ATI Fluid, Electrolyte, and Acid Base

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?

Bound peripheral pulses

Fluid overload results in increased vascular volume and places a greater workload on the heart. Thus, an expected finding is bounding peripheral pulses.

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?

Hypotension

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?

Sodium 128 mEq/L

Below the expected range and is likely the cause of altered mental status.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respirations are 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?

PaCO2

A nurse is planning dietary teaching for a client who has hypermagnesemia. Which of the following food choices contains the most magnesim and is, therefore, a food the nurse should plan to instruct the client to avoid?

Raw spinach

A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.35, 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?

Respiratory acidosis

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?

Potassium 6.1 mg/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 assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has respirations of 28/min. The client's ABG results are pH 7.52, PaO2 89 mm Hg, PaCO2 28 mm Hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take?

Provide calming interventions

The RR 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 planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings?

Orthostatic hypotension

Hypokalemia can lead to hypotension.

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first?

Withhold the medication

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?

Implement seizure precautions.

The client is at risk for seizures due to low excitation threshold as a result of the client's decreased calcium level.

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?

Serum potassium 3.0 mEq/L

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?

pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L

A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?

Mental status

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?

Auscultate the client's lungs.

The first action the nurse should tatke is to auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles.

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the instructions?

"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 reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis?

pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

A nurse is caring for a client who has a serum sodium level of 155 mEq/L. Which of the following IV fluid prescriptions should the nurse anticipate administering?

1,000 mL 0.225% sodium chloride

A hypotonic solution to gradually reduce hypernatremia without causing cerebral edema.

A nurse is caring for a client who has heart failure and is receiving furosemide. The client is experiencing irritability and anxiety. Which of the following actions should the nurse anticipate taking?

Recommend a potassium-sparing diuretic.

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?`

0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr

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.)

Administer IV fluids evenly over 24 hr.

Encourage the client to rise slowly when standing up.

Weigh the client every 8 hr.

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?

Decreased muscle strength

Hyperkalemia cn cause muscle weakness.

A nurse is reviewing the laboratory data on four clients. Which of the following serum laboratory values should the nurse expect for the client who is experiencing 2+ pitting ankle edema?

Hematocrit 34%

This hematocrit level is below the expected reference range. A 2+ pitting edema indicates fluid overload, which can cause hemodilution and a decreased hematocrit.

Dehydration can cause elevated Na, BUN, and Protein.

A nurse is teaching nutritional strategies to a client who has a low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching?

"I will add broccoli and kale to my diet."

Recommend broccoli and kale, which are good sources of calcium as alternatives to milk products.

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect?

Hyperactive deep-tendon reflexes

An expected finding for a client who has hypomagnesemia along with muscle cramps, numbness, and tingling.

A nurse is caring for a client who is experiencing respiratory distress as a result of acute pulmonary edema. Which of the following actions should the nurse take first?

Initiate high-flow oxygen therapy.

Administer high-flow oxygen therapy by face mask at 5 to 6L/min to keep the client's oxygen sat above 90%.

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess?

Cardiac rhythm

Calcium levels below the expected reference range can cause ECG changes, bradycardia, or tachycardia.

A nurse is providing teaching for 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?

"I will use the incentive spirometer every hour."

A nurse is assessing a client who has a serum phosphorus level of 2.4 mg/dL. Which of the following findings should the nurse expect?

Slow peripheral pulsations

Hypophosphatemia causes slow peripheral pulses that are difficult to detect and can eventually result in cardiac muscle damage.

A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following laboratory findings indicates that the fluid therapy has been effective?

Serum sodium 138 mEq/L

Isotonic dehydration includes loss of water and electrolytes. A level of 138 indicates that the fluid therapy has been effective.