs
 D. Bradycardia and pitting edema in lower extremities
The answer is C. The correct answer is increased blood pressure and crackles throughout the
lungs. Patients with CHF are in fluid volume overload and the heart can not compensate for the
extra fluid volume, therefore, the fluid starts to "backup". You would find an increased blood
pressure and crackles in the lungs. You would also see pitting edema in the lower extremities but
NOT bradycardia.

Respiratory Alkalosis and Acidosis

1. A patient is post-opt from knee surgery. The patient has been receiving
Morphine 4 mg IV every 2 hours. You notice the patient is exhibiting a respiratory
rate of 8 and is extremely drowsy. Which of the following conditions is the patient
at risk for?

 A. Respiratory acidosis
 B. Respiratory alkalosis
 C. Hypokalemia 
 D. Metabolic acidosis
The answer is A.
2. A patient attempted to commit suicide by ingesting a bottle of Aspirin. Which of
the following conditions is this patient at risk for?

 A. Hyperkalemia
 B. Hypercalcemia
 C. Respiratory alkalosis
 D. Respiratory acidosis 
The answer is C.

3. Respiratory alkalosis can affect other electrolyte levels in the body. Which of
the following electrolyte levels can also be affected in this condition?

 A. Calcium and sodium levels

 B. Potassium and sodium levels
 C. Calcium and potassium levels
 D. Potassium and phosphate levels 
The answer is C.

4. A patient is experiencing respiratory alkalosis. What is the most classic sign

and symptom of this condition?

 A. Bradypnea
 B. Tachypnea
 C. Bradycardia 
 D. None of the options are correct
The answer is B.

5. A patient has the following blood gases: PaCO2 25, pH 7.50, HCO3 19. Which of
the following could NOT be the cause of this condition?

 A. Anxiety attack
 B. Chronic obstructive pulmonary disease (COPD)
  C. Fever 
 D. Aspirin toxicity
The answer is B.

6. A patient on mechanical ventilation has the following blood gases: PaCO2 29,
pH 7.56, HCO3 23. Which of the following conditions is the patient experiencing?

 A. Respiratory alkalosis not compensated

 B. Respiratory alkalosis partially compensated
 C. Respiratory alkalosis fully compensated 
 D. Respiratory acidosis partially compensated
The answer is A.

7. A patient is experiencing respiratory acidosis due to brain trauma. Which of the

following lab values correlates with this acid imbalance?

 A. Potassium level of 6.0

 B. Potassium level of 2.5
 C. Potassium level of 5.0 
 D. Potassium level of 3.5
The answer is A.

8. Which patient is experiencing partially compensated respiratory acidosis?

 A. PaCO2 30, pH 7.35, HCO3 26

 B. PaCO2 53, pH 7.23, HCO3 28
 C. PaCO2 45, pH 7.49, HCO3 21 
 D. PaCO2 50, pH 7.30, HCO3 23
The answer is B.

9. Which of the following is not a cause of respiratory acidosis?

  A. Pulmonary emboli
 B. Asthma
 C. Chronic obstructive pulmonary disease (COPD) 
 D. Hyperventilation
The answer is D.

10. A patient with COPD has the following blood gases: PCO2 59, pH 7.26, HCO3
42. Which of the following conditions is presenting?

 A. Respiratory alkalosis
 B. Respiratory acidosis
 C. Metabolic alkalosis 
 D. Metabolic acidosis
The answer is B.

ARDS
1.) You're providing care to a patient who is being treated for aspiration
pneumonia. The patient is on a 100% non-rebreather mask. Which finding below
is a HALLMARK sign and symptom that the patient is developing acute
respiratory distress syndrome (ARDS)?

 A. The patient is experiencing bradypnea.

 B. The patient is tired and confused.
 C. The patient's PaO2 remains at 45 mmHg. 
 D. The patient's blood pressure is 180/96.
The answer is C. A hallmark sign and symptom found in ARDS is refractory hypoxemia.
This is where that although the patient is receiving a high amount of oxygen (here a
100% non-rebreather mask) the patient is STILL hypoxic. Option C is the answer
because it states the patient's arterial oxygen level is remaining at 45 mmHg (a normal
is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the
patient can be tired and confused from a low oxygen level BUT this question wants to
know the HALLMARK sign and symptom.

2. You're teaching a class on critical care concepts to a group of new nurses.

You're discussing the topic of acute respiratory distress syndrome (ARDS). At the
beginning of the lecture, you assess the new nurses understanding about this
condition. Which statement by a new nurse demonstrates he understands the
condition?

 A. "This condition develops because the exocrine glands start to work incorrectly
leading to thick, copious mucous to collect in the alveoli sacs."
 B. "ARDS is a pulmonary disease that gradually causes chronic obstruction of
airflow from the lungs." 
 C. "Acute respiratory distress syndrome occurs due to the collapsing of a lung
because air has accumulated in the pleural space."
 D. "This condition develops because alveolar capillary membrane
permeability has changed leading to fluid collecting in the alveoli sacs."
The answer is D. ARDS is a type of respiratory failure that occurs when the capillary
membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak
into the alveoli sac. Option A describes cystic fibrosis, option B describes COPD, and
option C describes a pneumothorax.

3. During the exudative phase of acute respiratory distress syndrome (ARDS), the
patient's lung cells that produce surfactant have become damaged. As the nurse
you know this will lead to?

 A. bronchoconstriction
 B. atelectasis
 C. upper airway blockage 
 D. pulmonary edema
The answer is B. Surfactant decreases surface tension in the lungs. Therefore, the
alveoli sacs will stay stable when a person exhales (hence the sac won’t collapse). If
there is a decrease in surfactant production this creates an unpredictable alveoli sac
that can easily collapse, hence a condition called ATELETASIS will occur (collapse of
the lung tissue) when there is a decrease production in surfactant.

4. A patient has been hospitalized in the ICU for a near drowning event. The
patient's respiratory function has been deteriorating over the last 24 hours. The
physician suspects acute respiratory distress syndrome. A STAT chest x-ray is
ordered. What finding on the chest x-ray is indicative of ARDS?

 A. infiltrates only on the upper lobes

 B. enlargement of the heart with bilateral lower lobe infiltrates 
  C. white-out infiltrates bilaterally
 D. normal chest x-ray
The answer is C. This is a finding found in ARDS....pronounce white-out infiltrates
bilaterally.

5. You're providing care to a patient who was just transferred to your unit for the
treatment of ARDS. The patient is in the exudative phase. The patient is ordered
arterial blood gases. The results are back. Which results are expected during this
early phase of acute respiratory distress syndrome that correlates with this
diagnosis?

 A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23

 B. PaO2 85, pH 7.42, PaCO2 37, HCO3 26 
 C. PaO2 50, pH 7.20, PaCO2 48, HCO3 29
 D. PaO2 55, pH 7.26, PaCO2 58, HCO3 19
The answer is A. This option demonstrates respiratory alkalosis. In the early stages of
ARDS (exudative) the patient will start to enter in respiratory alkalosis. The patient starts
to have tachypnea (the body’s way of trying to increase the oxygen level but it can’t).
They will have a very low PaO2 level (normal PaO2 is 80 mmHg), the blood pH will
become high (normal is 7.35-7.45) (alkalotic). In the late stage, the patient can enter
into respiratory acidosis.

6. Which patient below is at MOST risk for developing ARDS and has the worst
prognosis?

 A. A 52-year-old male patient with a pneumothorax.

 B. A 48-year-old male being treated for diabetic ketoacidosis.
 C. A 69-year-old female with sepsis caused by a gram-negative bacterial
infection. 
 D. A 30-year-old female with cystic fibrosis.
The answer is C. Sepsis is the MOST common cause of ARDS because of systemic
inflammation experienced. This is also true if the cause of the sepsis is a gram-negative
bacterium (this also makes the infection harder to treat…hence poor prognosis). With
sepsis, the immune cells that are present with the inflammation travel to the lungs and
damage the alveolar capillary membrane leading to fluid to leak in the alveolar sacs.
7. As the nurse you know that acute respiratory distress syndrome (ARDS) can be
caused by direct or indirect lung injury. Select below all the INDIRECT causes of
ARDS:

 A. Drowning
 B. Aspiration
 C. Sepsis 
 D. Blood transfusion 
 E. Pneumonia 
 F. Pancreatitis 
The answers are: C, D, F Indirect causes are processes that can cause inflammation
OUTSIDE of the lungs….so the issue arises somewhere outside the lungs. Therefore,
sepsis (infection…as long as it is outside the lungs), blood transfusion, and pancreatitis
are INDIRECT causes. Drowning, aspiration, and pneumonia are issues that arise in the
lungs (therefore, they are DIRECT causes of lung injury).

8. A patient is on mechanical ventilation with PEEP (positive end-expiratory

pressure). Which finding below indicates the patient is developing a complication
related to their therapy and requires immediate treatment?

 A. HCO3 26 mmHg
 B. Blood pressure 70/45
 C. PaO2 80 mmHg 
 D. PaCO2 38 mmHg
The answer is B. Mechanical ventilation with PEEP can cause issues with intrathoracic
pressure and decrease the cardiac output (watch out for a low blood pressure) along
with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air
that escapes into the skin because the lungs are leaking air).

9. You are caring for a patient with acute respiratory distress syndrome. As the
nurse you know that prone positioning can be beneficial for some patients with
this condition. Which findings below indicate this type of positioning was
beneficial for your patient with ARDS?

 A. Improvement in lung sounds 

 B. Development of a V/Q mismatch
  C. PaO2 increased from 59 mmHg to 82 mmHg 
 D. PEEP needs to be titrated to 15 mmHg of water 
The answers are A and C. Prone positioning helps improve PaO2 (82 mmHg is a good
finding) without actually giving the patient high concentrations of oxygen. It helps
improves perfusion and ventilation (hence correcting the V/Q mismatch). In this position,
the heart is no longer laying against the posterior part of the lungs (improves air
flow...hence improvement of lung sounds) and it helps move secretions from other
areas that were fluid filled and couldn’t move in the supine position, hence helping
improve atelectasis.

10. A patient is experiencing respiratory failure due to pulmonary edema. The

physician suspects ARDS but wants to rule out a cardiac cause. A pulmonary
artery wedge pressure is obtained. As the nurse you know that what
measurement reading obtained indicates that this type of respiratory failure is
NOT cardiac related?

 A. >25 mmHg
 B. <10 mmHg 
 C. >50 mmHg
 D. <18 mmHg
The answer is D. A pulmonary artery wedge pressure measures the left atrial pressure.
A pulmonary catheter is "wedged" with a balloon in the pulmonary arterial branch to
measure the pressure. If the reading is less than 18 mmHg it indicates this is NOT a
cardiac issue but most likely ARDS. Therefore, the pulmonary edema is due to damage
to the alveolar capillary membrane leaking fluid into the alveolar sac....NOT a heart
problem ex: heart failure.

11. You’re precepting a nursing student who is assisting you care for a patient on
mechanical ventilation with PEEP for treatment of ARDS. The student asks you
why the PEEP setting is at 10 mmHg. Your response is:

 A. "This pressure setting assists the patient with breathing in and out and helps
improve air flow." 
 B. "This pressure setting will help prevent a decrease in cardiac output and
hyperinflation of the lungs."
 C. "This pressure setting helps prevent fluid from filling the alveoli sacs."
 D. "This pressure setting helps open the alveoli sacs that are collapsed
during exhalation."
The answer is D. This setting of PEEP (it can range between 10 to 20 mmHg of water)
and it helps to open the alveoli sacs that are collapsed, especially during exhalation.