Fluid and electrolyte ATI
A nurse is assessing a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following findings should the nurse identify as a potential cause for the clients fluid and electrolyte inbalance?
The client reports that they performed yardwork for eight hours in 95 Fahrenheit temperature earlier that day
Hypervolemia
The state of low extracellular fluid volume common generally secondary to combined sodium and water loss
A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be a goal of treatment for the client?
a. Increase the carbon dioxide level.
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 indicate?
0.9 sodium
The nurse is calculating a clients intake and output for the last four hours. The client consumed 480 ml of water and 240ml of coffee. The client has also received IV fluids for four hours infusing at 100 ML's per hour. Which of the following represents the clients intake over the last four hours
1120 ml
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 confuse the blood over which of the following length of time?
4 hr
The nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia?
A client who has vomited four times during the last eight hours
can receive their blood donation . Which of the following responses should the nurse make ? ( Select all that apply . ) 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 .
A+, AB minus, a B+, a minus
The nurse is caring for a client who has the following or two blood gas ABG values PH 7.44, PaCO2 33mm Hg and HCO3- 24mEq/L. The nurse Should identify that these values are an indication of which of the following?
Acid base balance
A nurse is preparing to start an IV for a client who has a high risk for bleeding. Which of the following action should the nurse take?
Apply a blood pressure cuff set to 30mmhg
A nurse is teaching a newly licensed nurse about 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? Move the steps into the box on the right placing them in order a performance. Use all the steps
Assessment, analysis, planning, implementation, evaluation
The nurse is accessing a client who has been receiving IV therapy for several days and notes at the clients daily weight has increased. The nurse should identify that the client is an increased risk for developing which of the following IV related complications?
Circulatory overload
A nurse is caring for an old odor adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk of dehydration in older adult clients?
Decreased kidney function, decreased thirst response, decreased total body fluid.
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 ? ( Round the answer to the nearest whole number . Use a leading zero if it applies . Do not use a trailing zero . )
Divide 1950 by 13 and you get 150
The 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 clients bad
A nurse is reviewing ulterior 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 is correct pH 7.29 is correct PaCO₂ 35 mm Hg is correct
The nurse is caring for a client who has a peripherally inserted central catheter pick. For which of the following complications should the nurse monitor?
Infection at the access site
A nurse is reviewing a clients laboratory results. Which of the following results should the nurse report to the provider
Magnesium three
A nurse is reviewing the alter your blood gas ABG values for a client in notes the following results pH 7.49 , PaCO₂ 39 mm Hg , and HCO , - 35 mEq / L The nurse should interpret this ABG reading as an indication of which of the following acid - base imbalances ?
Metabolic alkalosis
The nurse is reviewing a clients latest ulterior blood cast ABG report. Which of the following values should the nurse identify as a party to report to the provider
PaO2 76 mm Hg
A nurse on a pediatric floor is teaching a newly licensed nurse about IV therapy. Which of the following information should the nurse include?
Perform range of motion exercises on the extremities containing the IV site
A nurse is reviewing laboratory results for a client and notes the following arterial blood gas ( ABG ) values : pH 7.31 , PaCO , 41 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
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 shift the nurse plan to use?
The 22 gauge
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 and the client denies being confused
The charges does 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 charge nurse intervene?
The nurse selects 0.45% sodium chloride to use to prime the tubing . 0.9% sodium chloride is the only IV solution that should be used to prime the tubing for blood administrationk
The nurse is caring for a client who has a prescription to receive one unit of packed red blood cells. The clients blood type is AB+ , And the nurse receives a unit of a minus blood from the blood blank. Which of the following actions should the nurse take it
Verify the unit a blood with another nurse
The nurses Participating in a blood drive and is taking a donation from a client who has type O plus blood. The client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make
You can only receive blood donation from donors with type O negative and type O positive blood
A nurse is caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as a priority to report to the provider?
a decrease in level of consciousness
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
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 ? ( Round the answer to the nearest whole number . Use a leading zero if it applies . Do not use a trailing zero . )
Divide 4200 by 24 hours and you'll get 175
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 next?
planning