Fluid Balances, Electrolytes, and pH

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ATI Quiz
cpeters
Quiz by cpeters, updated more than 1 year ago
cpeters
Created by cpeters over 9 years ago
184
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Resource summary

Question 1

Question
A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select all that apply.)
Answer
  • Decreased skin turgor
  • Concentrated urine
  • Bradycardia
  • Low-grade fever
  • Tachypnea

Question 2

Question
A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature 37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative of fluid volume excess? (Select all that apply.)
Answer
  • Dyspnea
  • Edema
  • Bradycardia
  • Hypertension
  • Weakness

Question 3

Question
A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should the nurse assess for that is indicative of fluid volume deficit?
Answer
  • Moist skin
  • Distended neck veins
  • Increased urinary output
  • Tachycardia

Question 4

Question
A nurse is caring for an older adult client in a long-term care facility. The client has become weak and confused. He ate 40% of his breakfast and lunch. Upon assessment, the client’s temperature is 38.3° C (100.9° F), pulse rate 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. He has lost ¾ lb and reports dizziness when assisted to the bathroom. He also has a nonproductive cough with diminished breath sounds in the right lower lobe. Which of the following actions should the nurse take?
Answer
  • Initiate fluid restrictions to limit intake.
  • Observe for signs of hypertension.
  • Encourage the client to ambulate to promote oxygenation.
  • Monitor respirations for shortness of breath.

Question 5

Question
A nurse is caring for a client who has laboratory findings of serum Na+ 133 mEq/L and K+ 3.4 mEq/L. Which of the following treatments can result in these laboratory findings?
Answer
  • Three tap water enemas
  • 0.9% sodium chloride solution IV at 50 mL/hr
  • 5% dextrose in water solution with 20 mEq of K+ IV at 80 mL/hr
  • Administration of glucocorticoids

Question 6

Question
A nurse is caring for a client who has a laboratory finding of serum potassium 5.4 mEq/L. The nurse should assess for which of the following clinical manifestations?
Answer
  • ECG changes
  • Constipation
  • Polyuria
  • Hypotension

Question 7

Question
A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which of the following electrolyte imbalances?
Answer
  • Hypercalcemia
  • Hyponatremia
  • Hyperphosphatemia
  • Hypomagnesemia

Question 8

Question
A nurse is assessing a client for Chovstek’s sign. Which of the following techniques should the nurse use to perform this test?
Answer
  • Apply a blood pressure cuff to the client’s arm.
  • Place the stethoscope bell over the client’s carotid artery.
  • Tap lightly on the client’s cheek.
  • Ask the client to lower his chin to his chest.

Question 9

Question
A nurse is assessing a client who has hyperkalemia. Which of the following conditions is associated with this electrolyte imbalance?
Answer
  • Diabetic ketoacidosis
  • Heart failure
  • Cushing’s syndrome
  • Thyroidectomy

Question 10

Question
A nurse is caring for a client admitted with confusion and lethargy. The client was found at home unresponsive with an empty bottle of aspirin lying next to her bed. Vital signs reveal a blood pressure of 104/72 mm Hg, heart rate of 116 beats/min with a regular rhythm, and a respiratory rate of 42/min and deep. Which of the following arterial blood gases findings should the nurse expect?
Answer
  • pH 7.68, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3 - 24 mEq/L
  • pH 7.48, PaO2 100 mm Hg, PaCO2 28 mm Hg, HCO3 - 23 mEq/L
  • pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3 - 18 mEq/L
  • pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3 - 29 mEq/L

Question 11

Question
A nurse is caring for a client who was in a motor-vehicle accident. He is reporting chest pain and difficulty breathing. A chest x-ray reveals the client has a pneumothorax, and arterial blood gases are obtained. Which of the following findings should the nurse expect?
Answer
  • pH 7.06, PaO2 86 mm Hg, PaCO2 52 mm Hg, HCO3 - 24 mEq/L
  • pH 7.42, PaO2 100 mm Hg, PaCO2 38 mm Hg, HCO3 - 23 mEq/L
  • pH 6.98, PaO2 100 mm Hg, PaCO2 30 mm Hg, HCO3 - 18 mEq/L
  • pH 7.58, PaO2 96 mm Hg, PaCO2 38 mm Hg, HCO3 - 29 mEq/L

Question 12

Question
A nurse is admitting a client who has been vomiting for 24 hr. Arterial blood gases are obtained. Based on the laboratory findings, which of the following conditions should the nurse expect?
Answer
  • Respiratory acidosis
  • Respiratory alkalosis
  • Metabolic acidosis
  • Metabolic alkalosis

Question 13

Question
A nurse is orienting a newly licensed nurse on conditions related to metabolic acidosis. Which of the following statements by the new nurse indicates the teaching has been effective?
Answer
  • “Metabolic acidosis can occur due to diabetic ketoacidosis.”
  • “Metabolic acidosis can occur in a client who has myasthenia gravis.”
  • “Metabolic acidosis can occur in a client who has asthma.”
  • “Metabolic acidosis can occur due to cancer.”

Question 14

Question
A nurse is assessing a client who has pancreatitis. His arterial blood gases reveal metabolic acidosis. Which of the following is an expected finding? (Select all that apply.)
Answer
  • Tachycardia
  • Hypertension
  • Bounding pulses
  • Hyperreflexia
  • Dysrhythmia
  • Tachypnea
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