Acid-Base ATI

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? Administer a hypertonic solution. Repeat the potassium level. Withhold the medication. Monitor for paresthesia.

Withhold the medication. The greatest risk to this client is injury from hyperkalemia. Therefore, the priority action is to withhold the oral potassium and notify the provider.

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? Sodium 152 mEq/L Chloride 102 mEq/L Magnesium 1.8 mEq/L Potassium 6.1 mg/L

Potassium 6.1 mg/L Hyperkalemia can cause a prolonged PR interval; a wide QRS complex; flat or absent P waves; and tall, peaked T waves.

A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? BUN 26 mg/dL Serum sodium 138 mEq/L Hct 56% Urine specific gravity 1.035

Serum sodium 138 mEq/L Isotonic dehydration includes loss of water and electrolytes. A serum sodium level of 138 mEq/L is within the expected reference range and indicates that the fluid therapy has been effective

A nurse is caring for a client who has a serum sodium level of 155 mEq/L. Which of the following IV fluid prescriptions should the nurse anticipate administering? 1,000 mL 0.9% sodium chloride 1,000 mL dextrose 5% in water 1,000 mL dextrose 10% in water 1,000 mL 0.225% sodium chloride

1,000 mL 0.225% sodium chloride This hypotonic solution should help decrease serum sodium levels.

A nurse is reviewing the laboratory data on four clients. Which of the following serum laboratory values should the nurse expect for the client who is experiencing 2+ pitting ankle edema? Sodium 138 mEq/L Hematocrit 34% BUN 22 mg/dL Protein 9 g/dL

Hematocrit 34% This hematocrit level is below the expected reference range. A 2+ pitting edema indicates fluid overload, which can cause hemodilution and a decreased hematocrit.

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? Implement seizure precautions. Administer phosphate. Initiate diuretic therapy. Prepare the client for hemodialysis.

Implement seizure precautions. The client is at risk for seizures due to low excitation threshold as a result of the client's decreased calcium level. The nurse should initiate seizure precautions to prevent injury.

A nurse is caring for a client who is experiencing respiratory distress as a result of acute pulmonary edema. Which of the following actions should the nurse take first? Assist with intubation. Initiate high-flow oxygen therapy. Administer a rapid-acting diuretic. Administer morphine IV.

Initiate high-flow oxygen therapy. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.

A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? Hyperactive deep-tendon reflexes Orthostatic hypotension Rapid, deep respirations Strong, bounding pulse

Orthostatic hypotension Hypokalemia can lead to hypotension. The nurse should monitor the client for orthostatic hypotension.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respirations are 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis?

PaCO2 With respiratory alkalosis, the PaCO2 level is decreased.

A nurse is planning dietary teaching for a client who has hypermagnesemia. Which of the following food choices contains the most magnesium and is, therefore, a food the nurse should plan to instruct the client to avoid? -Hard-boiled eggs -Cheddar cheese -Raw rhubarb -Raw spinach

Raw spinach The nurse should instruct the client to avoid raw spinach because it contains 79 mg of magnesium per 100 g.

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? Sodium 128 mEq/L Potassium 4.8 mEq/L Calcium 9.1 mg/dL Magnesium 2.0 mEq/L

Sodium 128 mEq/L This level is below the expected reference range and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort.

A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis?

pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L (Low pH + low HCO3) When pH and HCO3- are both above or below the expected reference range, a metabolic imbalance is present. A pH of 7.26 indicates acidosis and a HCO3- of 20 mEq/L indicates the acidosis is due to a metabolic cause. Therefore, the nurse should identify these findings as metabolic acidosis.

A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of laboratory results indicates that the client has metabolic alkalosis?

pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L An elevated pH and HCO3- with a PaCO2 within the expected reference range indicates metabolic alkalosis.

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the instructions? "If my stockings feel tight, I'll just roll them down for a while." "I'll put on my elastic stockings at the first sign of swelling." "When I sit down to watch television, I'll be sure to put my feet up." "It's okay to cross my legs as long as it's for less than an hour."

"When I sit down to watch television, I'll be sure to put my feet up." Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet will increase the return. The client should elevate them for at least 20 min several times per day.

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) Administer IV fluids evenly over 24 hr. Provide the client with a salt substitute. Assess for pitting edema. Encourage the client to rise slowly when standing up. Weigh the client every 8 hr.

Administer IV fluids evenly over 24 hr is correct. A client who has excessive fluid loss is typically prescribed IV replacement fluids. Administering IV fluids rapidly over a short period of time places the client at risk for fluid overload. Encourage the client to rise slowly when standing up is correct. This action can prevent injury from falls caused by orthostatic hypotension. Weigh the client every 8 hr is correct. Weighing the client every 8 hr will provide information regarding fluid balance.

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? Monitor the client's bowel sounds. Review the client's daily laboratory results. Auscultate the client's lungs. Palpate the client's peripheral pulses.

Auscultate the client's lungs. Using the airway, breathing, circulation approach to client care, the first action the nurse should take is to auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles.

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload?

Bounding peripheral pulses Fluid overload results in increased vascular volume and places a greater workload on the heart.

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? Deep-tendon reflexes Cardiac rhythm Peripheral sensation Bowel sounds

Cardiac rhythm When using the airway, breathing, circulation approach to client care, the nurse should determine that assessing the cardiac rhythm is the priority. Calcium levels below the expected reference range can cause ECG changes, bradycardia, or tachycardia.

A nurse is assessing a client who has a serum phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? Hepatic failure Abdominal pain Slow peripheral pulsations Increase in cardiac output

Slow peripheral pulsations Hypophosphatemia causes slow peripheral pulses that are difficult to detect and can eventually result in cardiac muscle damage.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances?

Respiratory acidosis Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.

A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? Urine output of 30 mL/hr Blood glucose of 180 mg/dL Serum potassium 3.0 mEq/L BUN 18 mg/dL

Serum potassium 3.0 mEq/L This serum potassium level is outside the expected reference range. The nurse should report this finding to the provider.

A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? "I will eat extra cheese because I can't drink milk." "I need to avoid foods with vitamin D because I am allergic to milk." "I will stop taking my calcium supplements if they irritate my stomach." "I will add broccoli and kale to my diet."

"I will add broccoli and kale to my diet." The nurse should recommend broccoli and kale, which are good sources of calcium as alternatives to milk products.

A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? "I should conserve energy by limiting my physical activity." "I will wait until my pain is at least 6 out of 10 before I use the PCA." "I will limit my daily fluid intake to 2 to 3 glasses." "I will use the incentive spirometer every hour."

"I will use the incentive spirometer every hour." Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Using an incentive spirometer will promote adequate chest expansion. The nurse should identify this statement as indicating an understanding of the teaching.

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? -Sodium polystyrene sulfonate 30 g/day -0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr -Bumetanide 8 mg/day -100 mL of dextrose 10% in water with 10 units of insulin

0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride.

A nurse is caring for a client who has heart failure and is receiving furosemide. The client is experiencing irritability and anxiety. Which of the following actions should the nurse anticipate taking? Offer whole grain wheat breads with meals. Recommend a potassium-sparing diuretic. Give potassium 20 mEq/L by IV bolus. Restrict oral fluids.

Recommend a potassium-sparing diuretic. The findings indicate hypokalemia likely caused by furosemide. The nurse should anticipate a prescription for a potassium-sparing diuretic.

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? Decreased muscle strength Decreased gastric motility Increased heart rate Increased blood pressure

Decreased muscle strength Hyperkalemia can cause muscle weakness. The nurse should monitor the client's muscle strength.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect?

Hyperactive deep-tendon reflexes Hyperactive DTRs are an expected finding for a client who has hypomagnesemia, along with muscle cramps, numbness, and tingling.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? Hypotension Peripheral edema Facial flushing Hyperreflexia

Hypotension Hypotension is a manifestation of respiratory acidosis due to vasodilation.

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? -skin turgor -urine output -mental status -weight

Mental status The greatest risk to this client is injury from declining mental status or a fall from worsened dehydration. Therefore, assessing the client's mental status is the priority.

A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has respirations of 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take? Instruct the client to cough forcefully. Assist the client with ambulation. Provide calming interventions. Discontinue the PCA.

Provide calming interventions. The client's respiratory rate is above the expected range. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase. This will help correct the pH imbalance.