Question 1

At a first aid station on a marathon route, a client complains of headache, muscle cramps, weakness, nausea, and confusion after the race. Which statement made by the client might explain these symptoms?

Accepted Answer

The symptoms described by the client are consistent with hyponatremia, which can occur when someone drinks excessive amounts of water, diluting the sodium concentration in their blood. This condition can lead to headache, muscle cramps, weakness, nausea, and confusion. Drinking several large bottles of water after the race, as mentioned in option A, could cause such an imbalance.

Question 2

A client has a continuous IV infusion at 60 mL/hr. The right-hand IV has infiltrated, and the nurse has started a new IV line on the left forearm. Which of the following interventions should the nurse also perform?

Accepted Answer

Changing the administration set is necessary when starting a new IV line after infiltration to prevent contamination and ensure the integrity of the infusion system.

Question 3

The nurse is caring for a client with gastroenteritis who has been vomiting for 48 hours. A family member of the client asks the nurse, "Why is he breathing that way?" What is the nurse's most accurate response after explaining the meaning of pH?

Accepted Answer

The answer of The nurse is caring for a client...

Question 4

The client presents to the emergency department with a bicarbonate (HCO_3-) level of 14 mEq/L. What may be the explanation for this laboratory result?

Accepted Answer

A low bicarbonate level in the blood often indicates metabolic acidosis, where the kidneys are unable to conserve bicarbonate (HCO3-) effectively, leading to its decreased level in the blood.

Question 5

The nurse is aware that a balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. In a healthy adult, which of the following regulate body fluids? Select all that apply.

Accepted Answer

The answer of The nurse is aware that a balance...

Question 6

A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A micro-drip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor?

Accepted Answer

The drip rate is calculated as follows:Drip rate = (Volume to be infused in mL) / (Time in minutes) x (Drop factor)Drip rate = (250 mL) / (2 hours x 60 minutes/hour) x (20 drops/mL)Drip rate = 125 drops/min

Question 7

A new father begins to hyperventilate as his baby is about to be born; he becomes light headed. The nurse instructs him to breathe into the paper bag until his breathing slows down. When he feels better he asks the nurse why using the paper bag helped him. What is the nurse's best response? "Breathing into the paper bag allowed you to

Accepted Answer

Breathing into a paper bag helps to rebreathe carbon dioxide, which can correct respiratory alkalosis. Hyperventilation causes a decrease in carbon dioxide levels in the blood, leading to respiratory alkalosis. Rebreathing carbon dioxide helps to increase the carbon dioxide levels back to normal.

Question 8

The nurse is caring for a client with no spontaneous respiratory effort who requires mechanical ventilation. The first blood gas after initiating the ventilator shows a pH of 7.52 and partial pressure of carbon dioxide (PCO₂) of 20. What intervention is required to correct this pH imbalance?

Accepted Answer

The blood gas results indicate respiratory alkalosis (high pH and low PCO2), suggesting that the client is being overventilated. Reducing the number of breaths per minute will help retain more CO2, lowering the pH towards normal levels.

Question 9

The nurse is providing care to the adult client in the acute care center. When the nurse began to assess the client's blood pressure, the client's hand began to "cramp" and involuntarily flex. What is the possible answer to this phenomenon?

Accepted Answer

The client is likely displaying signs of hypocalcemia. The involuntary flexing or cramping of the hand during blood pressure measurement is known as Trousseau's sign, which is a clinical manifestation of hypocalcemia.

Question 10

The nurse is providing care for the adult male client with a hematocrit of 30. Which condition would accurately explain this finding?

Accepted Answer

A hematocrit of 30 is lower than the normal range, indicating a lower concentration of red blood cells in the blood, which can be due to an intravascular fluid excess (overhydration or fluid overload), diluting the red blood cells.

Question 11

A 60-year-old woman complains of muscle weakness, constipation, nausea, and frequent urination and is displaying bizarre behavior. The woman takes prescribed thiazide diuretics and steroids for asthma. What statement made by the client might indicate an additional cause of her symptoms?

Accepted Answer

The symptoms described, along with the use of thiazide diuretics, steroids, and the intake of excessive calcium through supplements and dairy foods, suggest hypercalcemia, which can cause muscle weakness, constipation, nausea, frequent urination, and altered mental status.

Question 12

The nurse gathers the following data: blood pressure (BP) = 150/94 mm Hg; neck veins distended; pulse (P) = 104 beats/min; pulse bounding; respiratory rate (RR) = 20 breaths/min; temperature (T) = 37 $\degree$C (98.6 $\degree$F). What disorder should the nurse suspect?

Accepted Answer

The symptoms of high blood pressure, distended neck veins, a bounding pulse, and an elevated pulse rate are indicative of hypervolemia, which is an excess of fluid in the body.

Question 13

A client had gastric surgery 10 days ago and continues to require gastric suction because of a paralytic ileus. The client reports tingling in the fingers, has hypertonic reflexes, and has a respiratory rate of 8 breaths per minute that are deep in nature. The nurse recognizes that these symptoms are consistent with which diagnosis?

Accepted Answer

The symptoms described are consistent with metabolic alkalosis, which can occur due to prolonged gastric suctioning. Gastric suction can lead to a loss of hydrochloric acid, resulting in an increase in blood pH. Tingling in the fingers (paresthesia), hypertonic reflexes, and a decreased respiratory rate (as the body tries to retain CO2 to balance the pH) are signs of metabolic alkalosis.

Question 14

The nurse examines the electrocardiography (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect?

Accepted Answer

Tall T waves on an ECG are a classic sign of hyperkalemia, which is an elevated potassium level in the blood.

Question 15

The nurse is assessing the client in the long-term care facility and notes that client has bilateral pedal pitting edema. The nurse knows that this signifies excess volume in which fluid compartment?

Accepted Answer

Pitting edema occurs when excess fluid accumulates in the interstitial space, which is the space between cells outside of the blood vessels. This can lead to swelling observable in areas such as the feet (pedal edema).

Question 16

The nurse is caring for a client with heart failure. The client has chronic fluid volume excess secondary to ineffective pumping action of the heart. When teaching this client about fluid and electrolyte balance, which diet is most important for the nurse to explain?

Accepted Answer

For a client with heart failure and chronic fluid volume excess, a low-sodium diet is crucial. Sodium can cause the body to retain water, exacerbating fluid volume excess and putting additional strain on the heart.

Question 17

When performing a central venous catheter dressing change, which of the following steps is correct?

Accepted Answer

Having the client wear a mask or turn their head away from the site helps prevent contamination from respiratory droplets during the dressing change.

Question 18

The nurse is assessing the client with renal failure and notes that the client's respirations are depressed, the client is lethargic with depressed respirations. His blood pressure (BP) is 80/40 mm Hg; pulse (P) is 58 beats/min; respiration rate (RR) is 12 breaths/min; and hypoactive reflexes are present. Which of the following may be the cause of these symptoms?

Accepted Answer

The symptoms described are consistent with hypermagnesemia, which can occur when a client with renal failure takes frequent doses of magnesium-based laxatives. Renal failure impairs the body's ability to excrete magnesium, leading to accumulation and symptoms such as lethargy, depressed respirations, hypotension, bradycardia, and hypoactive reflexes.

Question 19

The nurse is to administer an intravenous (IV) solution to a client with diffuse edema. Which of the following prescriptions for this client would the nurse question?

Accepted Answer

Dextrose in water solutions (both 5% and 10%) are hypotonic, meaning they can exacerbate edema by moving more fluid into the interstitial spaces. However, among the options, 5% Dextrose in water (A) is the most hypotonic and would be the most likely to be questioned for a patient with diffuse edema, as it would contribute to further fluid shifting into the tissues. The other options contain either more dextrose (making them less hypotonic) or electrolytes/salts that would not exacerbate edema to the same extent.

Question 20

Which of the following older clients' needs to increase the daily fluid intake? One who typically drinks (assume three meals per day):

Accepted Answer

Client B has the lowest total daily fluid intake with only 1350 mL (250 mL x 3 meals + 600 mL throughout the day), which is below the general recommendation for older adults, typically around 1500-2000 mL per day depending on individual health conditions and needs.

Quiz 38: Fluids, Electrolytes, Acidbase Balance

At a first aid station on a marathon route, a client complains of headache, muscle cramps, weakness, nausea, and confusion after the race. Which statement made by the client might explain these symptoms?

A client has a continuous IV infusion at 60 mL/hr. The right-hand IV has infiltrated, and the nurse has started a new IV line on the left forearm. Which of the following interventions should the nurse also perform?

The nurse is caring for a client with gastroenteritis who has been vomiting for 48 hours. A family member of the client asks the nurse, "Why is he breathing that way?" What is the nurse's most accurate response after explaining the meaning of pH?

The client presents to the emergency department with a bicarbonate (HCO_3-) level of 14 mEq/L. What may be the explanation for this laboratory result?

The nurse is aware that a balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. In a healthy adult, which of the following regulate body fluids? Select all that apply.

A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A micro-drip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor?

The nurse is caring for a client with no spontaneous respiratory effort who requires mechanical ventilation. The first blood gas after initiating the ventilator shows a pH of 7.52 and partial pressure of carbon dioxide (PCO₂) of 20. What intervention is required to correct this pH imbalance?

The nurse is providing care to the adult client in the acute care center. When the nurse began to assess the client's blood pressure, the client's hand began to "cramp" and involuntarily flex. What is the possible answer to this phenomenon?

The nurse is providing care for the adult male client with a hematocrit of 30. Which condition would accurately explain this finding?

A 60-year-old woman complains of muscle weakness, constipation, nausea, and frequent urination and is displaying bizarre behavior. The woman takes prescribed thiazide diuretics and steroids for asthma. What statement made by the client might indicate an additional cause of her symptoms?

The nurse gathers the following data: blood pressure (BP) = 150/94 mm Hg; neck veins distended; pulse (P) = 104 beats/min; pulse bounding; respiratory rate (RR) = 20 breaths/min; temperature (T) = 37 $\degree$ C (98.6 $\degree$ F) . What disorder should the nurse suspect?

The nurse examines the electrocardiography (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect?

The nurse is assessing the client in the long-term care facility and notes that client has bilateral pedal pitting edema. The nurse knows that this signifies excess volume in which fluid compartment?

The nurse is caring for a client with heart failure. The client has chronic fluid volume excess secondary to ineffective pumping action of the heart. When teaching this client about fluid and electrolyte balance, which diet is most important for the nurse to explain?

When performing a central venous catheter dressing change, which of the following steps is correct?

The nurse is to administer an intravenous (IV) solution to a client with diffuse edema. Which of the following prescriptions for this client would the nurse question?

Which of the following older clients' needs to increase the daily fluid intake? One who typically drinks (assume three meals per day) :

Quiz 38: Fluids, Electrolytes, Acidbase Balance

At a first aid station on a marathon route, a client complains of headache, muscle cramps, weakness, nausea, and confusion after the race. Which statement made by the client might explain these symptoms?

A client has a continuous IV infusion at 60 mL/hr. The right-hand IV has infiltrated, and the nurse has started a new IV line on the left forearm. Which of the following interventions should the nurse also perform?

The nurse is caring for a client with gastroenteritis who has been vomiting for 48 hours. A family member of the client asks the nurse, "Why is he breathing that way?" What is the nurse's most accurate response after explaining the meaning of pH?

The client presents to the emergency department with a bicarbonate (HCO3-) level of 14 mEq/L. What may be the explanation for this laboratory result?

The nurse is aware that a balance between fluid intake and output is essential to maintain homeostasis. Excesses or deficits of intake can lead to severe disorders. In a healthy adult, which of the following regulate body fluids? Select all that apply.

A healthcare provider prescribes 250 mL of 0.9% sodium chloride to be infused over 2 hours. A micro-drip infusion set is being used. What is the drip rate (drops/min) that the nurse should monitor?

The nurse is caring for a client with no spontaneous respiratory effort who requires mechanical ventilation. The first blood gas after initiating the ventilator shows a pH of 7.52 and partial pressure of carbon dioxide (PCO2) of 20. What intervention is required to correct this pH imbalance?

The nurse is providing care to the adult client in the acute care center. When the nurse began to assess the client's blood pressure, the client's hand began to "cramp" and involuntarily flex. What is the possible answer to this phenomenon?

The nurse is providing care for the adult male client with a hematocrit of 30. Which condition would accurately explain this finding?

A 60-year-old woman complains of muscle weakness, constipation, nausea, and frequent urination and is displaying bizarre behavior. The woman takes prescribed thiazide diuretics and steroids for asthma. What statement made by the client might indicate an additional cause of her symptoms?

The nurse gathers the following data: blood pressure (BP) = 150/94 mm Hg; neck veins distended; pulse (P) = 104 beats/min; pulse bounding; respiratory rate (RR) = 20 breaths/min; temperature (T) = 37 °\degree° C (98.6 °\degree° F) . What disorder should the nurse suspect?

The nurse examines the electrocardiography (ECG) tracing of a client and notes tall T waves. What electrolyte imbalance should the nurse suspect?

The nurse is assessing the client in the long-term care facility and notes that client has bilateral pedal pitting edema. The nurse knows that this signifies excess volume in which fluid compartment?

The nurse is caring for a client with heart failure. The client has chronic fluid volume excess secondary to ineffective pumping action of the heart. When teaching this client about fluid and electrolyte balance, which diet is most important for the nurse to explain?

When performing a central venous catheter dressing change, which of the following steps is correct?

The nurse is to administer an intravenous (IV) solution to a client with diffuse edema. Which of the following prescriptions for this client would the nurse question?

Which of the following older clients' needs to increase the daily fluid intake? One who typically drinks (assume three meals per day) :

The client presents to the emergency department with a bicarbonate (HCO_3-) level of 14 mEq/L. What may be the explanation for this laboratory result?

The nurse is caring for a client with no spontaneous respiratory effort who requires mechanical ventilation. The first blood gas after initiating the ventilator shows a pH of 7.52 and partial pressure of carbon dioxide (PCO₂) of 20. What intervention is required to correct this pH imbalance?

The nurse gathers the following data: blood pressure (BP) = 150/94 mm Hg; neck veins distended; pulse (P) = 104 beats/min; pulse bounding; respiratory rate (RR) = 20 breaths/min; temperature (T) = 37 $\degree$ C (98.6 $\degree$ F) . What disorder should the nurse suspect?