Fluid, Electrolyte and Acid/Base Regulation Flashcards
(30 cards)
a nurse is assisting in the care of a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first?
Initiate continuous cardiac monitoring.
Elevate the head of the client’s bed.
Instruct the client to deep breathe and cough.
Initiate continuous SpO2 monitoring.
Elevate the head of the client’s bed.
16-gauge
a nurse is assisting in the care for a client who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge catheter than the 20-gauge being replaced. Which of the following gauge catheters should the nurse recommend using?
#18-gauge
#22-gauge
#14-gauge
22-gauge
a nurse has completed collecting data for a client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take next?
Implementation
Re-collection of data
Evaluation
Planning
Planning
a nurse is receiving report on four clients. The nurse should identify which of the following clients might be experiencing hypomagnesemia?
A client who has vomited four times during the last 8 hr.
A client who requested an extra breakfast tray to eat.
A client who can ambulate without assistance.
A client who reports extreme thirst.
A client who has vomited four times during the last 8 hr.
a nurse is calculating a client’s intake and output for the last 4 hrs. The client consumed 480mL of water and 240mL of coffee. The client has also received IV fluids for 4 hrss infusing at 100mL/hr. Which of the following amounts represents the clients intake over the last 4hrs?
1,120 mL
720 mL
480 mL
580 mL
1,120 mL
a nurse is collecting data from a client who is exhibiting signs of fluid and electrolyte imbalance. Which of the following reports from the client is an indication that they may have a fluid of electrolyte imbalance?
The client reports working in a warehouse in 21.1° C (70° F) temperature.
The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day.
The client reports that their provider decreased their diuretic dose.
The client reports they had a 24-hr intestinal virus 2 weeks ago.
The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day.
a nurse caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider?
Dry mucous membranes
Decreased urine output
Report of thirst
Decrease in level of consciousness
Decrease in level of consciousness
a nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increase the risk for dehydration in older adult clients?
select all that apply
Decreased kidney function
Decreased thirst response
Decreased total body fluid
Eating watermelon daily
Eating cucumbers with each meal
Decreased kidney function
Decreased thirst response
Decreased total body fluid
a nurse is reinforcing teaching with a newly licensed nurse about using the nursing process when caring for a client who has an acid-base imbalance. The nurse should include that the stages of the nursing process should be performed in what order?
data collection
eval
implementation
planning
data collection
planning
implantation
eval
a nurse is participating in a blood drive and is taking a donation from a client who has type O+ blood. The client asks what type of blood they can receive. Which of the following statements should the nurse make?
“You can receive a blood donation from donors with type O- and type O+ blood.”
“You can receive a blood donation from donors with type B- and type A+ blood.”
“You can receive a blood donation from donors with type B- and type AB+ blood.”
“You can receive a blood donation from donors with type AB- and type A- blood.”
“You can receive a blood donation from donors with type O- and type O+ blood.”
a nurse is caring for a client who has the follow ABGs; PH:7.44, PaCO2 37mm Hg, and HCO3 24mEq/L. The nurse should identify that these values are an indication of which of the following?
Metabolic acidosis
Respiratory acidosis
Acid-base balance
Respiratory alkalosis
Acid-base balance
a nurse is reviewing the latest ABGs for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process?
Planning
Data collection
Evaluation
Implementation
Evaluation
a nurse is reviewing lab results for a client and notes the following ABGs are, Ph: 7.31, PaCO2: 49mmHg and HCO3: 25mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances?
Metabolic acidosis
Respiratory acidosis
Metabolic alkalosis
Respiratory alkalosis
Respiratory acidosis
a nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for the client?
Increase the carbon dioxide level.
Increase the respiratory rate.
Increase the bicarbonate level.
Increase the pH level.
Increase the carbon dioxide level
Rationale: A state of respiratory alkalosis indicates that the client’s carbon dioxide level is currently below the expected reference range. The goal of treatment should be to raise the level of carbon dioxide level back to within the expected reference range for PaCO2 of 35 to 45 mm Hg.
a nurse on a pediatric floor is reinforcing teaching with a newly licensed nurse about IV therapy. Which of the following information should the nurse include?
Perform range of motion exercises on the extremity containing the IV site.
Shave the client’s hair if the IV is to be placed in the scalp.
IV sites can be placed in the lower extremities up to the age of 2 years.
Monitor the IV site, tubing, and connections every 4 hr.
IV sites can be placed in the lower extremities up to the age of 2 years.
a charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene?
The nurse selects 0.45% sodium chloride to use to prime the tubing.
The nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion.
The nurse uses tubing with a filter for the blood transfusion.
The nurse discards the tubing after the first unit of blood is completed.
The nurse selects 0.45% sodium chloride to use to prime the tubing.
a nurse is participating in blood drive and is taking a donation from a client who has type A- blood. The client asks the nurse what blood types can receive their blood conation. Which of the following responses should the nurse make?
select all that apply
A+
B+
O+
AB-
AB+
A-
A+
AB-
AB+
A-
a nurse is reviewing a clients laboratory results. Which of the following results should the nurse report to the provider?
Potassium 4.5 mEq/L
Sodium 138 mEq/L
Magnesium 3 mEq/L
Calcium 10 mg/dL
Magnesium 3 mEq/L
a nurse is preparing to administer 4200mL of IV fluids to a client to infuse over 24hr. The nurse should set the IV pump to deliver how many mL/hr?
175 mL/hr
a nurse is collecting data on a client who has been receiving IV therapy for several days and notes that the clients daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following Iv-related complications?
Phlebitis
Extravasation
Air embolism
Circulatory overload
Circulatory overload
a nurse is reviewing prescriptions for a client who needs IV fluids replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate?
3% sodium chloride solution
0.9% sodium chloride solution
0.45% sodium chloride solution
Dextrose 10% in water
0.9% sodium chloride solution
a nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective?
select all that apply
The client states their muscle spasms are absent.
The client reports a headache.
The client denies being confused.
The client reports being nauseated.
The client reports feeling tired.
The client states their muscle spasms are absent.
The client denies being confused.
a nurse is reviewing ABG values for a client who is experiencing metabolic acidosis. Which of the following ABG values should the nurse expect?
select all that apply
HCO3- 29 mEq/L
pH 7.29
PaCO2 49 mm Hg
pH 7.49
PaCO2 30 mm Hg
pH 7.29
PaCO2 49 mm Hg
a nurse is assisting in the care of a client who has heart failure and a prescription to receive a unit of packed red blood cells. the nurse should plan for the blood to infuse over which of the following lengths of time?
1 hr
2 hr
4 hr
6 hr
4 hr
Rationale:
Blood can be administered over a period of 1 to 4 hr. For a client who is at risk for circulatory overload, such as a client who has heart failure, a disorder in which compromised cardiac output results in poor tissue perfusion and fluid overload, the transfusion should be administered slowly (maximum time of 4 hr) to avoid increasing the workload of the heart. After 4 hr blood becomes unsafe as it is susceptible to bacterial invasion.
