ATI Engage Fundamentals RN 2.0: Fluid, Electrolyte, and Acid-Base Regulation

A nurse is caring for a client who has a prescription to receives one unit of packed red blood cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood bank. Which of the following actions should the nurse take?

Verify the unit of blood with another nurse. Rationale: The unit of blood is compatible with the client's blood type. However, the nurse should ensure that the blood unit had been verified by two nurses before initiating the transfusion.

A nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first?

Elevate the head of the client's bed. Rationale: The first action the nurse should take when using the airway, breathing, circulation approach to client care is to elevate the head of the client's bed. Placing the client in the Fowler's or semi-Fowler's position will promote effective breathing and chest expansion.

A nurse is reviewing the latest arterial blood gas (ABG) values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process?

Evaluation Rationale: Reviewing the client's ABG values is part of the evaluation stage of the nursing process. During the evaluation stage, the nurse should determine if the actions taken in the implementation stage were successful in meeting the goals in the client's plan of care.

A nurse on a pediatric floor is teaching a newly licensed nurse about IV therapy. Which of the following information should the nurse include?

Performing range of motion exercises on the extremity containing the IV site. Rationale: The nurse should instruct the newly licensed nurse to perform range of motion exercises on the client's extremity that contains the IV site.

A nurse is reviewing laboratory results for a client and notes the following arterial blood gas (ABG) values: pH 7.31, PaCO2 49 mm Hg, and HCO3 25 mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances?

Respiratory acidosis Rationale: This client's ABG values indicate respiratory acidosis. Respiratory acidosis is indicated by a pH value below the expected reference range of 7.35 to 7.45 and a PaCO2 value above the expected reference range of 35 to 45 mm Hg.

A nurse is participating in blood drive and is taking a donation from a client who has type O+ blood. The client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make?

"You can receive a blood donation from donors with type O- and type O+ blood." Rationale: Clients who have type O+ blood can only receive blood from donors who have type O- or type O+ blood. Clients who have type O- blood are universal donors, meaning that anyone can receive their blood, regardless of blood type.

A nurse is caring for a client who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge catheter than the #20-gauge being replaced. Which of the following gauge catheter should the nurse plan to use?

#22-gauge Rationale: The nurse should use a #22-gauge catheter as a replacement for the current #20-gauge IV catheter. As the client is dehydrated, it may be difficult to access a peripheral vein with a larger gauge catheter. As the gauge # increases, the actual catheter size decreases.

A nurse is calculating a client's intake and output for the last 4 hr. The client consumed 480 mL of water and 240 mL of coffee. The client has also received IV fluids for 4 hr infusing at 100 mL/hr. Which of the following amounts represents the client's intake over the last 4 hr?

1,120 mL Rationale: The client has taken in: 480 mL of water + 240 mL of coffee + (100 mL of fluids x 4 hr). 720 mL + 400 mL = 1,120 mL. The client's total intake in 4 hr is 1,120 mL.

A nurse is receiving report on four clients. The nurse should identify that which of the following clients may be experiencing hypomagnesemia?

A client who has vomited four times during the last 8 hr. Rationale: Nausea and vomiting are early manifestations of hypomagnesemia.

A nurse has completed assessing and analyzing data for a client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take first?

Planning Rationale: After assessing and analyzing data for a client who has an acid-base imbalance, the nurse should move into the planning stage of the nursing process and establish goals and outcomes for the client.

A nurse is assessing a client who has been receiving IV therapy for several days and notes that the client's daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV-related complications?

Circulatory overload Rationale: The nurse should identify that a client who has been receiving IV therapy and whose daily weight has increased is at risk for circulatory overload. The nurse should assess the client for other indications of circulatory overload, including tachycardia, increased blood pressure, edema, cough, and tachypnea. The nurse should also inform the provider of the client's increased weight.

A nurse is caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider?

Decrease in level of consciousness Rationale: When using the urgent vs non-urgent priority framework, the nurse determines that the priority finding is a decrease in the client's level of consciousness. This is an indication that the hypovolemia has progressed to a critical level and requires immediate intervention.

A nurse is reviewing arterial blood gas (ABG) values for a client who is experiencing uncompensated metabolic acidosis. Which of the following ABG values should the nurse expect? (Select all that apply.)

HCO3 19 mEq/L pH 7.29 PaCO2 35 mm Hg Rationale: The nurse should expect a client who is experiencing metabolic acidosis to have an HCO3- level below the expected reference range of 21 to 28 mEq/L, such as an HCO3- level of 19 mEq/L. The nurse should expect a client who is experiencing metabolic acidosis to have pH level below the expected reference range of 7.35 to 7.45, such as a pH level of 7.29. The nurse should expect a client who is experiencing metabolic acidosis to have a PaCO2 level within the expected reference range of 35 to 45 mm Hg, such as a PaCO2 level of 35 mm Hg.

A nurse is reviewing a client's laboratory results. Which of the following results should the nurse report to the provider?

Magnesium 3 mEq/L Rationale: A magnesium level of 3 mEq/L is above the expected reference range of 1.3 to 2.1 mEq/L. Therefore, the nurse should report this finding to the provider.

A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective? (Select all that apply.)

The client states their muscle spasms are absent. The client denied being confused. Rationale: The absence of muscle spasms indicates that the treatment for hyponatremia has been effective. The client reporting that they are not confused is an indication of adequate sodium levels. Therefore, this is an indication that the treatment for hyponatremia has been effective.

A nurse is caring for a client who has heart failure and a prescription to receive a unit of packed red blood cells. The nurse should plan to infuse the blood over which of the following lengths of time?

4 hr Rationale: Blood can be administered over a period of 1 to 4 hr. For a client who is at risk for circulatory overload, such as a client who has heart failure, a disorder in which compromised cardiac output results in poor tissue perfusion and fluid overload, the transfusion should be administered slowly (maximum time of 4 hr) to avoid increasing the workload of the heart.

A nurse is assessing a client who is exhibiting signs of fluid and electrolyte imbalance. Which of the following findings should the nurse identify as a potential cause for a client's fluid and electrolyte imbalance?

A client reports that they performed yard work for 8 hr in 35 C (95 F) temperature earlier that day. Rationale: The nurse should identify that working outside in high temperatures for an extended period can cause profuse sweating and lead to a fluid and electrolyte imbalance.

A nurse is caring for a client who has the following arterial blood gas (ABG) values: pH: 7.44, PaCO2 37 mm Hg, and HCO3 24 mEq/L. The nurse should identify that these values are an indication of which of the following?

Acid-base balance Rationale: The nurse should identify that this client's ABG values are within the expected reference ranges. The expected reference ranges are: pH 7.35 to 7.45, PaCO2 35 to 45 mm Hg, and HCO3- 21 to 28 mEq/L.

A nurse is preparing to start an IV for a client who has a high risk for bleeding. Which of the following actions should the nurse take?

Apply a blood pressure cuff set to 30 mm Hg. Rationale: Instead of using a tourniquet, the nurse should apply a blood pressure cuff set to 30 mm Hg prior to starting an IV for this client. This will help protect the client's extremity from bruising and bleeding.

A nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients? (Select all that apply)

Decreased kidney function Decreased thirst response Decreased total body fluid Rationale: The nurse should identify that an older adult client who has decreased kidney function is at an increased risk for dehydration. The nurse should expect that an older adult client who has a decreased thirst response might not drink enough fluids daily, which puts them at increased risk for dehydration. The nurse should expect that an older adult client who has decreased total body fluid to be at increased risk for dehydration.

A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for a client?

Increase the carbon dioxide level. Rationale: A state of respiratory alkalosis indicates that the client's carbon dioxide level is currently below the expected reference range. The goal of treatment should be to raise the level of carbon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm Hg.

The nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following complications should the nurse monitor?

Infection at the access site Rationale: This nurse should monitor the client who has a PICC for complications, such as infection at the access site and blood clots. It is important for the nurse to use aseptic technique when accessing and flushing the PICC line and during dressing changes.

A nurse is reviewing a client's latest arterial blood gas (ABG) report. Which of the following values should the nurse identify as the priority to report to the provider?

PaO2 76 mm HG Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority value to report to the provider is PaO2 76 mm Hg. This value is below the expected reference range of 80 to 100 mm Hg and could be an indication the client is decompensating.

A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the nurse intervene?

The nurse selects 0.45% sodium chloride to use to prime the tubing. Rationale: The charge nurse should intervene if the newly licensed nurse selects 0.45% sodium chloride to prime the tubing. The nurse should identify that 0.9% sodium chloride is the only IV solution that should be used to prime the tubing for blood administration.

A nurse is reviewing prescriptions for a client who needs intravenous fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate?

0.9% sodium chloride solution Rationale: A 0.9% sodium chloride solution is isotonic and is used for hydration needs such as from vomiting, diarrhea, hemorrhage, and shock. This is the most appropriate solution for the provider to prescribe for this client.

A nurse is teaching a newly licensed nurse about using the nursing process when caring for a client who has an acid-base imbalance. The nurse should include that the stages of the nursing process should be performed in what order?

Assessment Analysis Planning Implementation Evaluation

A nurse is preparing to administer 1,950 mL of 0.45% sodium chloride IV to infuse over 13 hr. THe nurse should set the IV pump to deliver how many mL/hr?

150 mL/hr

A nurse is preparing to administer 4,200 mL of intravenous fluids to a client to infuse over 24 hr. The nurse should set the IV pump to deliver how many mL/hr?

175 mL/hr

A nurse is participating in a blood drive and is taking a donation from a client who has type A- blood. The client asks the nurse what blood types can receive their blood donation. Which of the following responses should the nurse make? (Select all that apply.)

A+ AB- AB+ A-

A nurse is reviewing the arterial blood gas (ABG) values for a client and notes the following results: pH 7.49, PaCO2 39 mm Hg, and HCo3 35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances?

Metabolic alkalosis Rationale: This client's ABG values indicate metabolic alkalosis. Metabolic alkalosis is indicated by a pH value above the expected reference range of 7.35 to 7.45, an HCO3- value above the expected reference range of 21 to 28 mEq/L, and a PaCO2 level within the expected reference range of 35 to 45 mm Hg.