Fluid, Electrolyte and Acid-Base Regulation ATI
A nurse is caring for a client who has the following 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
A nurse is participating in a 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 blood donation from donors with type O- and type O+ blood
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 1950/13 = 150
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 blood pressure cuff set to 30 mm Hg
A nurse 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
A nurse is caring for a client who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge than the #20 gauge being replaced. Which of the following gauge catheters should the nurse plan to use?
#22-gauge
A nurse is participating in a blood drive and is taking donation from a client who has type A- blood. The client asks the nurse what blood types can receive their donation?
A+ AB- AB+ A-
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 teaching a newly licensed nurse about using the nursing process. 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 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 clients?
Decreased kidney function Decreased thirst response Decreased total body fluid
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
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 ROM exercises on the extremity containing the IV site`
A nurse is preparing to administer 4200 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 Flow rate (mL/hr)=Total volume (mL) / Infusion time (hr)
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
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
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 480 + 240 + 400 = 1,120 mL
A 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 8 hr
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 risk for developing which of the following IV-related complications
Circulatory overload
A nurse is reviewing ABG values for a client who is experiencing uncompensated metabolic acidosis. Which of the following ABG values should the nurse expect?
HCO3- 19 mEq/L pH 7.29 PaCO2 35 mm Hg
A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for the client?
Increase the carbon dioxide level
A nurse is reviewing a client's laboratory results. Which of the following results should the nurse report to the provider?
Magnesium 3mEq/L
A nurse is reviewing a client's latest ABG report. Which of the following values should the nurse identify as the priority to report to the provider?
PaO2 76 mm Hg
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
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 the client's fluid and electrolyte imbalance?
The client reports that they performed yard work for 8 hr in 35 C (95 F) temperature earlier that day
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 charge nurse intervene?
The nurse selects 0.45% sodium chloride to use to prime the tubing
A nurse is caring for a client who has a prescription to receive 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