ATI Fluid Electrolyte and Acid-Base Regulation

Correct Answer: D

Rationale: The correct answer is D: Read food labels to determine sodium content. The nurse should assess the client's sodium level of 144 mEq/L, which is slightly above the normal range. High sodium intake can lead to fluid retention, hypertension, and other health issues. By reading food labels to determine sodium content, the nurse can identify sources of high sodium intake in the client's diet and provide appropriate dietary recommendations. This assessment is crucial in managing the client's sodium levels and overall health. Assessing the client's dietary intake of foods high in potassium (Choice A) is not the priority in this case since the client's potassium level is within the normal range. Assessing the client's neuromuscular status (Choice B) is important but not the first priority when considering the electrolyte imbalances present. Assessing the client's fluid intake and output (Choice C) is also important but does not address the immediate concern related to the client's elevated sodium level.

Correct Answer: A

Rationale: The correct answer is A: Increased rate and depth of respirations. In this case, the client's arterial blood gas values show a pH within normal range (7.36), PaCO2 below normal (33 mm Hg), and HCO3 below normal (18 mEq/L), indicating a metabolic acidosis. To compensate for the acidosis, the client will hyperventilate, leading to increased rate and depth of respirations to blow off excess CO2 and attempt to normalize the pH. Options B, C, and D are incorrect because increased urinary output, thirst, hunger, and release of acids from the kidneys are not direct compensatory mechanisms for metabolic acidosis.

Correct Answer: D

Rationale: The correct action is to stop the infusion of intravenous fluids. Edema and tenderness above the IV site suggest infiltration, where fluid leaks into surrounding tissues. Stopping the infusion prevents further damage and helps prevent complications. Applying cold compresses (A) may not address the underlying issue. Elevating the extremity (B) is helpful for other conditions like swelling due to dependent edema, not infiltration. Flushing the catheter (C) can exacerbate the issue by pushing more fluid into the tissue.

Correct Answer: A

Rationale: The correct answer is A: Assess the airway. The nurse should prioritize airway assessment as the client's ABGs indicate respiratory acidosis (low pH, high PaCO2). This suggests potential airway obstruction or inadequate ventilation. Ensuring a patent airway is crucial for adequate oxygenation. Administering bronchodilators (B) or mucolytics (D) may help with airway clearance but should come after ensuring a clear airway. Providing oxygen (C) is important, but addressing the underlying respiratory acidosis by first assessing the airway is the priority in this situation to prevent further deterioration.

Correct Answer: D

Rationale: The correct answer is D: Hypercalcemia. Bone metastases in lung cancer can lead to increased release of calcium into the blood, causing hypercalcemia. The patient's symptoms of weakness and abdominal pain are consistent with hypercalcemia. Hypernatremia (choice A) is unlikely as the symptoms do not align with high sodium levels. Hypomagnesemia (choice B) and hypophosphatemia (choice C) are less likely as they are not typically associated with bone metastases in lung cancer. In summary, the patient's presentation of weakness and abdominal pain in the setting of lung cancer with bone metastases points to hypercalcemia as the most likely electrolyte imbalance.