Fluid, Electrolyte, and Acid-Base ATI

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (select all that apply) a) Administer IV fluids to the client evenly over 24 hr. b) Provide the client with a salt substitute. c) Assess the client for pitting edema. d) Encourage the client to rise slowly when standing up. e) Weigh the client every 8 hr.

a) Administer IV fluids to the client evenly over 24 hr. d) Encourage the client to rise slowly when standing up. e) Weigh the client every 8 hr. A client who has excessive fluid loss is typically prescribed Iv replacement fluids. Administering IV fluids rapidly over a short period of time places the client at risk for fluid volume overload. This action can prevent injury from falls caused by orthostatic hypotension. Weighing the client every 8 hour will provide information regarding fluid balance.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? a) Confusion b) Peripheral edema c) Facial flushing and warmth d) Hyperreflexia

a) Confusion A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease and coma may occur.Facial flushing and warmth are manifestations of metabolic acidosis. Pale, cyanotic, dry skin is a manifestation of respiratory acidosis as ineffective breathing causes a lack of perfusion to the tissues. Hyporeflexia, not hyperreflexia, is a manifestation of respiratory acidosis. As acidosis increases, hyperkalemia can occur, causing muscle weakness, flaccid paralysis, and hyporeflexia.

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? a) Decreased muscle strength b) Decreased gastric motility c) Increased heart rate d) Increased blood pressure

a) Decreased muscle strength

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? a) Hyperactive deep-tendon reflexes b) Increased bowel sounds c) Drowsiness d) Decreased blood pressure

a) Hyperactive deep-tendon reflexes Hyperactive deep-tendon reflexes are an expected finding for a client who has hypomagnesemia, along with muscle cramps, numbness, and tingling

While reviewing a client's laboratory results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? a) Implement seizure precautions. b) Administer phosphate. c) Initiate diuretic therapy. d) Prepare the client for hemodialysis.

a) Implement seizure precautions. The client is at risk for seizures due to low excitation threshold as a result of decreased calcium level. The nurse should initiate seizure precautions to prevent injury.

A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? a) One large hard-boiled egg b) 1 cup bran cereal c) 1/2 cup almonds d) 1 cup cooked spinach

a) One large hard-boiled egg One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mm Hg, PaCO2 56 mm Hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis

a) Respiratory acidosis Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? a) Sodium 128 mEq/L b) Potassium 4.8 mEq/L c) Calcium 9.1 mg/dL d) Magnesium 2.0 mEq/L

a) Sodium 128 mEq/L This level is below the expected reference range and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort.

A nurse is admitting a client who takes 40 mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia . Which of the following medications should the nurse prepare to administer? a) Sodium polystyrene sulfonate 30 g/day b) 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr c) Bumetanide 8 mg/day d) 100 mL of dextrose 10% in water with 10 units of insulin

b) 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride.

A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium? a) 1/2 cup chopped celery b) 1 cup plain yogurt c) One slice whole grain bread d) 1/2 cup cooked tofu

b) 1 cup plain yogurt One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium.

A nurse is assessing a client who has a calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? a) Deep-tendon reflexes b) Cardiac rhythm c) Peripheral sensation d) Bowel sounds

b) Cardiac rhythm When using the airway, breathing, circulation approach to client care, the nurse should determine that assessing the cardiac rhythm is the priority. Calcium levels below the expected reference range can cause ECG changes, bradycardia, or tachycardia.

A nurse is reviewing the laboratory report of a client who has fluid volume excess. Which of the following laboratory values should the nurse expect? a) Hgb 20 g/dL b) Hct 34% c) BUN 25 mg/dL d) Urine specific gravity 1.050

b) Hct 34% Hematocrit 37-47% -> The nurse should identify that a client who has fluid volume excess can have a hematocrit level that is below the expected reference range of 37 to 47% for females or 42 to 52% for males. Fluid volume excess can cause hemodilution and a decreased hematocrit level. BUN: 10-20 mg/dL (dehydration= high BUN; FVE= low BUN)Hemoglobin: 12-16 for females and 14-18 g/dL for males (dehydration= increased hemoglobin; FVE= decreased hemoglobin)Specific gravity: 1.010-1.025 (dehydration = high SG; FVE= low specific gravity)

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? a) Assist with intubation. b) Initiate high-flow oxygen therapy. c) Administer a rapid-acting diuretic. d) Provide cardiac monitoring.

b) Initiate high-flow oxygen therapy. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.

A nurse is planning care for a client who has potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? a) Hyperactive deep-tendon reflexes b) Orthostatic hypotension c) Rapid, deep respirations d) Strong, bounding pulse

b) Orthostatic hypotension The nurse should plan to monitor the client for orthostatic hypotension, which places him at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia. The nurse should plan to monitor the client for hyporeflexia. Manifestations of hypokalemia include weak hand grip strength and weak deep-tendon reflexes. The nurse should plan to monitor the client for respiratory distress. Weakening of the respiratory muscles and shallow respirations are manifestations of hypokalemia. The nurse should plan to monitor the client for a weak and thready pulse. A weak, thready pulse is a manifestation of hypokalemia.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside the expected reference range if the client is experiencing respiratory alkalosis? a) PaO2 b) PaCO2 c) Sodium d) Bicarbonate

b) PaCO2 With respiratory alkalosis, the PaCO2 level is decreased.

A nurse is evaluating a client who is receiving IV fluids to treat dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective? a) BUN 26 mg/dL b) Sodium 142 mEq/L c) Hct 56% d) Urine specific gravity 1.035

b) Sodium 142 mEq/L

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? a) "If my stockings feel tight, I'll just roll them down for a while." b) "I'll put on my elastic stockings at the first sign of swelling." c) "When I sit down to watch television, I'll be sure to put my feet up." d) "It's okay to cross my legs as long as it's for less than an hour."

c) "When I sit down to watch television, I'll be sure to put my feet up." Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet will increase the return. The client should elevate them for at least 20 min several times per day.

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs." Which of the following actions should the nurse take first? a) Monitor the client's bowel sounds. b) Review the client's daily laboratory results. c) Auscultate the client's lungs. d) Palpate the client's peripheral pulses.

c) Auscultate the client's lungs. An adverse effect of many diuretics is hypokalemia. When using the airway, breathing, circulation approach to client care, the nurse should first auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? a) Increased urine specific gravity b) Hypoactive bowel sounds c) Bounding peripheral pulses d) Decreased respiratory rate

c) Bounding peripheral pulses

A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HCO3- 25 mEq/L. Which of the following actions should the nurse take? a) Instruct the client to cough forcefully. b) Assist the client with ambulation. c) Provide calming interventions. d) Discontinue the PCA.

c) Provide calming interventions. The client's respiratory rate is above the expected range. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase. This will help correct the pH imbalance.

A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse report to the provider? a) Urine output 30 mL/hr b) Blood glucose 180 mg/dL c) Serum potassium 3.0 mEq/L d) BUN 18 mg/dL

c) Serum potassium 3.0 mEq/L This serum potassium level is outside the expected reference range. The nurse should report this finding to the provider.

A nurse is assessing a client who has a phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect? a) Hepatic failure b) Abdominal pain c) Slow peripheral pulses d) Increase in cardiac output

c) Slow peripheral pulses

A nurse is preparing to administer oral potassium to a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? a) Administer a hypertonic solution. b) Repeat the potassium level. c) Withhold the medication. d) Monitor for paresthesia.

c) Withhold the medication.' The greatest risk to the client is bradycardia, hypotension, and life-threatening cardiac complications due to hyperkalemia, defined as a potassium level above 5.0 mEq/L. Therefore, the nurse's priority action is to withhold the oral potassium and notify the provider.

A nurse is teaching nutritional strategies to a client who has a low calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? a) "I will eat more cheese because I can't drink milk." b) "I need to avoid foods with vitamin D because I am allergic to milk." c) "I will stop taking my calcium supplements if they irritate my stomach." d) "I will add broccoli and kale to my diet."

d) "I will add broccoli and kale to my diet." The nurse should recommend that the client consume broccoli and kale, which are good sources of calcium, as alternatives to dairy products.

A nurse is providing teaching to a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? a) "I should conserve energy by limiting my physical activity." b) "I will wait until my pain is at least 6 out of 10 before I use the PCA." c) "I will limit my daily fluid intake to two to three glasses." d) "I will use the incentive spirometer every hour."

d) "I will use the incentive spirometer every hour." Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Using an incentive spirometer will promote adequate chest expansion. The nurse should identify this statement as indicating an understanding of the teaching.

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? a) Dextrose 5% in 0.9% sodium chloride b) Dextrose 5% in lactated Ringer's c) 3% sodium chloride d) 0.45% sodium chloride

d) 0.45% sodium chloride A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? a) Skin turgor b) Urine output c) Weight d) Mental status

d) Mental status

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following laboratory values supports this finding? a) Sodium 152 mEq/L b) Chloride 102 mEq/L c) Magnesium 1.8 mEq/L d) Potassium 6.1 mEq/L

d) Potassium 6.1 mEq/L Hyperkalemia can cause a prolonged PR interval; a wide QRS complex; flat or absent P waves; and tall, peaked T waves.

A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of laboratory results indicates that the client has metabolic alkalosis? a) pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L b) pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 26 mEq/L c) pH 7.31, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 23 mEq/L d) pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

d) pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L When pH and HCO3- are both above or below the expected reference range, a metabolic imbalance is present. A pH of 7.26 indicates acidosis and a HCO3- of 20 mEq/L indicates the acidosis is due to a metabolic cause. Therefore, the nurse should identify these findings as metabolic acidosis.

A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? a) pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L b) pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L c) pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L d) pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

d) pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L When pH and HCO3- are both above or below the expected reference range, a metabolic imbalance is present. A pH of 7.26 indicates acidosis and a HCO3- of 20 mEq/L indicates the acidosis is due to a metabolic cause. Therefore, the nurse should identify these findings as metabolic acidosis.