ANCC /ADULT-GERONTOLOGY ACUTE CARE NURSE
PRACTITIONER (AGACNP) LATEST TEST 2022/2023
1.Which of the following is most accurate regarding treatment of hyponatremia?
a. use of a V2 receptor antagonist is contraindicated in asymptomatic patients with hypovolemic
hyponatremia.
b. hypertonic saline is recommended in normovolemic (euvolemic), asymptomatic patients with
hyponatremia.
c. in general, chronic hyponatremia can be safely corrected more quickly than acute hyponatremia.
d. consider potassium repletion in patients with hypovolemia secondary to the use of diuretics.
(correct answers)d. consider potassium repletion in patients with hypovolemia secondary to the use of
diuretics.
2.Your patient has a serum Na less than 135 and an SOsm less than 270 (norm 280-295), what type of
hyponatremia do they have?
a. hypotonic hyponatremia
b. isotonic hyponatremia
c. hypertonic hyponatremia
(correct answers)a. hypotonic hyponatremia
3.Your pt has a serum Na less than 135 and their SOsm is between 280-295. You're suspicious because
they have extremely high triglycerides. What type of hyponatremia do they have?
a. hypotonic hyponatremia
b. isotonic hyponatremia
c. hypertonic hyponatremia
(correct answers)b. isotonic hyponatremia
4.Your pt has a serum Na less than 135 and their SOsm is greater than 290.
What type of hyponatremia do they have?
a. hypotonic hyponatremia
b. isotonic hyponatremia
,c. hypertonic hyponatremia
(correct answers)c. hypertonic hyponatremia
5.What is the only type of hyponatremia that requires the treatment to be directed at the serum Na?
a. hypotonic hyponatremia
b. isotonic hyponatremia
c. hypertonic hyponatremia
(correct answers)a. hypotonic hyponatremia
Otherwise, treatment includes:
• Therapy is guided by symptoms, level of serum sodium and rapidity of development
• Rate of correction is critical to avoid CNS insult
You have a patient with a Na less than 120 and they're experiencing seizures and/or coma. What fluid do
you use?
How fast can you bring up the Na?
To what level should you bring the Na to? (correct answers)-Use 3% hypertonic saline
-increase serum Na by only 1-2 mEq/L/hr until Na rises by 12-15 mEq/L OR to a level of 120 mEq/L
-Max correction rate is 8-12 mEq/L/24 hr or 25 mEq/L/48 hrs
Your pt has a Na less that 115 mEq/L and are having moderate symptoms. How should you treat them?
(correct answers)Two options:
1. Give 3% hypertonic as in severe symptoms
2. OR treat on basis of volume status as discussed in mild or asymptomatic patients.
Your patient is hyponatremic but has either mild or no symptoms at all. How do you treat them?
(correct answers)• If the patient is hypovolemic, give NS to correct the volume status. ADH secretion will
stop, kidneys will excrete the excess water
• If the patient is Hypervolemic, administer loop diuretics. Lasix 40-80 mg IV or PO is the usual
treatment. ADH stops, kidneys excrete extra water
E. All cases: restrict water or total fluid intake to 1000ml/24 hours or less
F. DC drugs that enhance Na excretion
,G. Associated hypokalemia: supplement with PO or intravenous PRN
There may be underlying conditions causing hyponatremia that should be treated. How would you treat
these conditions?
-hypothyroidism
-adrenal insufficiency
-SIADH (correct answers)• Hypothyroidism - replacement as indicated. Always rule out thyroid
irregularities first
• Adrenal insufficiency - cortisol therapy
• SIADH treatment is geared at blocking the ADH effect in the kidney
o Conivaptan - used in the hospitalized patient with hypervolemic or euvolemic hyponatremia only. A
loading dose of 20 mg is given followed by a continuous infusion
o Tolvaptan - Used in Hypervolemic or euvolemic hyponatremic patients only. Must be initiated in the
hospital starting at 15 mg daily. Titrate to max dose of 60 mg daily, limit to 30- day course.
o Demeclocycline - 150-300 mg PO Q6H for long-term therapy
How often is serum Na monitored in symptomatic hyponatremia? (correct answers)Every 2-4 hours
What should you consider in your geriatric patient with hyponatremia? (correct answers)Carefully assess
their fluid intake. If they have chronic hyponatremia, they need to be aware of potential bone loss and
tendency to fracture. Mild hyponatremia is associated with increased mortality.
Define hypernatremia (correct answers)• Serum Na greater than 146 mEq/L and represents a state of
hyper osmolality
• Always indicates hyper osmolality or a deficit of total body water
• May also be caused by a primary Na gain in addition to a water deficit which is more common
It is a "water problem" - either excess water loss or inability to acquire water. More common in
debilitated elderly, infants, handicapped
What are two causes of primary water loss that may cause hypernatremia? (correct answers)o Central
(pituitary) diabetes insipidus; lack of ADH secretion
o Nephrogenic (renal) diabetes insipidus; failed response to ADH
What are some other ways a patient may have hypernatremia? (correct answers)o Renal osmotic
diuresis is seen in glucosuria of DM, Mannitol or glycerol infusion or high urea excretion in catabolic
states such as burns
, o GI fluid loss through persistent diarrhea or postsurgical drainage o Cutaneous fluid loss in burns or
profuse sweating
o Excessive administration of hypertonic sodium bicarbonate (NaHCO3) in CPR or lactic acidosis, or 3%
saline infusions
What do the brain cells do in hyponatremia vs hypernatremia? (correct answers)Hyponatremia =
swollen
Hypernatremia = shrinkage
What kind of symptoms may you see in a patient with a Na between 151-160? (correct answers)-
depends on the time frame of development.
If acute you may see nausea, weakness, lethargy, confusion. If there is a chronic condition, there may be
no or mild CNS symptoms
What kind of symptoms may you see in a patient with a Na greater than 160? (correct answers)- If it
develops acutely may see stupor and coma.
If it is chronic elevation, will see moderate to severe CNS symptoms
Your pt has a serum Na greater than 146 and a urine osmolality (UOsm) less than 300, what does this
suggest? (correct answers)central or nephrogenic DI
Your pt has a serum Na greater than 146 and a urine osmolality (UOsm) between 300-400, what does
this suggest? (correct answers)osmotic diuresis
Your pt has a serum Na greater than 146 and a urine osmolality (UOsm) greater than 400, what does this
suggest? (correct answers)GI, cutaneous or insensible fluid losses
What other tests can be done for hypernatremia? (correct answers)-Serum ADH may be helpful.
-Water deprivation test:
1. Withhold all fluids
2. Monitor BP, Na and UOsm then when UOsm is nearly constant with a less than 30mOsm/L change for
2-3 hours administer AVP or DDAVP per protocol.
3. Measure urine volume and UOsm after 1 hour. Central DI will show an increase in UOsm to 600- 700
mOsm/L. Nephrogenic DI will have little or no increase in UOsm
How fast can you correct hypernatremia? (correct answers)• A more rapid correction of serum Na is
indicated for acute, symptomatic hypernatremia but no faster than 1-2 mEq/L/hr to avoid cerebral
edema
PRACTITIONER (AGACNP) LATEST TEST 2022/2023
1.Which of the following is most accurate regarding treatment of hyponatremia?
a. use of a V2 receptor antagonist is contraindicated in asymptomatic patients with hypovolemic
hyponatremia.
b. hypertonic saline is recommended in normovolemic (euvolemic), asymptomatic patients with
hyponatremia.
c. in general, chronic hyponatremia can be safely corrected more quickly than acute hyponatremia.
d. consider potassium repletion in patients with hypovolemia secondary to the use of diuretics.
(correct answers)d. consider potassium repletion in patients with hypovolemia secondary to the use of
diuretics.
2.Your patient has a serum Na less than 135 and an SOsm less than 270 (norm 280-295), what type of
hyponatremia do they have?
a. hypotonic hyponatremia
b. isotonic hyponatremia
c. hypertonic hyponatremia
(correct answers)a. hypotonic hyponatremia
3.Your pt has a serum Na less than 135 and their SOsm is between 280-295. You're suspicious because
they have extremely high triglycerides. What type of hyponatremia do they have?
a. hypotonic hyponatremia
b. isotonic hyponatremia
c. hypertonic hyponatremia
(correct answers)b. isotonic hyponatremia
4.Your pt has a serum Na less than 135 and their SOsm is greater than 290.
What type of hyponatremia do they have?
a. hypotonic hyponatremia
b. isotonic hyponatremia
,c. hypertonic hyponatremia
(correct answers)c. hypertonic hyponatremia
5.What is the only type of hyponatremia that requires the treatment to be directed at the serum Na?
a. hypotonic hyponatremia
b. isotonic hyponatremia
c. hypertonic hyponatremia
(correct answers)a. hypotonic hyponatremia
Otherwise, treatment includes:
• Therapy is guided by symptoms, level of serum sodium and rapidity of development
• Rate of correction is critical to avoid CNS insult
You have a patient with a Na less than 120 and they're experiencing seizures and/or coma. What fluid do
you use?
How fast can you bring up the Na?
To what level should you bring the Na to? (correct answers)-Use 3% hypertonic saline
-increase serum Na by only 1-2 mEq/L/hr until Na rises by 12-15 mEq/L OR to a level of 120 mEq/L
-Max correction rate is 8-12 mEq/L/24 hr or 25 mEq/L/48 hrs
Your pt has a Na less that 115 mEq/L and are having moderate symptoms. How should you treat them?
(correct answers)Two options:
1. Give 3% hypertonic as in severe symptoms
2. OR treat on basis of volume status as discussed in mild or asymptomatic patients.
Your patient is hyponatremic but has either mild or no symptoms at all. How do you treat them?
(correct answers)• If the patient is hypovolemic, give NS to correct the volume status. ADH secretion will
stop, kidneys will excrete the excess water
• If the patient is Hypervolemic, administer loop diuretics. Lasix 40-80 mg IV or PO is the usual
treatment. ADH stops, kidneys excrete extra water
E. All cases: restrict water or total fluid intake to 1000ml/24 hours or less
F. DC drugs that enhance Na excretion
,G. Associated hypokalemia: supplement with PO or intravenous PRN
There may be underlying conditions causing hyponatremia that should be treated. How would you treat
these conditions?
-hypothyroidism
-adrenal insufficiency
-SIADH (correct answers)• Hypothyroidism - replacement as indicated. Always rule out thyroid
irregularities first
• Adrenal insufficiency - cortisol therapy
• SIADH treatment is geared at blocking the ADH effect in the kidney
o Conivaptan - used in the hospitalized patient with hypervolemic or euvolemic hyponatremia only. A
loading dose of 20 mg is given followed by a continuous infusion
o Tolvaptan - Used in Hypervolemic or euvolemic hyponatremic patients only. Must be initiated in the
hospital starting at 15 mg daily. Titrate to max dose of 60 mg daily, limit to 30- day course.
o Demeclocycline - 150-300 mg PO Q6H for long-term therapy
How often is serum Na monitored in symptomatic hyponatremia? (correct answers)Every 2-4 hours
What should you consider in your geriatric patient with hyponatremia? (correct answers)Carefully assess
their fluid intake. If they have chronic hyponatremia, they need to be aware of potential bone loss and
tendency to fracture. Mild hyponatremia is associated with increased mortality.
Define hypernatremia (correct answers)• Serum Na greater than 146 mEq/L and represents a state of
hyper osmolality
• Always indicates hyper osmolality or a deficit of total body water
• May also be caused by a primary Na gain in addition to a water deficit which is more common
It is a "water problem" - either excess water loss or inability to acquire water. More common in
debilitated elderly, infants, handicapped
What are two causes of primary water loss that may cause hypernatremia? (correct answers)o Central
(pituitary) diabetes insipidus; lack of ADH secretion
o Nephrogenic (renal) diabetes insipidus; failed response to ADH
What are some other ways a patient may have hypernatremia? (correct answers)o Renal osmotic
diuresis is seen in glucosuria of DM, Mannitol or glycerol infusion or high urea excretion in catabolic
states such as burns
, o GI fluid loss through persistent diarrhea or postsurgical drainage o Cutaneous fluid loss in burns or
profuse sweating
o Excessive administration of hypertonic sodium bicarbonate (NaHCO3) in CPR or lactic acidosis, or 3%
saline infusions
What do the brain cells do in hyponatremia vs hypernatremia? (correct answers)Hyponatremia =
swollen
Hypernatremia = shrinkage
What kind of symptoms may you see in a patient with a Na between 151-160? (correct answers)-
depends on the time frame of development.
If acute you may see nausea, weakness, lethargy, confusion. If there is a chronic condition, there may be
no or mild CNS symptoms
What kind of symptoms may you see in a patient with a Na greater than 160? (correct answers)- If it
develops acutely may see stupor and coma.
If it is chronic elevation, will see moderate to severe CNS symptoms
Your pt has a serum Na greater than 146 and a urine osmolality (UOsm) less than 300, what does this
suggest? (correct answers)central or nephrogenic DI
Your pt has a serum Na greater than 146 and a urine osmolality (UOsm) between 300-400, what does
this suggest? (correct answers)osmotic diuresis
Your pt has a serum Na greater than 146 and a urine osmolality (UOsm) greater than 400, what does this
suggest? (correct answers)GI, cutaneous or insensible fluid losses
What other tests can be done for hypernatremia? (correct answers)-Serum ADH may be helpful.
-Water deprivation test:
1. Withhold all fluids
2. Monitor BP, Na and UOsm then when UOsm is nearly constant with a less than 30mOsm/L change for
2-3 hours administer AVP or DDAVP per protocol.
3. Measure urine volume and UOsm after 1 hour. Central DI will show an increase in UOsm to 600- 700
mOsm/L. Nephrogenic DI will have little or no increase in UOsm
How fast can you correct hypernatremia? (correct answers)• A more rapid correction of serum Na is
indicated for acute, symptomatic hypernatremia but no faster than 1-2 mEq/L/hr to avoid cerebral
edema
