Targeted ATI Fluid, Electrolyte, and Acid-Base
1. A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?
a. Skin turgor
i. The nurse should assess skin turgor to monitor the client's hydration status. Poor skin turgor is a
manifestation of dehydration. However, another assessment is the nurse's priority.
b. Urine output
i. The nurse should assess urine output to monitor the client's hydration status. Decreased urine output is
a manifestation of dehydration. However, another assessment is the nurse's priority.
c. Weight
i. The nurse should weigh the client because weight loss is a manifestation of dehydration. Decreased
weight is the best indication of the client's fluid status. However, another assessment is the nurse's
priority.
d. 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. Hgb 20 g/dL
i. The nurse should identify that a client who has dehydration can have a Hgb level that is above the
expected reference range of 12 to 16 g/dL for females or 14 to 18 g/dL for males. Fluid volume excess
can cause hemodilution and a decreased hemoglobin level.
b. Hct 34%
i. The nurse should identify that a client who has fluid volume excess can have a Hct level that is below
the 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.
c. BUN 25 mg/dL
i. The nurse should identify that a client who has dehydration can have a BUN that is above the expected
reference range of 10 to 20 mg/dL. Fluid volume excess can cause a decrease in BUN.
d. Urine specific gravity 1.050
i. The nurse should identify that a client who has dehydration can have a urine specific gravity that is
above the expected reference range of 1.010 to 1.025. Fluid volume excess can cause a decrease in
urine specific gravity.
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.
b. Potassium 4.8 mEq/L
i. This finding is within the expected reference range. However, the nurse should continue to monitor for
hypokalemia while the client is taking hydrochlorothiazide.
c. Calcium 9.1 mg/dL
i. This finding is within the expected reference range. However, the nurse should continue to monitor for
hypercalcemia while the client is taking hydrochlorothiazide.
d. Magnesium 2.0 mEq/L
i. This finding is within the expected reference range. However, the nurse should continue to monitor for
hypomagnesemia while the client is taking hydrochlorothiazide.
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. One large, hard-boiled egg
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.
b. 1 cup bran cereal
i. One cup of bran cereal contains 112 mg of magnesium. Therefore, the nurse should include a different
food as containing the lowest amount of magnesium.
c. ½ cup almonds
, i. One-half cup of almonds contains 193 mg of magnesium. Therefore, the nurse should include a
different food as containing the lowest amount of magnesium.
d. 1 cup cooked spinach
i. One cup of cooked spinach contains 157 mg of magnesium. Therefore, the nurse should include a
different 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. Deep-tendon reflexes
i. The nurse should assess the client's deep-tendon reflexes because this total serum calcium level is
below the expected reference range of 9 to 10.5 mg/dL, and hypocalcemia can cause neuromuscular
changes. However, there is another assessment the nurse should make first.
b. 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.
c. Peripheral sensation
i. The nurse should assess the client's peripheral sensation to check for paresthesia because this total
serum calcium level is below the expected reference range, and hypocalcemia can cause
neuromuscular changes. However, there is another assessment the nurse should make first.
d. Bowel sounds
i. The nurse should assess the client's bowel sounds to check for hypermotility because this total serum
calcium level is below the expected reference range, and hypocalcemia can cause increased peristalsis.
However, there is another assessment the nurse should make first.
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. Dextrose 5% in 0.9% sodium chloride
i. A sodium level of 155 mEq/L is an indication of hypernatremia. Dextrose 5% in 0.9% sodium chloride is
a hypertonic solution. The nurse should anticipate a prescription for a hypotonic solution.
b. Dextrose 5% in lactated Ringer’s
i. A sodium level of 155 mEq/L is an indication of hypernatremia. Lactated Ringer's contains sodium and
other electrolytes and is not indicated for hypernatremia.
c. 3% sodium chloride
i. A sodium level of 155 mEq/L is an indication of hypernatremia, and 3% sodium chloride is a hypertonic
solution. The nurse should anticipate a prescription for a hypotonic solution.
d. 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.
b. Increased bowel sounds
i. Decreased bowel sounds are an expected finding for a client who has hypomagnesemia.
c. Drowsiness
i. Insomnia is an expected finding for a client who has hypomagnesemia.
d. Decreased blood pressure
i. Increased blood pressure is an expected finding for a client who has hypomagnesemia.
8. A nurse is assessing a client who has a phosphorous level of 2.4 mg/dL. Which of the following findings should the nurse
expect?
a. Hepatic failure
i. This phosphorus level is below the expected reference range of 3 to 4.5 mg/dL. The nurse should assess
a client who has hypophosphatemia for manifestations of kidney failure, not hepatic failure.
b. Abdominal pain
i. This phosphorus level is below the expected reference range. Hypophosphatemia causes weakness of
skeletal muscles and rhabdomyolysis, which is acute muscle breakdown. It does not cause abdominal
pain.
c. 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.
d. Increase in cardiac output
i. This phosphorus level is below the expected reference range. The nurse should expect a decrease in
cardiac output.
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. Assist with intubation
i. The nurse should be prepared to assist the provider with intubation and mechanical ventilation if less
invasive measures are ineffective. However, there is another action the nurse should take first.
b. 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%.
c. Administer a rapid-acting diuretic
i. The nurse should administer a rapid-acting diuretic IV bolus to the client to relieve pulmonary
congestion. However, there is another action the nurse should take first.
d. Provide cardiac monitoring
i. The nurse should provide cardiac monitoring because premature ventricular contractions and
dysrhythmias are manifestations of pulmonary edema. However, there is another action the nurse
should take first.
10. A nurse is planning care for a client who has a potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for
which of the following findings?
a. Hyperactive deep-tendon reflexes
i. The nurse should plan to monitor the client for hyporeflexia. Manifestations of hypokalemia include
weak hand grip strength and weak deep-tendon reflexes.
b. Orthostatic hypotension
i. 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.
c. Rapid, deep respirations
i. The nurse should plan to monitor the client for respiratory distress. Weakening of the respiratory
muscles and shallow respirations are manifestations of hypokalemia.
d. Strong, bounding pulse
i. The nurse should plan to monitor the client for a weak and thready pulse. A weak, thready pulse is a
manifestation of hypokalemia.
11. A nurse is providing teaching to 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?
a. “I should conserve energy by limiting my physical activity.”
i. The nurse should encourage the client to ambulate and change positions frequently to prevent
postoperative complications.
b. “I will wait until my pai is at least 6 out of 10 before I use the PCA.”
i. The nurse should encourage the client to use the PCA when feeling acute pain to prevent the pain from
worsening.
c. “I will limit my daily fluid intake to two to three glasses.”
i. Dehydration can cause metabolic acidosis. The nurse should encourage the client to take in
approximately 2,200 mL of fluid daily. This includes fluid intake of six to eight glasses containing 240 mL
each, as well as liquids obtained from eating solid foods. Limiting fluid intake to two to three 8 oz
glasses would not meet the client's total daily intake needs.
d. “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. Instruct the client to cough forcefully
i. Coughing forcefully will not treat the underlying cause of the ABG results.
b. Assist the client with ambulation
, i. Ambulation can exacerbate the client's respiratory distress and is not appropriate at this time.
c. 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.
d. Discontinue the PCA
i. Discontinuing the PCA will not treat the underlying cause of the ABG results and could exacerbate the
client's respiratory distress.
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. Urine output 30 mL/hr
i. The expected reference range for urinary output is between 1,500 to 2,000 mL daily. A urinary output
of less than 30 mL/hr, known as oliguria, can indicate dehydration, impaired renal blood flow, or renal
failure. However, a urine output of 30 mL/hr does not need to be reported to the provider.
b. Blood glucose 180 mg/dL
i. A blood glucose level of 200 mg/dL or less is an indication that the client's diabetic ketoacidosis is
resolving and is within the expect reference range for a casual glucose level. Therefore, the nurse does
not need to report this finding to the provider.
c. 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.
d. BUN 18 mg/dL
i. A BUN of 18 mg/dL is within the expected reference range. A BUN of 30 mg/dL or greater can occur
due to dehydration for a client who has diabetic ketoacidosis.
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. “If my stockings feel tight, I’ll just roll them down for a while.”
i. The client should not roll the stockings down, because the rolled part can become a constricting band
around the leg which can impede circulation.
b. “I’ll put on my elastic stockings at the first sign of swelling.”
i. The client should don graduated compression stockings upon awakening and remove them at bedtime.
Wearing the stockings throughout the day prevents swelling of the extremities and improves
circulation.
c. “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.
d. “It’s okay to cross my legs as long as it’s for less than an hour.”
i. The client should not cross their legs. Doing so can further impair circulation of the lower extremities.
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. ½ cup chopped celery
i. One-half cup of chopped celery contains 132 g of potassium. Therefore, there is another food the nurse
should recommend as containing the greatest amount of potassium.
b. 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.
c. One slice whole grain bread
i. One slice of whole grain bread contains 60 g of potassium. Therefore, there is another food the nurse
should recommend as containing the greatest amount of potassium.
d. ½ cup cooked tofu
i. One-half cup of cooked tofu contains 164 g of potassium. Therefore, there is another food the nurse
should recommend 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 expect?
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.
1. A nurse is assessing a client who has dehydration. Which of the following assessments is the priority?
a. Skin turgor
i. The nurse should assess skin turgor to monitor the client's hydration status. Poor skin turgor is a
manifestation of dehydration. However, another assessment is the nurse's priority.
b. Urine output
i. The nurse should assess urine output to monitor the client's hydration status. Decreased urine output is
a manifestation of dehydration. However, another assessment is the nurse's priority.
c. Weight
i. The nurse should weigh the client because weight loss is a manifestation of dehydration. Decreased
weight is the best indication of the client's fluid status. However, another assessment is the nurse's
priority.
d. 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. Hgb 20 g/dL
i. The nurse should identify that a client who has dehydration can have a Hgb level that is above the
expected reference range of 12 to 16 g/dL for females or 14 to 18 g/dL for males. Fluid volume excess
can cause hemodilution and a decreased hemoglobin level.
b. Hct 34%
i. The nurse should identify that a client who has fluid volume excess can have a Hct level that is below
the 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.
c. BUN 25 mg/dL
i. The nurse should identify that a client who has dehydration can have a BUN that is above the expected
reference range of 10 to 20 mg/dL. Fluid volume excess can cause a decrease in BUN.
d. Urine specific gravity 1.050
i. The nurse should identify that a client who has dehydration can have a urine specific gravity that is
above the expected reference range of 1.010 to 1.025. Fluid volume excess can cause a decrease in
urine specific gravity.
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.
b. Potassium 4.8 mEq/L
i. This finding is within the expected reference range. However, the nurse should continue to monitor for
hypokalemia while the client is taking hydrochlorothiazide.
c. Calcium 9.1 mg/dL
i. This finding is within the expected reference range. However, the nurse should continue to monitor for
hypercalcemia while the client is taking hydrochlorothiazide.
d. Magnesium 2.0 mEq/L
i. This finding is within the expected reference range. However, the nurse should continue to monitor for
hypomagnesemia while the client is taking hydrochlorothiazide.
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. One large, hard-boiled egg
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.
b. 1 cup bran cereal
i. One cup of bran cereal contains 112 mg of magnesium. Therefore, the nurse should include a different
food as containing the lowest amount of magnesium.
c. ½ cup almonds
, i. One-half cup of almonds contains 193 mg of magnesium. Therefore, the nurse should include a
different food as containing the lowest amount of magnesium.
d. 1 cup cooked spinach
i. One cup of cooked spinach contains 157 mg of magnesium. Therefore, the nurse should include a
different 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. Deep-tendon reflexes
i. The nurse should assess the client's deep-tendon reflexes because this total serum calcium level is
below the expected reference range of 9 to 10.5 mg/dL, and hypocalcemia can cause neuromuscular
changes. However, there is another assessment the nurse should make first.
b. 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.
c. Peripheral sensation
i. The nurse should assess the client's peripheral sensation to check for paresthesia because this total
serum calcium level is below the expected reference range, and hypocalcemia can cause
neuromuscular changes. However, there is another assessment the nurse should make first.
d. Bowel sounds
i. The nurse should assess the client's bowel sounds to check for hypermotility because this total serum
calcium level is below the expected reference range, and hypocalcemia can cause increased peristalsis.
However, there is another assessment the nurse should make first.
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. Dextrose 5% in 0.9% sodium chloride
i. A sodium level of 155 mEq/L is an indication of hypernatremia. Dextrose 5% in 0.9% sodium chloride is
a hypertonic solution. The nurse should anticipate a prescription for a hypotonic solution.
b. Dextrose 5% in lactated Ringer’s
i. A sodium level of 155 mEq/L is an indication of hypernatremia. Lactated Ringer's contains sodium and
other electrolytes and is not indicated for hypernatremia.
c. 3% sodium chloride
i. A sodium level of 155 mEq/L is an indication of hypernatremia, and 3% sodium chloride is a hypertonic
solution. The nurse should anticipate a prescription for a hypotonic solution.
d. 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.
b. Increased bowel sounds
i. Decreased bowel sounds are an expected finding for a client who has hypomagnesemia.
c. Drowsiness
i. Insomnia is an expected finding for a client who has hypomagnesemia.
d. Decreased blood pressure
i. Increased blood pressure is an expected finding for a client who has hypomagnesemia.
8. A nurse is assessing a client who has a phosphorous level of 2.4 mg/dL. Which of the following findings should the nurse
expect?
a. Hepatic failure
i. This phosphorus level is below the expected reference range of 3 to 4.5 mg/dL. The nurse should assess
a client who has hypophosphatemia for manifestations of kidney failure, not hepatic failure.
b. Abdominal pain
i. This phosphorus level is below the expected reference range. Hypophosphatemia causes weakness of
skeletal muscles and rhabdomyolysis, which is acute muscle breakdown. It does not cause abdominal
pain.
c. 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.
d. Increase in cardiac output
i. This phosphorus level is below the expected reference range. The nurse should expect a decrease in
cardiac output.
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. Assist with intubation
i. The nurse should be prepared to assist the provider with intubation and mechanical ventilation if less
invasive measures are ineffective. However, there is another action the nurse should take first.
b. 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%.
c. Administer a rapid-acting diuretic
i. The nurse should administer a rapid-acting diuretic IV bolus to the client to relieve pulmonary
congestion. However, there is another action the nurse should take first.
d. Provide cardiac monitoring
i. The nurse should provide cardiac monitoring because premature ventricular contractions and
dysrhythmias are manifestations of pulmonary edema. However, there is another action the nurse
should take first.
10. A nurse is planning care for a client who has a potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for
which of the following findings?
a. Hyperactive deep-tendon reflexes
i. The nurse should plan to monitor the client for hyporeflexia. Manifestations of hypokalemia include
weak hand grip strength and weak deep-tendon reflexes.
b. Orthostatic hypotension
i. 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.
c. Rapid, deep respirations
i. The nurse should plan to monitor the client for respiratory distress. Weakening of the respiratory
muscles and shallow respirations are manifestations of hypokalemia.
d. Strong, bounding pulse
i. The nurse should plan to monitor the client for a weak and thready pulse. A weak, thready pulse is a
manifestation of hypokalemia.
11. A nurse is providing teaching to 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?
a. “I should conserve energy by limiting my physical activity.”
i. The nurse should encourage the client to ambulate and change positions frequently to prevent
postoperative complications.
b. “I will wait until my pai is at least 6 out of 10 before I use the PCA.”
i. The nurse should encourage the client to use the PCA when feeling acute pain to prevent the pain from
worsening.
c. “I will limit my daily fluid intake to two to three glasses.”
i. Dehydration can cause metabolic acidosis. The nurse should encourage the client to take in
approximately 2,200 mL of fluid daily. This includes fluid intake of six to eight glasses containing 240 mL
each, as well as liquids obtained from eating solid foods. Limiting fluid intake to two to three 8 oz
glasses would not meet the client's total daily intake needs.
d. “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. Instruct the client to cough forcefully
i. Coughing forcefully will not treat the underlying cause of the ABG results.
b. Assist the client with ambulation
, i. Ambulation can exacerbate the client's respiratory distress and is not appropriate at this time.
c. 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.
d. Discontinue the PCA
i. Discontinuing the PCA will not treat the underlying cause of the ABG results and could exacerbate the
client's respiratory distress.
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. Urine output 30 mL/hr
i. The expected reference range for urinary output is between 1,500 to 2,000 mL daily. A urinary output
of less than 30 mL/hr, known as oliguria, can indicate dehydration, impaired renal blood flow, or renal
failure. However, a urine output of 30 mL/hr does not need to be reported to the provider.
b. Blood glucose 180 mg/dL
i. A blood glucose level of 200 mg/dL or less is an indication that the client's diabetic ketoacidosis is
resolving and is within the expect reference range for a casual glucose level. Therefore, the nurse does
not need to report this finding to the provider.
c. 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.
d. BUN 18 mg/dL
i. A BUN of 18 mg/dL is within the expected reference range. A BUN of 30 mg/dL or greater can occur
due to dehydration for a client who has diabetic ketoacidosis.
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. “If my stockings feel tight, I’ll just roll them down for a while.”
i. The client should not roll the stockings down, because the rolled part can become a constricting band
around the leg which can impede circulation.
b. “I’ll put on my elastic stockings at the first sign of swelling.”
i. The client should don graduated compression stockings upon awakening and remove them at bedtime.
Wearing the stockings throughout the day prevents swelling of the extremities and improves
circulation.
c. “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.
d. “It’s okay to cross my legs as long as it’s for less than an hour.”
i. The client should not cross their legs. Doing so can further impair circulation of the lower extremities.
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. ½ cup chopped celery
i. One-half cup of chopped celery contains 132 g of potassium. Therefore, there is another food the nurse
should recommend as containing the greatest amount of potassium.
b. 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.
c. One slice whole grain bread
i. One slice of whole grain bread contains 60 g of potassium. Therefore, there is another food the nurse
should recommend as containing the greatest amount of potassium.
d. ½ cup cooked tofu
i. One-half cup of cooked tofu contains 164 g of potassium. Therefore, there is another food the nurse
should recommend 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 expect?
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.
