Fluid Imbalances - ATI PDF

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Fluid, Electrolyte and Acid-base ATI Answers 1. A nurse is assessing a client who has dehydration. Which of the following assessments is the priority? Mental Status 2. 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- 24 mEq/L. Which of the following actions should the nurse take? Provide calming interventions 3. 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? Hypotonic solution, 0.45% sodium chloride. 4. 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. Sodium level is back to normal range. 5. 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? 1 large hard-boiled egg contains 5 mg of magnesium. 6. 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 7. When 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

8. 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% NaCl with 10 mEq/L of KCl at 100 mL/hr. 9. A nurse is assessing a client who is receiving hydrochlorothiazide and notes the client is confused and lethargic. Which of the following laboratory values should the nurse report to the provider? Sodium 128 mEq/L 10. 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? Initiate high-flow oxygen therapy. 11. 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. 12. A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? Hyperactive deep-tendon reflexes 13. 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 mEq/L 14. 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? Hematocrit 34% 15. 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? Respiratory acidosis – low pH and elevated PaCO2. 16. 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? Bounding peripheral pulses 17. A nurse is planning care for a client who has a serum potassium level 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? Orthostatic hypotension 18. A nurse is preparing to administer oral potassium for a client who has potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? Withhold the medication 19. 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 20. 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 21. 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.

22. A nurse is caring for a client who requires nasogastric suction. 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. 23. 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 to the client evenly over 24 hr. Encourage the client to rise slowly when standing up. Weigh the client every 8 hr. 24. A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? Confusion 25. 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? When I sit down to watch television, I’ll be sure to put my feet up. 26. 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? 1 Cup plain yogurt 27. A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appear 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 28. 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 29. A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? Decreased muscle strength.

30. 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? Slow peripheral pulses...