ATI Fluid, Electrolyte, and Acid-Base Regulation fully solved graded A+ 2023/2024

ATI Fluid, Electrolyte, and Acid-Base RegulationA 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? a. 1 hr b. 2 hr c. 4 hr d. 6 hr - correct answer c. 4 hr Rationale: The transfusion should be administered slowly (max time of 4hrs) to avoid increasing the workload of the heart A nurse is assisting in the care of a client who has a prescription to receive one unit of packed red blood cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood bank. Which of the following actions should the nurse take? a. Return the blood unit as it is not compatible with the client's blood type. b. Stay with the client for 15 min prior to starting the blood transfusion. c. Verify the unit of blood with another nurse. d. Prime the blood tubing with 0.45% sodium chloride. - correct answer c. Verify the unit of blood with another nurse. Rationale: The unit of blood is compatible with the client's blood type. However, the nurse should ensure that the blood unit had been verified by 2 nurses before initiating the transfusion A nurse is assisting an RN who is preparing to start an IV for a client who has a high risk for bleeding. Which of the following actions should the nurse take? a. Apply a cold compress to the selected IV site. b. Ask the client to hold the extremity up prior to searching for an IV site. c. Ask the client to spread the fingers of the selected extremity. d. Apply a blood pressure cuff set to 30 mm Hg. - correct answer d. Apply a blood pressure cuff set to 30 mm Hg Rationale: Instead of using a tourniquet, the nurse should apply a BP cuff set to 30 mm Hg prior to starting an IV for this client. This will help protect the client's extremity from bruising & bleeding 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.) a. The client states their muscle spasms are absent. b. The client reports a headache. c. The client denies being confused. d. The client reports being nauseated. e. The client reports feeling tired. - correct answer a. The client states their muscle spasms are absent. c. The client denies being confused. Rationale: The absence of muscle spasms & client reporting that they are not confused is an indication of adequate sodium levels 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? a. Initiate continuous cardiac monitoring. b. Elevate the head of the client's bed. c. Instruct the client to deep breathe and cough. d. Initiate continuous SpO2 monitoring. - correct answer b. Elevate the head of the client's bed Rationale: The 1st action the nurse should take when using the airway, breathing, circulation approach to client care is to elevate the HOB. Placing the client in a Fowler's or semi-Fowler's position will promote effective breathing & chest expansion