Chapter 24 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Chapter 24 High Acuity Nursing 6th Edition by Kathleen Dorman Wagner

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

Question 1

Type: MCSA

A patient with hypoxia is at risk for disruption of the sodium potassium pump. Which would the nurse expect if this occurs?

1. Decreased serum potassium
2. Cell death
3. Increase in the cells’ ability to use active transport
4. Decreased extracellular fluid

Correct Answer: 2

Rationale 1: The amount of potassium in the extracellular fluids would increase.

Rationale 2: Without the counterregulating forces provided by the sodium potassium pump, cells will fill with fluid and will rupture and die.

Rationale 3: Dysfunction of the sodium potassium pump will not increase the cells’ ability to use active transport.

Rationale 4: Since the cells can no longer hold fluid, the extracellular fluid component increases.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 24-1

Question 2

Type: MCSA

A patient is admitted with bleeding from the gastrointestinal tract. The nurse plans interventions to support the balance of which fluid volume compartment?

1. Transcellular
2. Intravascular
3. Interstitial
4. Intracellular

Correct Answer: 2

Rationale 1: Transcellular fluid is cerebral spinal fluid, peritoneal fluid, and synovial fluid.

Rationale 2: Intravascular fluid is one extracellular compartment that consists of plasma. In the case of bleeding, the fluid compartment that will be affected first will be the intravascular fluid.

Rationale 3: Interstitial fluid is found between the cells.

Rationale 4: Intracellular fluid is that fluid found within the cells. Interstitial fluid is found between the cells.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-1

Question 3

Type: MCSA

The nurse is planning the care of a patient in the intensive care unit. With regards to maintaining adequate fluid volume for this patient, the nurse realizes that interventions should be planned to reduce the risk of which condition?

1. Retention of potassium
2. Retention of sodium
3. Loss of calcium
4. Loss of magnesium

Correct Answer: 2

Rationale 1: Most intensive care patients experience a reduced potassium level and do not retain potassium. As retention of a different electrolyte occurs, potassium is excreted by the kidney.

Rationale 2: Under normal situations, the regulation of water is through the thirst mechanism. In the intensive care unit, however, many patients have altered levels of consciousness and will not have this mechanism in place. Because of this, hypernatremia or retention of sodium is a common electrolyte imbalance in these types of patients.

Rationale 3: Calcium balance is not typically associated with fluid volume.

Rationale 4: Magnesium balance is not typically associated with fluid volume.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 24-2