Fluid, Electrolytes & Acid-Base Balance
A nurse is reviewing prescriptions for a client who needs IV 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 clients intake and output for the last 4hr. The client consumed 480mL of water and 240 mL of coffee. The client has also received IV fluids for 4hr infusing at 100 mL/hr. Which of the following amounts represents the clients intake over the last 4hr?
1,120 mL
A nurse is preparing to administer 1950mL of .45% sodium chloride IV to infuse over 13hr. The nurse should set the IV pump to deliver how many mL/hr?
150mL/hr= 1950mL/13hr
A nurse is preparing to administer 4200 mL of IV fluids to a client to infuse over 24hr. The nurse should set the IV pump to deliver how many mL/hr?
175 mL/hr = 4200 mL/24hr
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?
4hr
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 8hr
A nurse is caring for a client who has the following ABG values: pH 7.44, PaCO2 37 mmHg, HCO3- 24mEq/L. The nurse should identify that these values are an indication of which of the following?
Acid-base imbalance
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 BP cuff set to 30 mmHg
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?
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 adult clients?
Decreased kidney function, decreased thirst response, decreased total body fluid
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 clients bed
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 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 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 .45% sodium chloride to use to prime the tubing
A nurse is reviewing lab results for a client and notes the following ABG values: pH 7.31, PaCO2 49mmHg, 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 participating in a blood drive and is taking a donation from a client who has type A- blood. The client asks the nurse what types can receive their blood donation. Which of the following responses should the nurse make?
A+, AB-, AB+, A-
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 assessing a client who has been receiving IV therapy for several days and notes that the clients 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
A nurse is 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 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 mmHg
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 CO2 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
A nurse is reviewing a clients lab results. Which of the following results should the nurse report to the provider?
Magnesium 3 mEq/L
A nurse is reviewing the ABG values for a client and notes the following results: pH 7.49, PaCO2 39mmHg, 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 clients latest ABG report. Which of the following values should the nurse identify as the priority to report to the provider?
PaO2 76 mmHg
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 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 clients fluid and electrolyte imbalance?
The client reports that they performed yard work for 8hr in 35 degree celsius (95 degree fahrenheit) temperature 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 packed red blood cells. The clients 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 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
