N 528 Assessment #2 Fluid, Electrolyte,
and Acid-Base - ATI
What assessment is a priority to do with a client with Dehydration ? - ANSMental status
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? - ANSHct 34%
Fluid volume excess can cause hemodilution and a decreased hematocrit level
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? - ANSSodium 128 mEq/L
The nurse should report this finding to the provider and monitor the client for weakened
respiratory effort
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? - ANSOne large hard-boiled egg
One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should
recommend this food as containing the lowest amount of magnesium.
A nurse is assessing a client who has a calcium level of 8.1 mg/dL. Which of the following
findings is the priority for the nurse to assess? - ANSCardiac Rhythm
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
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? - ANSA 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.
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should
the nurse expect? - ANSHyperactive deep-tendon reflexes. Other expected findings include
muscle cramps, numbness, and tingling. Increased BP, Decreased bowel sounds and insomnia
, 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? - ANSThis phosphorus level is below the expected reference
range. The nurse should expect the client to have slow peripheral pulses. Decrease in cardiac
output. Weakness of skeletal muscles and rhabdomyolysis, which is acute muscle breakdown.
Assess for manifestations of kidney failure.
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? - ANSInitiate high-flow
oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.
cardiac manifestations of pulmonary edema - ANSpremature ventricular contractions and
dysrhythmias
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? - ANSorthostatic hypotension,
which places them at risk for falls. Weakening of the respiratory muscles and shallow
respirations, weak and thready pulse. weak hand grip strength and weak deep-tendon reflexes.
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? - ANS"I will use the incentive spirometer every hour."
Respiratory depression and limited chest expansion are both causes of respiratory acidosis.
Using an incentive spirometer will promote adequate chest expansion.
Dehydration can cause what type of acid-base imbalance - ANSmetabolic acidosis
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? - ANSCalming 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.
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? - ANSSerum potassium 3.0 mEq/L.
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.
A nurse is providing teaching to a client who has venous insufficiency of the lower extremities.
Which of the following statements by the client indicates an understanding of the teaching? -
ANSVenous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet
and Acid-Base - ATI
What assessment is a priority to do with a client with Dehydration ? - ANSMental status
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? - ANSHct 34%
Fluid volume excess can cause hemodilution and a decreased hematocrit level
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? - ANSSodium 128 mEq/L
The nurse should report this finding to the provider and monitor the client for weakened
respiratory effort
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? - ANSOne large hard-boiled egg
One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should
recommend this food as containing the lowest amount of magnesium.
A nurse is assessing a client who has a calcium level of 8.1 mg/dL. Which of the following
findings is the priority for the nurse to assess? - ANSCardiac Rhythm
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
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? - ANSA 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.
A nurse is assessing a client who has hypomagnesemia. Which of the following findings should
the nurse expect? - ANSHyperactive deep-tendon reflexes. Other expected findings include
muscle cramps, numbness, and tingling. Increased BP, Decreased bowel sounds and insomnia
, 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? - ANSThis phosphorus level is below the expected reference
range. The nurse should expect the client to have slow peripheral pulses. Decrease in cardiac
output. Weakness of skeletal muscles and rhabdomyolysis, which is acute muscle breakdown.
Assess for manifestations of kidney failure.
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? - ANSInitiate high-flow
oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%.
cardiac manifestations of pulmonary edema - ANSpremature ventricular contractions and
dysrhythmias
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? - ANSorthostatic hypotension,
which places them at risk for falls. Weakening of the respiratory muscles and shallow
respirations, weak and thready pulse. weak hand grip strength and weak deep-tendon reflexes.
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? - ANS"I will use the incentive spirometer every hour."
Respiratory depression and limited chest expansion are both causes of respiratory acidosis.
Using an incentive spirometer will promote adequate chest expansion.
Dehydration can cause what type of acid-base imbalance - ANSmetabolic acidosis
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? - ANSCalming 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.
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? - ANSSerum potassium 3.0 mEq/L.
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.
A nurse is providing teaching to a client who has venous insufficiency of the lower extremities.
Which of the following statements by the client indicates an understanding of the teaching? -
ANSVenous insufficiency makes it difficult for blood flow to return to the heart. Elevating the feet
