Fluid, Electrolyte, and Acid Base Regulation Assessment

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? A) Nurse selects 0.45% sodium chloride to use to prime the tubing B) Nurse asks another nurse to check blood unit label and client identification prior to beginning the transfusion C)Nurse uses tubing with a filter for the blood transfusion D) Nurse discards tubing after first unit of blood is completed

A

A nurse is calculating a client's intake and output for the last 4hr. The client consumed 480ml of water and 240ml of coffee. The client also received IV fluids for 4 hr infusing at 100ml/hr. Which of the following represents client's intake over the last 4 hr? A) 1120ml B)720ml C)480ml D)580ml

A

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? A) Increase CO2 B) Increase RR C) Increase HCO3 D) Increase pH level

A

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 4x the last 8 hr B) Client who requested extra breakfast tray to eat C) Client who can ambulate without assistance D) Client who reports extreme thirst

A

A nurse on a pediatric floor is teaching a newly licensed nurse about IV therapy. Which of the following info should the nurse include? A) Perform ROM exercises on the extremity containing the IV site B) Shave the client's hair if the IV is to be places in the scalp C) IV sites can be placed in lower extremities up to age 2 years D) Monitor IV site, tubing, and connections every 4 hours

A

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 A) Decreased kidney function B) Decreased thirst response C) Decreased total body fluid D) Eating watermelon daily E) Eating cucumbers with each meal

A, B, C,

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 A) Client states their muscle spasms are absent B) Client reports a headache C) Client denies being confused D) Client reports being nauseated E) Client reports feeling tired

A, C,

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? SELECT ALL THAT APPLY A) HCO3 19 mEq/L B) pH 7.29 C) PaCO2 49mm Hg D) pH 7.49 E) PaCO2 35 mmHg

A,B,E

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? a) The need for multiple IV sticks b) Infection at the access site c) Dehydration d) Infiltration

B

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? A) Initiate continuous cardiac monitoring B) Elevate head of client's bed C) Instruct the client to deep breathe and cough D)Initiate continuous SpO2 monitoring

B

A nurse is reviewing lab results for a client and notes the following ABG values: pH 7.31, PaCO2 49mm Hq, and HCO3 25mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances? A) Metabolic acidosis B) Respiratory Acidosis C) Metabolic Alkalosis D) Respiratory Alkalosis

B

A nurse is reviewing prescriptions for a client who needs IV replacement therapy due to V/D. Which of the following fluid prescriptions should the nurse expect to initiate? A) 3% sodium chloride solution B) 0.9% sodium chloride solution C) 0.45% sodium chloride solution D) Dextrose 10% in water

B (isotonic)

A nurse is caring for a client who has heart failure and a prescription to receive a unit of packed RBC. The nurse should plan to infuse the blood over which of the following lengths of time? A) 1 hr B) 2hr C)4hr D) 6hr

C

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? A) metabolic acidosis B) Respiratory acidosis C) Acid-base balance D)Respiratory Alkalosis

C

A nurse is reviewing a client's lab results. Which of the following results should the nurse report to the provider? A) Potassium 4.5 mEq/L B) Sodium 138 mEq/L C) Magnesium 3 mEq/L D) Calcium 10mg/dL

C

A nurse is reviewing the ABG values for a client and notes the following results: pH 7.49, PaCo2 39mm Hg, and HCO3 35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances? A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis

C

A nurse is reviewing the latest 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? A) Planning B) Assessment C) Evaluation D) Implementation

C

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? A) Implementation B) Reassessment C) Evaluation D)Planning

D

A nurse is assessing a client who has been receiving IV therapy for several days and notes 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? A) Phlebitis B) Extravasation C) Air embolism D) Circulatory overload

D

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) Dry mucous membranes B) Decreased urine output C) Report of thirst D) Decrease in level of consciousness

D

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? A) Apply cold compress to selected IV site B) Ask the client to hold extremity up prior to searching for an IV site C) Ask client to spread fingers of the selected extremity D) Apply blood pressure cuff set to 30mm Hg

D

A nurse is reviewing a client's latest ABG report. Which of the following values should the nurse identify as priority to report to the provider? A) pH 7.37 B) PaCO2 43mm Hg C) HCO3 27 mEq/L D) PaO2 76 mm Hg

D