Fluid and electrolye target assess ATI PDF

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1. A nurse is assessing who has dehydration. Which of the following assessments is the priority? a. Mental status i. The greatest risk to this client is injury from a fall due to a decline in their mental status. Therefore, assessing the client’s mental status is the nurse’s priority. 2. 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. Hct 34% i. The nurse should identify that a client who has fluid volume excess can have a HCT level that is below 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. 3. 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 i. This level is below the expected reference range of 136 to 145 mEq/L 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.

4. 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. 1 large, hard-boiled eggs i. One large, hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium.

5. 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? a. Cardiac rhythm i. When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's cardiac rhythm because this total serum calcium level is below the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia.

6. 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. 0.45% sodium chloride i. 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.

7. A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? a. Hyperactive deep-tendon reflexes

i.

Hyperactive deep-tendon reflexes are an expected finding for a client who has hypomagnesemia. Other expected findings include muscle cramps, numbness, and tingling.

8. 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. SLOW PERIPHERAL pulses i. This phosphorus level is below the expected reference range. The nurse should expect the client to have slow peripheral pulses. The nurse might also find that the client's pulses are difficult to find and easy to block.

9. 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. Initiate high-flow oxygen therapy i. When using the airway, breathing, circulation approach to client care, the nurse should first administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.

10. 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? a. Orthostatic hypotension i. The nurse should plan to monitor the client for orthostatic hypotension, 11.

which places them at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia. The nurse should plan to monitor the client for orthostatic hypotension, which places them at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia.

a. I will use the incentive spirometer every hour i. Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Using an incentive spirometer will promote adequate chest expansion.

12. 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, PoO2 89 mm hg, and HCO3- 24 mEq/L. Which of the following actions should the nurse take? a. Provide calming interventions i. The client's respiratory rate is above the expected reference range of 12 to 20/min. The nurse should instruct the client to breathe slowly. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase to expected levels of 35 to 45 mm Hg and lower the pH to expected levels of 7.35 to 7.45.

13. A nurse is reviewing the medical record of a client who had 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. Serum potassium 3.0 mEq/L i. This serum potassium level is below the expected reference range. Hypokalemia is a serious complication that can occur when a client who has diabetic ketoacidosis is receiving insulin to treat the condition. The nurse should report this finding to the provider.

14. 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 teaching? a. When I sit down to watch television, I’ll be sure to put my feet up

i.

Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet will increase venous return. The client should elevate their feet for at least 20 min several times per day.

15. 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 cup plain yogurt i. One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium. 16. A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse except? a. confusion i. 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 can occur.

17. 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. 0.9% sodium chloride with 10 mEq/L of potassium chloride at 100 mL/hr i. 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, not to exceed 20 mEq/hr. The dilution should be 1 mEq of potassium chloride to 10 mL of 0.9% sodium chloride.

18. A nurse is admitting a client who has status asthmaticus. The client's ABG results are pH 7.32, PaO2 74 mmhg, PaC02 56 mm hg, and HCO3- 26 mEq/L. The nurse should interpret these laboratory values as which of the following imbalances. a. Respiratory Acidosis i. 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.

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

20. 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. PaCo2 i. The nurse should anticipate that a client who has respiratory alkalosis will have a decreased PaCO2 level due to hyperventilation.

21. A nurse is caring for a client who had dehydration and is receiving IV fluids. Which assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? a. Bounding peripheral pulses i. The nurse should recognize that increased vascular volume results in full, bounding peripheral pulses.

22. 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? a. Administer IV fluids to the client evenly over 24 hr b. Encourage the client to rise slowly when standing up c. Weigh the client every 8 hr i. Administer IV fluids to the client evenly over 24 hr is correct. A

ii.

iii. iv. v.

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. Provide the client with a salt substitute is incorrect. There is no reason to limit the client's sodium intake. A client who has hypernatremia might require dietary sodium restriction. However, this client might require electrolyte replacement, depending on the cause of fluid loss. Assess the client for pitting edema is incorrect. This action is appropriate for a client who has fluid volume overload. Encourage the client to rise slowly when standing up is correct. This action can prevent injury from falls caused by orthostatic hypotension. Weigh the client every 8 hr is correct. Weighing the client every 8 hr will provide information regarding fluid balance.

23. A nurse is caring for a client who requires nasogastric suctioning. Which of the following set of laboratory results indicates that the client has metabolic alkalosis? a. pH 7.51, Pa02 94 mm Hg, PaC02 36 mm Hg, HCO3- 31 mEq/L i. An elevated pH and HCO - with a PaCO that is either elevated or within the 3

2

expected reference range indicates metabolic alkalosis.

24. A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? a. Decreased muscle strength i. The nurse should expect the client to experience muscle weakness, fatigue, paresthesia, and nausea.

25. 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. Potassium 6.1 mEq/L i. Hyperkalemia, defined as a potassium level above 5.0 mEq/L, can cause a prolonged PR interval, a wide QRS complex, flat or absent P waves, and tall, peaked T waves.

26. A nurse is reviewing the ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? a. pH 7.26, Pa02 84mm hg, PaC02 38 mmhg, HCO3- 20 mEq/L i. A pH below 7.35 is an indication of acidosis. An HCO - below 22 mEq/L is an 3

indication of metabolic acidosis.

27. 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. Auscultate the client’s lungs i. An adverse effect of many diuretics, including furosemide, 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.

28. While reviewing a client's laboratory results, a nurse notes a serum calcium level of 0.8 mg/dL. Which of the following actions should the nurse take? a. Implement seizure precautions i. The client is at risk for seizures due to low excitation threshold as a result of a decreased calcium level. The nurse should initiate seizure precautions to prevent injury.

29. 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? a. Withhold the medication i. The greatest risk to the client is bradycardia, hypotension, and lifethreatening 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.

30. 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. Sodium 142 mEq/L i. A sodium level of 142 mEq/L is within the expected reference range of 136 to 145 mEq/L and indicates that the fluid therapy has been effective....