ATI Fluid, Electrolyte, and Acid-Base Regulation

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? a. 1,120 mL b. 720 mL c. 480 mL d. 580 mL

a. 1,120 mL Rationale: 480mL + 240mL +4hr (100mL/hr) = 1120mL

A nurse is assisting in the care of 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 the head of the client's bed. c. Instruct the client to deep breathe and cough. d. Initiate continuous SpO2 monitoring.

b. Elevate the head of the client's bed Rationale: The 1st action the nurse should take when using the airway, breathing, circulation approach to client care is to elevate the HOB. Placing the client in a Fowler's or semi-Fowler's position will promote effective breathing & chest expansion

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? a. pH 7.37 b. PaCO2 43 mm Hg c. HCO3- 27 mEq/L d. PaO2 76 mm Hg

d. PaO2 76 mm Hg Rationale: This value is below the expected reference range of 80 to 100 mm Hg & could be an indication the client is decompensating

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. The client states their muscle spasms are absent. b. The client reports a headache. c. The client denies being confused. d. The client reports being nauseated. e. The client reports feeling tired.

a. The client states their muscle spasms are absent. c. The client denies being confused. Rationale: The absence of muscle spasms & client reporting that they are not confused is an indication of adequate sodium levels

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 mL/hr Rationale: 1950mL/13hr = 150mL/hr

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? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

b. Respiratory acidosis

A nurse is reviewing arterial blood gas (ABG) values for a client who is experiencing 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 49 mm Hg d. pH 7.49 e. PaCO2 35 mm Hg

a. HCO3- 19 mEq/L b. pH 7.29 e. PaCO2 35 mm Hg

A nurse has completed collecting 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. Re-collection of data c. Evaluation d. Planning

d. Planning Rationale: After assessing & analyzing data for a client who has an acid base imbalance, the nurse should move into the planning stage of the nursing process & establish goals & outcomes for the client

A nurse is assisting in the care of a client who has heart failure and a prescription to receive a unit of packed red blood cells. The nurse should plan for the blood to infuse over which of the following lengths of time? a. 1 hr b. 2 hr c. 4 hr d. 6 hr

c. 4 hr Rationale: The transfusion should be administered slowly (max time of 4hrs) to avoid increasing the workload of the heart

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? a. "You can receive a blood donation from donors with type O- and type O+ blood." b. "You can receive a blood donation from donors with type B- and type A+ blood." c. "You can receive a blood donation from donors with type B- and type AB+ blood." d. "You can receive a blood donation from donors with type AB- and type A- blood."

a. "You can receive a blood donation from donors with type O- and type O+ blood." Rationale: Clients who have type O+ blood can only receive blood from donors who have type O- or O+ blood.

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? a. Dry mucous membranes b. Decreased urine output c. Report of thirst d. Decrease in level of consciousness

d. Decrease in level of consciousness Rationale: This is an indication that the hypovolemia has progressed to a critical level & requires immediate interventions Dry mucous membranes, decreased urine output, report of thirst are non-urgent because it is an early & expected finding of hypovolemia

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. The nurse selects 0.45% sodium chloride to use to prime the tubing. b. The nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion. c. The nurse uses tubing with a filter for the blood transfusion. d. The nurse discards the tubing after the first unit of blood is completed.

a. The nurse selects 0.45% sodium chloride to use to prime the tubing. Rationale: The charge nurse should intervene if the newly licensed nurse selects 0.45% sodium chloride to use to prime the tubing. The nurse should identify that 0.9% sodium chloride is the only IV solution that should be used to prime the tubing for blood administration

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.) a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid d. Eating watermelon daily e. Eating cucumbers with each meal

a. Decreased kidney function b. Decreased thirst response c. Decreased total body fluid Rationale: The nurse should identify that an older adult client who has decreased kidney function, decreased thirst response, decreased total body fluid is at risk for dehydration

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 the carbon dioxide level. b. Increase the respiratory rate. c. Increase the bicarbonate level. d. Increase the pH level.

a. Increase the carbon dioxide level

A nurse on a pediatric floor is reinforcing teaching with a newly licensed nurse about IV therapy. Which of the following information should the nurse include? a. Perform range of motion exercises on the extremity containing the IV site. b. Shave the client's hair if the IV is to be placed in the scalp. c. IV sites can be placed in the lower extremities up to the age of 2 years. d. Monitor the IV site, tubing, and connections every 4 hr.

a. Perform range of motion exercises on the extremity containing the IV site.

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? a. 3% sodium chloride solution b. 0.9% sodium chloride solution c. 0.45% sodium chloride solution d. Dextrose 10% in water

b. 0.9% sodium chloride solution Rationale: A 0.9% sodium chloride solution is isotonic & is used for hydration needs such as from vomiting, diarrhea, hemorrhage & shock. 3% sodium chloride solution is hypertonic & is used for emergent replacement solutes experiencing manifestations of hyponatremia. 0.45% sodium chloride solution is hypotonic & is used to treat hypernatremia & DKA. Dextrose 10% in water is hypertonic & is used to treat hypoglycemia

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. Infection at the access site Rationale: The nurse should monitor the client who has a PICC for complications, such as infection at the access site & blood clots. It is important for the nurse to use aseptic technique when accessing & flushing the PICC line & during dressing change

A nurse is collecting data from a client who is exhibiting signs of a fluid and electrolyte imbalance. Which of the following reports from the client is an indication that they may have a fluid or electrolyte imbalance? a. The client reports working in a warehouse in 21.1° C (70° F) temperature. b. The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. c. The client reports that their provider decreased their diuretic dose. d. The client reports they had a 24-hr intestinal virus 2 weeks ago.

b. The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. Rationale: The nurse should identify that working outside in high temperature for an extended period can cause profuse sweating & lead to a fluid & electrolyte imbalance

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? a. Metabolic acidosis b. Respiratory acidosis c. Acid-base balance d. Respiratory alkalosis

c. Acid-base balance Rationale: The nurse should identify that this client's ABG values are within the expected reference range

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? a. Planning b. Data collection c. Evaluation d. Implementation

c. Evaluation Rationale: Reviewing the client's ABG values is part of the evaluation stage of the nursing process

A nurse is reviewing a client's laboratory 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 10 mg/dL

c. Magnesium 3 mEq/L Rationale: A magnesium level of 3 mEq/L is above the expected reference range of 1.3 to 2.1 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? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

c. Metabolic alkalosis

A nurse is assisting in the care of 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? a. Return the blood unit as it is not compatible with the client's blood type. b. Stay with the client for 15 min prior to starting the blood transfusion. c. Verify the unit of blood with another nurse. d. Prime the blood tubing with 0.45% sodium chloride.

c. Verify the unit of blood with another nurse. Rationale: The unit of blood is compatible with the client's blood type. However, the nurse should ensure that the blood unit had been verified by 2 nurses before initiating the transfusion

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 mL/hr Rationale: 4200mL/24hr = 175mL/hr

A nurse is reinforcing teaching with 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.) 1. Data Collection 2. Evaluation 3. Implementation 4. Planning

1,4,3,2

A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia? a. A client who has vomited four times during the last 8 hr. b. A client who requested an extra breakfast tray to eat. c. A client who can ambulate without assistance. d. A client who reports extreme thirst.

a. A client who has vomited four times during the last 8 hr. Rationale: Nausea & vomiting are early manifestations of hypomagnesemia. Other manifestations of hypomagnesemia include decreased appetite & weakness which could make it difficult to ambulate. Extreme thirst is a manifestation of hypernatremia

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. A+ b. B+ c. O+ d. AB- e. AB+ f. A-

a. A+ d. AB- e. AB+ f. A-

A nurse is assisting in the care 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 recommend using? a. #16-gauge b. #18-gauge c. #22-gauge d. #14-gauge

c. #22-gauge Rationale: As the gauge # increases, the actual catheter size decreases

A nurse is assisting an RN who 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 a cold compress to the selected IV site. b. Ask the client to hold the extremity up prior to searching for an IV site. c. Ask the client to spread the fingers of the selected extremity. d. Apply a blood pressure cuff set to 30 mm Hg.

d. Apply a blood pressure cuff set to 30 mm Hg Rationale: Instead of using a tourniquet, the nurse should apply a BP cuff set to 30 mm Hg prior to starting an IV for this client. This will help protect the client's extremity from bruising & bleeding

A nurse is collecting data on 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? a. Phlebitis b. Extravasation c. Air embolism d. Circulatory overload

d. Circulatory overload Rationale: The nurse should identify that a client who has been receiving IV therapy & whose daily weight has increased is at risk for circulatory overload. Other indications of circulatory overload include tachycardia, increased BP, edema, cough & tachypnea