ATI fluid quiz

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis? A. A client who has diarrhea B. A client who is vomiting C. A client who is taking a thiazide diuretic D. A client who has salicylate intoxication

A. A client who has diarrhea

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia? A. Abnormally prominent U wave B. Elevated ST segment C. Wide QRS D. Inverted P wave

A. Abnormally prominent U wave

A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take? A. Administer the blood as ordered B. Contact the prover for further orders C. Notify the blood bank of the discrepancy D. Complete an incident report

A. Administer the blood as ordered

A nurse is preparing to administer blood to a client. The unit of blood on hand is type O negative, and the client has type A positive blood. Which of the following actions should the nurse take? A. Administer the blood as ordered B. Contact the provider for further orders C. Notify the blood bank D. Complete an incident report

A. Administer the blood as ordered

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications? A. Cardiac dysrhythmias B. Hypoglycemia C. Seizures D. Neurogenic shock

A. Cardiac dysrhythmias

A nurse is preparing to administer a transfusion of RBs to a client who has heart failure. For which of the following manifestations should the nurse monitor to prevent fluid volume overload? (Select all that apply.) A. Dyspnea B. Gastrointestinal bloating C. Jugular vein distention D. Confusion E. Hypotension

A. Dyspnea C. Jugular vein distention D. Confusion

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock? A. Increased heart rate B. Widening pulse pressure C. Increased deep tendon reflexes D. Pulse oximetry 96%

A. Increased heart rate

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.) A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate D. Increased Hct E. Increased temperature

A. Increased heart rate B. Increased blood pressure C. Increased respiratory rate

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding? A. Potassium 2.9 mEq/L B. Phosphorous 4.5 mEq/L C. Sodium 145 mEq/L D. Calcium 8.2 mg/dL

A. Potassium 2.9 mEq/L

A nurse is caring for a client who has a serum potassium level of 5.5 mEq/L. The provider prescribes polystyrene sulfonate. If this medication is effective, the nurse should expect which of the following changes on the client's ECG? A. Reduction of T-wave amplitude B. Shortening of P-wave duration C. Widening of the QRS complex D. Restoration of QRS complex amplitude

A. Reduction of T-wave amplitude

A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia? A. Shallow respirations B. Hypertensive crisis C. Diarrhea D. Hyperreflexia

A. Shallow respirations

A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect? A. Tingling of the extremities B. Hypoactive deep tendon reflexes C. Shortened QT intervals D. Constipation

A. Tingling of the extremities

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings? A. Urine specific gravity 1.035 B. Hematocrit 44% C. BUN 19 mg/L D. Sodium 155 mEq/L

A. Urine specific gravity 1.035

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time? A. Brachial B. Carotid C. Femoral D. Popliteal

B. Carotid

A nurse is monitoring a client who is receiving a unit of packed RBs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload? A. Flushing B. Dyspnea C. Bradycardia D. Vomiting

B. Dyspnea

A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic? A. Pitting edema B. Fatigue C. Dyspnea D. Oliguria

B. Fatigue

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A. Bp B. Heart rate C. Urine output D. Weight

B. Heart rate

A nurse is caring for a client who has esophageal varices and is hypotensive after vomiting 500 mL of blood. Which of the following actions is the nurse's priority? A. Elevate the client's feet B. Increase the client's IV fluid rate C. Initiate a dopamine IV infusion for the client D. Administer a unit of packed

B. Increased the client's IV fluid rate

A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mE/L. Which of the following actions should the nurse take? A. Suggest that the client use a salt substitute B. Obtain a 12-lead ECG C. Advise the client to add citrus juices and bananas to her diet D. Obtain a blood sample for a serum sodium level

B. Obtain a 12-lead ECG

A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care? A. Monitor the client's intake and output every 6 hr B. Offer the client 240 mL (8oz) of oral fluids every 4 hr C. Check the client's IV infusion every 8 hr D. Administer furosemide to the client

B. Offer the client 240 mL (8oz) of oral fluids every 4 hr

A nurse is reviewing the serum laboratory findings for a client who has hypertension and is prescribed hydrochlorothiazide. Which of the following findings should the nurse report to the provider? A. Sodium 136 mEq/L B. Potassium 2.3 mEq/L C. Chloride 99 mEq/L D. Calcium 10 mg/dL

B. Potassium 2.3 mEq/L

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate? A. Maintain an IV of 0.45% sodium chloride B. Restrict fluid intake to 1,000 mL/day C. Provide a diet containing 2 g of sodium per day D. Administer desmopressin acetate 0.2 mg orally

B. Restrict fluid intake to 1,000 mL/day

A nurse is caring for a client who has hypernatremia and requires I fluid therapy due to his PO status. Which of the following solutions should the nurse prepare to infuse for this client? A. Lactated ringer's B. Dextrose 5% in 0.9% sodium chloride C. 0.45% sodium chloride D. Dextrose 10% in water

C. 0.45% sodium chloride

A nurse is caring for a client who has a prescription for potassium chloride (KCL) 20 mE PO daily. The nurse reviews the client's most recent laboratory results and finds the client's potassium level is 5.2 mEq/L. Which of the following actions should the nurse take? A. Give the ordered KCL as prescribed B. Omit the KCL dose and document it was not given C. Call the prescribing physician and inform her of the client's serum potassium level results D. Call the lab to verify the client's results

C. Call the prescribing physician and inform of the client's serum potassium level results

A nurse is preparing to insert an IV catheter for a client and has selected the insertion site. Place the following steps in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) A. Dilate the vein B. Flush the catheter C. Cleanse the site with an antiseptic swab D. Insert the catheter E. Apply a tourniquet or Bp cuff

C. Cleanse the site with an antiseptic swab E. Apply a tourniquet or Bp cuff A. Dilate the vein D. Insert the catheter B. Flush the catheter

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings? A. Decreased urine specific gravity B. Decreased Hgb C. Increased BUN D. Increased urine ketones

C. Increased BUN

A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing? A. Hypotension B. Anuria C. Increased respiratory rate D. Decreased LOC

C. Increased respiratory rate

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding? A. Hypertension B. Flushing of the skin C. Oliguria D. Bradypnea

C. Oliguria

A nurse caring for a client who is vomiting. Which of the following actions should the nurse take first? A. Provide the client with a emesis basin B. Notify housekeeping C. Prevent the client from aspirating D. Administer an antiemetic to the client

C. Prevent the client from aspirating

A nurse is performing an admission assessment on a client. Which of the following findings should the nurse identify as an indication that the client is dehydrated? A. Low body temperature B. Jugular vein distention C. Skin tenting present D. Blood pressure 178/90 Hg

C. Skin tenting present

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer? A. Lactulose B. Sevelamer C. Sodium polystyrene (Kayexalate) D. Darbepoetin Alfa

C. Sodium polystyrene (Kayexalate)

A nurse is providing teaching for a client who is on diuretic therapy and has a new prescription for potassium chloride (KCL) 20 mEg extended release PO daily. Which of the following instructions should the nurse provide about the new prescription? A. Take the extended release tablets on an empty stomach B. Add an antacid if the medication causes indigestion C. Take the extended release tablets whole D. Expect urinary output to decrease while on this medication

C. Take the extended release tablets whole

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? A. Hyperactive reflexes B. Extreme thirst C. Weak, irregular pulse D. Hyperactive bowel sounds

C. Weak, irregular pulse

A nurse is the emergency department is caring for a client. Vital signs: Temperature 38.4° C (101.2° F) Pulse 122/min Respirations 24/min Blood pressure 102/58 mm/Hg Pulse oximetry 95% on room air Nurses notes: 0800: Client reports diarrhea, vomiting, abdominal cramps, and headache for the last 12 hr. States "I think I ate some chicken that wasn't totally cooked." Client reports diarrhea and vomiting all through the night. Denies bloody or black stools, or hematemesis. Client rates headache pain 7 on a 0 to 10 pain scale. States "Unable to keep down ibuprofen. I just throw it back up." 0815: Provider at bedside, update given. 0830: Prescriptions received. Blood collected from client for complete blood count (CBC), basic metabolic profile (BMP); stool collected for culture; urine collected for urinalysis 0845: IV catheter to right arm initiated, 0.9% sodium chloride at 125 mL/hr started; ibuprofen 400 mg IV bolus administered 0900: The client is at risk for developing fluid volume deficit vomiting and diarrhea due to Condition Finding hypertension bacteria meningitis IV therapy seizures bowel impaction OVeR abdomina cramo ing Client resting quietly, cool cloth on head, waiting on room a

Condition: C. Fluid volume deficit Finding: B. Vomiting and diarrhea

A nurse is assessing four clients for fluid balance. The nurse should identify that which of the following clients is exhibiting manifestations of dehydration? A. A client who has a urine specific gravity of 1.010 B. A client who has a weight gain of 2.2 kg (2lb) in 24 hr C. A client who has a hematocrit of 45% D. A client who has a temperature 39 C (102 F)

D. A client who has a temperature of 39 C (102 F)

A nurse is completing a medication history for a client who reports using over-the-counter calcium carbonate antacid. Which of the following recommendations should the nurse make about taking this medication? A. Decreased bulk in the diet to counteract the adverse effect of diarrhea B. Take the medication with dairy products to increase absorption C. Reduce sodium intake D. Drink a glass of water after taking the medication

D. Drink a glass of water after taking the medication

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. His blood urea nitrogen (BUN) is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following nursing interventions is appropriate? A. Collect a urine specimen for culture and sensitivity B. Continue routine care because the results are within the expected reference range C. Decrease the IV fluid infusion rate and limit oral fluid intake D. Evaluate urine for amount and for specific gravity

D. Evaluate urine for amount and for specific gravity

A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect? A. Hypothermia B. Protruding eyeballs C. Elevated blood pressure D. Furrows in the tongue

D. Furrows in the tongue

A nurse is caring for a 78-year-old client who was recently admitted from the emergency room and is reporting weakness. Medical Hx: 78-year-old female admitted with watery diarrhea × 4 days Denies vomiting Reports having an upper respiratory infection 1 week ago and was treated with ampicillin Reports anorexia, unaware of any weight loss Lives alone Past medical history includes hypertension, COPD, and diabetes mellitus Walks for 30 min 5 out of 7 days/week Drinks an occasional glass of wine Smokes one-two cigarettes/day Nurses Notes: 0800: Alert and oriented × 3 Reports weakness and dizziness Skin pale and cool, poor skin turgor Mucous membranes dry with a white coating Denies nausea Lungs clear to auscultation Abdomen soft with hyperactive bowel sounds × 4 Reports diffuse abdominal tenderness on palpation Reports 3 watery bowel movements in the last 8 hr Urine dark yellow in color Output 30 mL/hr The client is at risk for developing hypernatremia and metabolic alkalosis Word Choices hypermagne- hypervolemia hyperkalemia metabolic acidosis 1000: Up to bathroom with assistance of assistive personnel. Has syncopal episode. Assisted back to bed. No injuries noted. Instructed to not get ou

D. Hypernatremia E. Metabolic acidosis

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock? A. Decrease in the respiratory rate from 20 to 16/min B. Decrease in the urinary output from 50 mL to 30 mL/hr C. Increase in the temperature from 37.5 C (99.5 F) to 38.6 C (101.5 F) D. Increase in the heart rate from 88 to 110/min

D. Increase in the heart rate from 88 to 110/min

A nurse is attempting to flush the IV saline lock for a client. The client reports pain above the catheter site. Which of the following actions should the nurse take? A. Inject the solution more slowly while flushing the IV saline lock B. Apply a warm compress to the IV site C. Apply firm pressure to the plunger of the of they syringe during the IV flush to improve patency D. Remove the IV saline lock

D. Remove the IV saline lock

The nurse is preparing a medication for a client and observes the date of expiration on the vial occurred 2 months ago. Which of the following actions should the nurse take? A. Give the medication B. Discard the medication C. Notify the provider D. Return the medication to the pharmacy

D. Return the medication to the pharmacy

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL C. The client who has end-stage renal failure and is scheduled for dialysis today D. The client who has gastroenteritis and is febrile

D. The client who has gastroenteritis and is febrile

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia? A. Decreased heart rate B. Dyspnea C. Increased blood pressure D. Weak pulse

D. Weak pulse

A nurse is caring for a client who has an elevated potassium level and is on a cardiac monitor. The nurse is aware that hyperkalemia may be associated with changes to the T-wave. On the graphic, point and click on the area of the electrocardiogram (ECG) that represents the T-wave.

Order of the ECG P, Q, R, S, T