ATI Fluid Electrolyte and Acid-Base Regulation

ATI Fluid Electrolyte and Acid-Base Regulation Related

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A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?

  • A. Do you take any over-the-counter medications?
  • B. You appear anxious. What is causing your distress?
  • C. Do you have a history of anxiety attacks?
  • D. You are breathing fast. Is this causing you to feel light-headed?
Correct Answer: B

Rationale: The correct answer is B: "You appear anxious. What is causing your distress?" because hyperventilation can be triggered by emotional distress or anxiety. By addressing the underlying cause of the hyperventilation, the nurse can provide appropriate interventions to help the client manage their anxiety and subsequently reduce the hyperventilation episodes.

A: "Do you take any over-the-counter medications?" - This question is not directly related to addressing the client's anxiety or distress, which is the primary concern in hyperventilation.

C: "Do you have a history of anxiety attacks?" - While relevant to understanding the client's medical history, this question does not address the immediate cause of hyperventilation in this specific situation.

D: "You are breathing fast. Is this causing you to feel light-headed?" - This question focuses on the physical symptoms of hyperventilation rather than exploring the emotional or psychological triggers, which are essential in managing hyperventilation caused by anxiety.

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You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the followin

  • A. Diminished deep tendon reflexes
  • B. Tachycardia
  • C. Cool, clammy skin
  • D. Acute flank pain
Correct Answer: A

Rationale: Step 1: High magnesium levels can lead to hypermagnesemia, which can cause decreased neuromuscular function.
Step 2: Diminished deep tendon reflexes are a sign of neuromuscular impairment, indicating potential hypermagnesemia.
Step 3: Assessing for diminished deep tendon reflexes is crucial to monitor neuromuscular function in patients with high magnesium levels.
Summary: A is correct because hypermagnesemia affects neuromuscular function. B, C, and D are incorrect as they do not directly relate to the effects of high magnesium levels.

A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that do mot apply.)

  • A. Electrocardiogram changes
  • B. Slow, shallow respirations
  • C. Paralytic ileus
  • D. Skeletal muscle weakness
Correct Answer: B

Rationale: Correct Answer: B - Slow, shallow respirations

Rationale:
1. Electrolyte imbalance in renal failure often leads to respiratory alkalosis, causing rapid and deep respirations, not slow and shallow.
2. Electrocardiogram changes (A) are common with electrolyte imbalances, particularly potassium and calcium.
3. Paralytic ileus (C) is a complication of electrolyte imbalances, affecting gastrointestinal motility.
4. Skeletal muscle weakness (D) is a common manifestation of electrolyte imbalances, especially potassium and magnesium deficiencies.

Summary:
Choice B is incorrect because slow, shallow respirations are not typically associated with electrolyte imbalances related to renal failure. Choices A, C, and D are commonly seen complications of electrolyte imbalances and should be assessed by the nurse.

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a
thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that
she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance
should you first suspect?

  • A. Hypophosphatemia
  • B. Hypocalcemia
  • C. Hypermagnesemia
  • D. Hyperkalemia
Correct Answer: B

Rationale: The correct answer is B: Hypocalcemia. Following a thyroidectomy, there is a risk of damaging the parathyroid glands, leading to hypocalcemia. Symptoms such as tingling in lips and fingers, muscle spasms, and increased muscle tone are classic signs of hypocalcemia. The initial concern should be hypocalcemia due to its potential to cause serious complications such as tetany and laryngospasm. Options A, C, and D are incorrect as they do not align with the symptoms described. Hypophosphatemia may present with weakness and respiratory failure, hypermagnesemia with hypotension and respiratory depression, and hyperkalemia with muscle weakness and cardiac arrhythmias.

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

  • A. Monitor daily hemoglobin and hematocrit values.
  • B. Administer furosemide (Lasix) intravenously.
  • C. Encourage the client to take deep breaths.
  • D. Teach the client fall prevention measures.
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.

You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient
has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all
that do not apply

  • A. Milk
  • B. Beef
  • C. Poultry
  • D. Liver
Correct Answer: B

Rationale: The correct answer is B: Beef. While beef is a good source of protein, it is not high in phosphate. Milk, poultry, and liver are high in phosphate and would be beneficial for a patient with hypophosphatemia. Beef is not typically a significant source of phosphate and therefore would not be as effective in increasing phosphate levels in the body compared to the other options. It is important for the patient to focus on consuming foods that are high in phosphate to help correct the hypophosphatemia.

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