a nurse evaluates a clients arterial blood gas values abgs ph 730 pao2 86 mm hg paco2 55 mm hg and hco3 22 meql which intervention should the nurse i

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?

A. Assess the airway.
B. Administer prescribed bronchodilators.
C. Provide oxygen.
D. Administer prescribed mucolytics

Correct answer: A

Rationale:

2. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?

A. Air emboli
B. Phlebitis
C. Infiltration
D. Fluid overload

Correct answer: C

Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the vein's wall. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort, and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli (Choice A) involves air entering the bloodstream. Phlebitis (Choice B) is inflammation of a vein. Fluid overload (Choice D) is an excessive volume of fluid in the circulatory system.

3. Under normal circumstances, the kidneys provide the greatest means of water loss. Which organ provides the second greatest means of water loss?

A. Skin
B. Lungs
C. Intestines
D. Muscles

Correct answer: A

Rationale: The correct answer is A: Skin. After the kidneys, the skin is the second largest route of water loss through perspiration. Choice B, Lungs, is incorrect as the lungs primarily exchange gases and do not play a significant role in water loss. Choice C, Intestines, is also incorrect as water loss through the intestines is minimal since most water is reabsorbed during digestion. Choice D, Muscles, is incorrect as muscles are not a major source of water loss in the body.

4. Which hormones increase the amount of water in the body?

A. ADH
B. Aldosterone
C. ANH
D. ADH and aldosterone

Correct answer: D

Rationale: The correct answer is D, ADH and aldosterone. Both antidiuretic hormone (ADH) and aldosterone increase water retention by the kidneys, thereby increasing blood volume. ADH acts on the kidneys to increase water reabsorption, while aldosterone acts on the kidneys to promote sodium reabsorption, leading to water retention. Choice A, ADH, is partially correct as it alone increases water retention. Choice B, aldosterone, is also partially correct as it alone increases water retention. Choice C, ANH (atrial natriuretic hormone), actually decreases water retention by promoting sodium excretion and inhibiting aldosterone release.