ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. A nurse is assessing a client with hypokalemia and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
- A. Assess the client's respiratory rate, rhythm, and depth.
- B. Measure the client's pulse and blood pressure.
- C. Document findings and monitor the client.
- D. Call the healthcare provider.
Correct answer: A
Rationale: In a client with hypokalemia experiencing diminished handgrip strength, the priority action for the nurse is to assess the client's respiratory rate, rhythm, and depth. Hypokalemia can lead to muscle weakness, including respiratory muscles, potentially causing respiratory distress. Assessing the respiratory status is crucial to determine if immediate interventions are needed to maintain adequate oxygenation. Measuring the client's pulse and blood pressure (Choice B) is important but should come after assessing the respiratory status. Simply documenting findings and monitoring the client (Choice C) may delay necessary interventions. Calling the healthcare provider (Choice D) is not the first action indicated in this situation; assessing the client's respiratory status takes precedence.
2. . A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an exam
- A. Increased rate and depth of respirations
- B. ncreased urinary output
- C. Increased thirst and hunger
- D. ncreased release of acids from the kidneys
Correct answer: A
Rationale:
3. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?
- A. . Apply oxygen by mask or nasal cannula
- B. Apply a paper bag over the clients nose and mouth.
- C. Administer 50 mL of sodium bicarbonate intravenously.
- D. Administer 50 mL of 20% glucose and 20 units of regular insulin.
Correct answer: A
Rationale:
4. While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
- A. Grade 3 phlebitis at IV site
- B. infection at IV site
- C. Thrombosed area at IV site
- D. infiltration at IV site
Correct answer: A
Rationale:
5. After teaching a client who was malnourished and is being discharged, a nurse assesses the clients understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis?
- A. I will drink at least three glasses of milk each day.
- B. . I will eat three well-balanced meals and a snack daily.
- C. . I will not take pain medication and antihistamines together.
- D. I will avoid salting my food when cooking or during meals.
Correct answer: A
Rationale:
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