a nurse is assessing a client with hypokalemia and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago wh

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. Extracellular fluid includes:

A. plasma and intracellular fluid.
B. interstitial and intracellular fluids.
C. plasma and interstitial fluid.
D. plasma, interstitial fluid, and intracellular fluid.

Correct answer: C

Rationale: The correct answer is C: 'plasma and interstitial fluid.' Extracellular fluid consists of all body fluids outside the cells, primarily including plasma (the liquid component of blood) and interstitial fluid (the fluid between cells). Choices A, B, and D are incorrect because intracellular fluid is located within the cells, not in the extracellular fluid compartment.

3. Which negative ion is most important in intracellular fluid?

A. Phosphate ions.
B. Protein molecules.
C. Chlorine.
D. Phosphate ions and protein molecules.

Correct answer: D

Rationale: Intracellular fluid contains phosphate ions and protein molecules as essential anions. Phosphate ions play a crucial role in various cellular processes, including energy transfer. Proteins, being large molecules with negative charges, also contribute significantly to the negative ion concentration within cells. Chlorine is primarily an extracellular anion and is not as prominent as phosphate ions and proteins within intracellular fluid, making it a less important negative ion in this context. Therefore, the correct answer is D because both phosphate ions and protein molecules are crucial negative ions in intracellular fluid.

4. While assessing clients on a medical-surgical unit, which client is at risk for hypokalemia?

A. Client with pancreatitis who has continuous nasogastric suctioning
B. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
C. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
D. Client with uncontrolled diabetes and a serum pH level of 7.33

Correct answer: A

Rationale: Continuous nasogastric suctioning can lead to hypokalemia due to the loss of gastric contents rich in potassium. Therefore, a client with pancreatitis who has continuous nasogastric suctioning is at risk for hypokalemia. Option B is incorrect because ACE inhibitors may lead to hyperkalemia, not hypokalemia. Option C is incorrect as receiving packed red blood cells can lead to hyperkalemia due to the potassium content in the blood product. Option D is incorrect because a serum pH level of 7.33 indicates acidosis, which is not directly associated with hypokalemia.