Fluid, Electrolyte, and Acid-Base Regulation
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
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 a blood donation from donors with type O- and type O+ blood."
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 catheters should the nurse plan to use?
#22-gauge
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. This solution is isotonic and is used for hydration needs.
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
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.)
150
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.)
175
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 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 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 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
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. This helps protect the client's extremity from bruising and bleeding.
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 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 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 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
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 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 laboratory results. Which of the following results should the nurse report to the provider?
Magnesium 3 mEq/L
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
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
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 extremity containing the IV site.
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 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
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 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. Working outside in high temp for an extended period can cause profuse sweating and lead to fluid and electrolyte imbalance.
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 denies being confused.
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. Only use 0.9% sodium chloride IV solution to prime tube for blood administration
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? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Assessment Analysis Planning Implementation Evaluation
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. Unit of blood is correct but ensure it is verified by two nursed before transfusion.
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
