ATI Fluid Electrolyte and Acid-Base Regulation

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ATI Fluid Electrolyte and Acid-Base Regulation Questions

Question 1 of 5

A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

Correct Answer: B

Rationale: The correct answer is B: Report of headache and stiff neck. This finding indicates a potential complication of epidural anesthesia called a post-dural puncture headache, which can lead to serious consequences like meningitis or subdural hematoma. The nurse should act immediately by notifying the healthcare provider for further evaluation and management. Redness at the catheter insertion site (A) may indicate local inflammation but doesn't require immediate intervention. Temperature elevation (C) could be a sign of infection but isn't as urgent as a headache and stiff neck. Pain rating of 8 (D) is important but doesn't indicate an immediate threat to the client's health like a post-dural puncture headache.

Question 2 of 5

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

Correct Answer: D

Rationale: The correct answer is D: Teach the client fall prevention measures. In metabolic alkalosis, the client may experience muscle weakness and confusion, increasing the risk of falls. Teaching fall prevention measures is essential to ensure the client's safety. Monitoring hemoglobin and hematocrit values (A) is not directly related to managing metabolic alkalosis. Administering furosemide (B) is not appropriate for metabolic alkalosis. Encouraging deep breaths (C) may not address the underlying cause of the alkalosis.

Question 3 of 5

A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?

Correct Answer: B

Rationale: The correct answer is B: Sodium bicarbonate 100 mEq diluted in 1 L of D5W. In this case, the client is experiencing metabolic acidosis due to low HCO3 levels (16 mEq/L) with a low pH (7.28). Sodium bicarbonate helps correct metabolic acidosis by increasing the HCO3 levels. Furosemide (A) is a diuretic and can worsen the client's electrolyte imbalance. Mechanical ventilation (C) is not indicated for metabolic acidosis. Indwelling urinary catheter (D) does not address the underlying acid-base imbalance. Therefore, the nurse should expect the provider to order sodium bicarbonate to correct the metabolic acidosis.

Question 4 of 5

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

Correct Answer: B

Rationale: The correct answer is B: Prepare to assist with chest tube insertion. Chest pain and difficulty breathing after subclavian central venous catheter insertion could indicate a pneumothorax, a potential complication. Chest tube insertion is indicated to help re-expand the lung and relieve the pressure in the thoracic cavity. This intervention takes priority over the other options because it addresses the potential life-threatening complication of a pneumothorax. Administering nitroglycerin (choice A) is not indicated for chest pain in this scenario. Placing a sterile dressing over the IV site (choice C) is not appropriate for managing chest pain and difficulty breathing. Re-positioning the client into the Trendelenburg position (choice D) is not effective in addressing a pneumothorax and may worsen the client's condition.

Question 5 of 5

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause

Correct Answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation leads to excessive elimination of carbon dioxide, causing a decrease in PaCO2 levels, resulting in respiratory alkalosis. This is the most common cause of hyperventilation. Respiratory acidosis (choice A) occurs when there is retention of carbon dioxide. Increased PaCO2 (choice C) is a consequence of respiratory acidosis, not alkalosis. CNS disturbances (choice D) can lead to abnormal breathing patterns but are not the most common cause of hyperventilation.

Similar Questions

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause
You are called to your patients room by a family member who voices concern about the patients status. On assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?
A patient's most recent laboratory results show a slight decrease in potassium. The physician has opted to forego drug therapy but has suggested increasing the patient's dietary intake of potassium. Which of the following would be a good source of potassium?
The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?
The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?

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