What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly pt

who is intermittently confused?

1. risk of dehydration
2. risk of kidney damage
3. risk of stroke
4. risk of bleeding

Answer: 1

Rationale 1: As an adult age, the thirst mechanism declines. Adding this in a pt with an altered
level of consciousness, there is an increased risk of dehydration & high serum osmolality.
Rationale 2: The risks for kidney damage are not specifically related to aging or fluid &
electrolyte issues.
Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues.
Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte issues.

The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk for
developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit

Answer: 1

Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished, leading
to an intracellular fluid deficit.
Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus.
Because this pt was severely burned, the fluid within the cells is diminished, leading to an
intracellular fluid deficit.
Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the interstitial
fluid between the cells. Because this pt was severely burned, the fluid within the cells is
diminished, leading to an intracellular fluid deficit.
Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the interstitial
fluid between the cells. Because this pt was severely burned, the fluid within the cells is
diminished, leading to an intracellular fluid deficit.

A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagnosis of
diabetes insipidus. The nurse chooses which of the following nursing diagnoses as most
appropriate?
1. Risk for Imbalanced Fluid Volume
2. Excess Fluid Volume
3. Imbalanced Nutrition
4. Ineffective Tissue Perfusion
Answer: 1

Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabetes
insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that can
increase the serum levels of sodium.
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially
during the early stages of treatment.
Rationale 3: Imbalanced Nutrition does not apply.
Rationale 4: Ineffective Tissue Perfusion does not apply

A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the pt's
primary healthcare provider with which of the following 24-hour urine output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL
Answer: 1
Rationale 1: A urine output of less than 30 mL per hour must be reported to the primary
healthcare provider. This indicates inadequate renal perfusion, placing the pt at increased risk for
acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over a 24-hour period
is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).

A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the pt's
primary healthcare provider with which of the following 24-hour urine output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL
Answer: 1
Rationale 1: A urine output of less than 30 mL per hour must be reported to the primary
healthcare provider. This indicates inadequate renal perfusion, placing the pt at increased risk for
acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over a 24-hour period
is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).

A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need
which of the following precautions implemented?
1. seizure
2. infection
3. neutropenic
4. high-risk fall
Answer: 1
Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet
environment, raised side rails, & having an oral airway at the bedside would be included.
Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia.
Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia.
Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.

A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of the
following might have contributed to the pt's health problem?
1. corticosteroid
2. thiazide diuretic
3. narcotic
4. muscle relaxer
Answer: 1
Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as
corticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.
Rationale 2: Excessive sodium is lost with the use of thiazide diuretics.
Rationale 3: Narcotics do not typically affect electrolyte balance.
Rationale 4: Muscle relaxants do not typically affect electrolyte balance.
A pt prescribed spironolactone is demonstrating ECG changes & complaining of muscle
weakness. The nurse realizes this pt is exhibiting signs of which of the following?
1. hyperkalemia
2. hypokalemia
3. hypercalcemia
4. hypocalcemia
Answer: 1
Rationale 1: Hyperkalemia is serum potassium level greater than 5.0 mEq/L. Decreased
potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common
manifestations of hyperkalemia are muscle weakness & ECG changes.
Rationale 2: Hypokalemia is seen in non-potassium diuretics such as furosemide.
Rationale 3: Hypercalcemia has been associated with thiazide diuretics.
Rationale 4: Hypocalcemia is seen in pts who have received many units of citrated blood & is
not associated with diuretic use.
The nurse is planning care for a pt with fluid volume overload & hyponatremia. Which of the
following should be included in this pt's plan of care?
1. Restrict fluids.
2. Administer intravenous fluids.
3. Provide Kayexalate.
4. Administer intravenous normal saline with furosemide.
Answer: 1
Rationale 1: The nursing care for a pt with hyponatremia is dependent on the cause. Restriction
of fluids to 1,000 mL/day is usually implemented to assist sodium increase & to prevent the
sodium level from dropping further due to dilution.
Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit
& hypernatremia.
Rationale 3: Kayexalate is used in pts with hyperkalemia.
Rationale 4: The administration of normal saline with furosemide is used to increase calcium
secretion.
When caring for a pt diagnosed with hypocalcemia, which of the following should the nurse
additionally assess in the pt?
1. other electrolyte disturbances
2. hypertension
3. visual disturbances
4. drug toxicity
Answer: 1
Rationale 1: The pt diagnosed with hypocalcemia may also have high phosphorus or decreased
magnesium levels.
Rationale 2: The pt with hypocalcemia may exhibit hypotension, & not hypertension.
Rationale 3: Visual disturbances do not occur with hypocalcemia.
Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.
A pt with a history of stomach ulcers is diagnosed with hypophosphatemia. Which of the
following interventions should the nurse include in this pt's plan of care?
1. Request a dietitian consult for selecting foods high in phosphorous.
2. Provide aluminum hydroxide antacids as prescribed.
3. Instruct pt to avoid poultry, peanuts, & seeds.
4. Instruct to avoid the intake of sodium phosphate.
Answer: 1
Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause & promoting
a high phosphate diet, especially milk, if it is tolerated. Other foods high in phosphate are dried
beans & peas, eggs, fish, organ meats, Brazil nuts & peanuts, poultry, seeds & whole grains.
Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided.
Rationale 3: Poultry, peanuts, & seeds are part of a high phosphate diet.
Rationale 4: Mild hypophosphatemia may be corrected by oral supplements, such as sodium
phosphate.
When analyzing an arterial blood gas report of a pt with COPD & respiratory acidosis, the nurse
anticipates that compensation will develop through which of the following mechanisms?
1. The kidneys retain bicarbonate.
2. The kidneys excrete bicarbonate.
3. The lungs will retain carbon dioxide.
4. The lungs will excrete carbon dioxide.
Answer: 1
Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate.
Rationale 2: Excreting bicarbonate causes acidosis to develop.
Rationale 3: Retaining carbon dioxide causes respiratory acidosis.
Rationale 4: Excreting carbon dioxide causes respiratory alkalosis
The nurse is caring for a pt diagnosed with renal failure. Which of the following does the nurse
recognize as compensation for the acid-base disturbance found in pts with renal failure?
1. The pt breathes rapidly to eliminate carbon dioxide.
2. The pt will retain bicarbonate in excess of normal.
3. The pH will decrease from the present value.
4. The pt's oxygen saturation level will improve.
Answer: 1
Rationale 1: In metabolic acidosis compensation is accomplished through increased ventilation
or "blowing off" C02. This raises the pH by eliminating the volatile respiratory acid &
compensates for the acidosis.
Rationale 2: Because compensation must be performed by the system other than the affected
system, the pt cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure
is a lower than normal bicarbonate value.
Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the
disease process, not the compensation.
Rationale 4: Oxygenation disturbance is not part of the acid-base status of the pt with renal
failure.
When caring for a group of pts, the nurse realizes that which of the following health problems
increases the risk for metabolic alkalosis?
1. bulimia
2. dialysis
3. venous stasis ulcer
4. COPD
Answer: 1
Rationale 1: Metabolic alkalosis is cause by vomiting, diuretic therapy or nasogastric suction,
among others. A pt with bulimia may engage in vomiting or indiscriminate use of diuretics.
Rationale 2: A pt receiving dialysis has kidney failure, which causes metabolic acidosis.
Rationale 3: A venous stasis ulcer does not result in an acid-base disorder.
Rationale 4: The pt diagnosed with COPD typically has hypercapnea & respiratory acidosis.

The nurse is caring for a pt who is anxious & dizzy following a traumatic experience. The
arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, & HCO3 24. The nurse
would anticipate which initial intervention to correct this problem?
1. Encourage the pt to breathe in & out slowly into a paper bag.
2. Immediately administer oxygen via a mask & monitor oxygen saturation.
3. Prepare to start an intravenous fluid bolus using isotonic fluids.
4. Anticipate the administration of intravenous sodium bicarbonate.

Answer: 1
Rationale 1: This pt is exhibiting signs of hyperventilation that is confirmed with the blood gas
results of respiratory alkalosis. Breathing into a paper bag will help the pt to retain carbon
dioxide & lower oxygen levels to normal, correcting the cause of the problem.
Rationale 2: The oxygen levels are high, so oxygen is not indicated, & would exacerbate the
problem if given. Intravenous fluids would not be the initial intervention.
Rationale 3: Not enough information is given to determine the need for intravenous fluids.
Rationale 4: Bicarbonate would be contraindicated as the pH is already high.

A pt is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the pt is
receiving this replacement is
1. to sustain respiratory function.
2. to help regulate acid-base balance.
3. to keep a vein open.
4. to encourage urine output.
Answer: 2
Rationale 1: Potassium does not sustain respiratory function.
Rationale 2: Electrolytes have many functions. They assist in regulating water balance, help
regulate & maintain acid-base balance, contribute to enzyme reactions, & are essential for
neuromuscular activity.
Rationale 3: Intravenous fluids are used to keep venous access not potassium.
Rationale 4: Urinary output is impacted by fluid intake not potassium.
An elderly pt does not complain of thirst. What should the nurse do to assess that this pt is not
dehydrated?
1. Ask the physician for an order to begin intravenous fluid replacement.
2. Ask the physician to order a chest x-ray.
3. Assess the urine for osmolality.
4. Ask the physician for an order for a brain scan.
Answer: 3
Rationale 1: It is inappropriate to seek an IV at this stage.
Rationale 2: There is no indication the pt is experiencing pulmonary complications thus a cheat
x-ray is not indicated.
Rationale 3: The thirst mechanism declines with aging, which makes older adults more
vulnerable to dehydration & hyperosmolality. The nurse should check the pt's urine for
osmolality as a 1st step in determining hydration status before other detailed & invasive testing is
done.
Rationale 4: There is no data to support the need for a brain scan.
An elderly pt who is being medicated for pain had an episode of incontinence. The nurse realizes
that this pt is at risk for developing
1. dehydration.
2. over-hydration.
3. fecal incontinence.
4. a stroke.
Correct Answer: 1
Rationale 1: Functional changes of aging also affect fluid balance. Older adults who have self-
care deficits, or who are confused, depressed, tube-fed, on bed rest, or taking medications (such
as sedatives, tranquilizers, diuretics, & laxatives), are at greatest risk for fluid volume imbalance.
Rationale 2: There is inadequate evidence to support the risk of over-hydration.
Rationale 3: There is inadequate evidence to support the risk of fecal incontinence.
Rationale 4: There is inadequate evidence to support the risk of a stroke.
The nurse assesses a pt's weight loss as being 22 lbs. How many liters of fluid did this pt lose?
Correct Answer: 10
Rationale: Each liter of body fluid weighs 1 kg or 2.2 lbs. This pt has lost 10 liters of fluid.
A postoperative pt with a fluid volume deficit is prescribed progressive ambulation yet is weak
from an inadequate fluid status. What can the nurse do to help this pt?
1. Assist the pt to maintain a standing position for several minutes.
2. This pt should be on bed rest.
3. Assist the pt to move into different positions in stages.
4. Contact physical therapy to provide a walker.
Answer: 3
Rationale 1: The pt should avoid prolonged standing.
Rationale 2: Bed rest can promote skin breakdown.
Rationale 3: The pt needs to be taught how to avoid orthostatic hypotension which would include
assisting & teaching the pt how to move from one position to another in stages.
Rationale 4: A physician referral is needed for physical therapy intervention & is not indicated in
this situation.
A postoperative pt is diagnosed with fluid volume overload. Which of the following should the
nurse assess in this pt?
1. poor skin turgor
2. decreased urine output
3. distended neck veins
4. concentrated hemoglobin & hematocrit levels
Answer: 3
Rationale 1: Poor skin turgor is associated with fluid volume deficit.
Rationale 2: Decreased urine output is associated with fluid volume deficit.
Rationale 3: Circulatory overload causes manifestations such as a full, bounding pulse; distended
neck & peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in
the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which
dilution of plasma by excess fluid causes a decreased hematocrit & blood urea nitrogen (BUN);
& possible cerebral edema.
Rationale 4: Increased hemoglobin & hematocrit values are associated with fluid volume deficit.
An elderly pt is at home after being diagnosed with fluid volume overload. Which of the
following should the home care nurse instruct this pt to do?
1. Wear support hose.
2. Keep legs in a dependent position.
3. Avoid wearing shoes while in the home.
4. Try to sleep without extra pillows.
Answer: 1
Rationale 1: The home care nurse should instruct this pt about ways to decrease dependent
edema, which include wearing support hose, elevating feet when in a sitting position, & resting
in a recliner or bed with extra pillows.
Rationale 2: The pt should elevate the legs.
Rationale 3: As long as the shoes are well fitting, there is not reason to avoid wearing them.
Rationale 4: It is appropriate for the pt to use extra pillows to keep the head up while sleeping.
A pt with fluid retention related to renal problems is admitted to the hospital. The nurse realizes
that this pt could possibly have which of the following electrolyte imbalances?
1. hypokalemia
2. hypernatremia
3. carbon dioxide
4. magnesium
Answer: 2
Rationale 1: The kidneys are the principal organs involved in the elimination of potassium. Renal
failure is often associated with elevations potassium levels.
Rationale 2: The kidney is the primary regulator of sodium in the body. Fluid retention is
associated with hypernatremia.
Rationale 3: Carbon dioxide abnormalities are not normally seen in this type of pt.
Rationale 4: Magnesium abnormalities are not normally seen in this type of pt.
An elderly pt comes into the clinic with the complaint of watery diarrhea for several days with
abdominal & muscle cramping. The nurse realizes that this pt is demonstrating which of the
following?
1. hypernatremia
2. hyponatremia
3. fluid volume excess
4. hyperkalemia
Answer: 2
Rationale 1: Hypernatremia is associated with fluid retention & overload. FVE is associated with
hypernatremia.
Rationale 2: This elderly pt has watery diarrhea, which contributes to the loss of sodium. The
abdominal & muscle cramps are manifestations of a low serum sodium level.
Rationale 3: This pt is more likely to develop clinical manifestations associated with fluid
volume deficit.
Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias.
A pt is admitted with hypernatremia caused by being str&ed on a boat in the Atlantic Ocean for
five days without a fresh water source. Which of the following is this pt at risk for developing?
1. pulmonary edema
2. atrial dysrhythmias
3. cerebral bleeding
4. stress fractures
Answer: 3
Rationale 1: Pulmonary edema is not associated with dehydration.
Rationale 2: Atrial dysrhythmias are not a factor for this pt.
Rationale 3: The brain experiences the most serious effects of cellular dehydration. As brain cells
contract, the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels
may tear, bleed, & lead to cerebral vascular bleeding.
Rationale 4: There have been no activities to support the development or occurrence of stress
fractures.
The nurse is admitting a pt who was diagnosed with acute renal failure. Which of the following
electrolytes will be most affected with this disorder?
1. calcium
2. magnesium
3. phosphorous
4. potassium
Answer: 4
Rationale 1: This pt will be less likely to develop a calcium imbalance.
Rationale 2: This pt will be less likely to develop a magnesium imbalance.
Rationale 3: This pt will be less likely to develop a phosphorous imbalance.
Rationale 4: Because the kidneys are the principal organs involved in the elimination of
potassium, renal failure
A pt who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. Which of the
following does the nurse realize might occur with this pt?
1. Digoxin toxicity may occur.
2. A higher dose of digoxin (Lanoxin) may be needed.
3. A diuretic may be needed.
4. Fluid volume deficit may occur.
Answer: 1
Rationale 1: Hypokalemia increases the risk of digitalis toxicity in pts who receive this drug for
heart failure.
Rationale 2: More digoxin is not needed.
Rationale 3: A diuretic may cause further fluid loss.
Rationale 4: There is inadequate information to assess for concerns related to fluid volume
deficits.

A pt is prescribed 40 mEq potassium as a replacement. The nurse realizes that this replacement
should be administered
1. directly into the venous access line.
2. mixed in the prescribed intravenous fluid.
3. via a rectal suppository.
4. via intramuscular injection.
Answer: 2
Rationale 1: Never administer undiluted potassium directly into a vein.
Rationale 2: The intravenous route is the recommended route for diluted potassium.
Rationale 3: The nurse should administer diluted potassium into the pt's intravenous line.
Rationale 4: The nurse should administer diluted potassium into the pt's intravenous line.

An elderly pt with a history of sodium retention arrives to the clinic with the complaints of "heart
skipping beats" & leg tremors. Which of the following should the nurse ask this pt regarding
these symptoms?

1. "Have you stopped taking your digoxin medication?"

2. "When was the last time you had a bowel movement?"
3. "Were you doing any unusual physical activity?"
4. "Are you using a salt substitute?"
Answer: 4
Rationale 1: Although this pt may be prescribed digoxin this is not the primary focus of this
question.
Rationale 2: The pt's bowel habits are not of concern at this time.
Rationale 3: The cardiac & musculoskeletal discomforts being reported are not consistent with
physical exertion.
Rationale 4: The pt has a history of sodium retention & might think that a salt substitute can be
used. Advise pts who are taking a potassium supplement or potassium-sparing diuretic to avoid
salt substitutes, which usually contain potassium.
A 35-year-old female pt comes into the clinic postoperative parathyroidectomy. Which of the
following should the nurse instruct this pt?
1. Drink one glass of red wine per day.
2. Avoid the sun.
3. Milk & milk-based products will ensure an adequate calcium intake.
4. Red meat is the protein source of choice.
Answer: 3
Rationale 1: This pt should avoid alcohol.
Rationale 2: This pt can benefit from sun exposure.
Rationale 3: This pt is at risk for developing hypocalcemia. This risk can be avoided if instructed
to ingest milk & milk-based products.
Rationale 4: Protein monitoring is not indicated.
A pt is admitted for treatment of hypercalcemia. The nurse realizes that this pt's intravenous
fluids will most likely be which of the following?
1. dextrose 5% & water
2. dextrose 5% & ? normal saline
3. dextrose 5% & ? normal saline
4. normal saline
Answer: 4
Rationale 1: If isotonic saline is not used, the pt is at risk for hyponatremia in addition to the
hypercalcemia.
Rationale 2: This solution is hypotonic. Isotonic saline is used because sodium excretion is
accompanied by calcium excretion through the kidneys.
Rationale 3: This solution is hypotonic. Isotonic saline is used because sodium excretion is
accompanied by calcium excretion through the kidneys.
Rationale 4: Isotonic saline is used because sodium excretion is accompanied by calcium
excretion through the kidneys.
A 28-year-old male pt is admitted with diabetic ketoacidosis. The nurse realizes that this pt will
have a need for which of the following electrolytes?
1. sodium
2. potassium
3. calcium
4. magnesium
Answer: 4
Rationale 4: One risk factor for hypomagnesaemia is an endocrine disorder, including diabetic
ketoacidosis.

An elderly pt with peripheral neuropathy has been taking magnesium supplements. The nurse
realizes that which of the following symptoms can indicate hypomagnesaemia?
1. hypotension, warmth, & sweating
2. nausea & vomiting
3. hyperreflexia
4. excessive urination
Answer: 1
Rationale 1: Elevations in magnesium levels are accompanied by hypotension, warmth, &
sweating.
Rationale 2: Lower levels of magnesium are associated with nausea & vomiting.
Rationale 3: Lower levels of magnesium are associated & hyperreflexia.
Rationale 4: Urinary changes are not noted.
A pt is admitted with burns over 50% of his body. The nurse realizes that this pt is at risk for
which of the following electrolyte imbalances?
1. hypercalcemia
2. hypophosphatemia
3. hypernatremia
4. hypermagnesemia
Correct Answer: 2

Rationale 1: Pts who experience burns are not at an increased risk for developing increased blood
calcium levels.
Rationale 2: Causes of hypophosphatemia include stress responses & extensive burns.
Rationale 3: Pts who experience burns are not at an increased risk for developing increased blood
sodium levels.
Rationale 4: Pts who experience burns are not at an increased risk for developing increased blood
magnesium levels.
A pt is diagnosed with hyperphosphatemia. The nurse realizes that this pt might also have an
imbalance of which of the following electrolytes?
1. calcium
2. sodium
3. potassium
4. chloride
Answer: 1
Rationale 1: Excessive serum phosphate levels cause few specific symptoms. The effects of high
serum phosphate levels on nerves & muscles are more likely the result of hypocalcemia that
develops secondary to an elevated serum phosphorus level. The phosphate in the serum
combines with ionized calcium, & the ionized serum calcium level falls.
The nurse is reviewing a pt's blood pH level. Which of the systems in the body regulate blood
pH? Select all that apply.
1. renal
2. cardiac
3. buffers
4. respiratory
Answer: 1,3
Rationale 1: Three systems work together in the body to maintain the pH despite continuous acid
production: buffers, the respiratory system, & the renal system.
Rationale 2: The cardiac system is responsible for circulating blood to the body. It does not help
maintain the body's pH.
Rationale 3: Three systems work together in the body to maintain the pH despite continuous acid
production: buffers, the respiratory system, & the renal system.
Rationale 4: Three systems work together in the body to maintain the pH despite continuous acid
production: buffers, the respiratory system, & the renal system.
The nurse observes a pt's respirations & notes that the rate is 30 per minute & the respirations are
very deep. The metabolic disorder this pt might be demonstrating is which of the following?
1. hypernatremia
2. increasing carbon dioxide in the blood
3. hypertension
4. pain
Answer: 2
Rationale 1: Hypernatremia is associated with profuse sweating & diarrhea.
Rationale 2: Acute increases in either carbon dioxide or hydrogen ions in the blood stimulate the
respiratory center in the brain. As a result, both the rate & depth of respiration increase. The
increased rate & depth of lung ventilation eliminates carbon dioxide from the body, & carbonic
acid levels fall, which brings the pH to a more normal range.
Rationale 3: The respiratory rate in a pt exhibiting hypertension is not altered.
Rationale 4: Pain may be manifested in rapid, shallow respirations.