Fluid, Electrolyte and Acid-base regulation

A change 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 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 peripherally inserted central catheter. for which of the following complications should the nurse monitor?

infection at the access site

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 95 F temp earlier that day.

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?

the client states their muscle spasms are absent The client denies being confused

A nurse is caring for a client who has a prescription to receive one unit of 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

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

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 chloride solutions

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/L. Which of the following amounts represents the client's intake over the last 4 hr?

1,120mL

A nurse is caring for a client who has heart failure and a prescription to receive a unit a 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 hrs.

a nurse is caring for a client who has the following arterial blood gas values: pH 7.44, PaCO2 37 mm Hg, and HCO -3 24 mEq/L. The nurse should identify that 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.

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 increase risk for developing which of the following IV-related complications?

Circulatory overload

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 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?

Decreased kidney function, Decreased thirst response, Decreased total body fluid

A nurse is reviewing the latest arterial blood gas 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 values for a client who is experiencing uncompensated metabolic acidosis. Which of the following ABG values should the nurse expect?

HCO-3 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 3 mEq/L

A nurse is reviewing the arterial blood gas values for a client and notes the following results: pH 7.49, PaCO2 39 mm Hg, and HCO-3 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 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 extremely 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 values: pH 7.31, PaCO2 49 mm Hg, and HCO-3 25 mEq/L. The nurse should interpret these findings as an indicator of which of the following acid-base imbalances?

Respiratory acidosis

A nurse is prepping 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

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 nurses make?

A+/ AB-/ AB+/ A-

Order of nursing practice

Assessment is the first step Analysis is the second step Planning is the third step Implementing is the fourth step Evaluation is the final step

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 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 make?

You can receive a blood donation from donor with type O- and type O+ blood.