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
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Nursing Elites

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?

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. How would a decrease in blood protein concentration impact the fluid volumes?

Correct answer: D

Rationale: A decrease in blood protein concentration would lead to a reduction in osmotic pressure, which is responsible for drawing fluid back into the capillaries. This decrease in osmotic pressure would result in an increase in interstitial fluid volume as fluid moves out of the capillaries, and a decrease in blood plasma volume as less fluid is drawn back into the circulation. Therefore, the correct answer is to increase interstitial fluid volume and decrease blood plasma volume. Choices A, B, and C are incorrect because they do not reflect the impact of decreased blood protein concentration on fluid volumes.

3. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

Correct answer: C

Rationale:

4. .A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?

Correct answer: D

Rationale:

5. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all tha do not t apply.)

Correct answer: C

Rationale:

Similar Questions

A client at risk for mild hypernatremia is being taught by a nurse. Which statement should the nurse include in this client's teaching?
Third spacing occurs when fluid moves out of the intravascular space but not into the intracellular space. Based on this fluid shift, the nurse will expect the patient to demonstrate:
The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?
A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)
The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:

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