a nurse is planning care for a client who is hyperventilating the clients arterial blood gas values are ph 730 pao2 94 mm hg paco2 31 mm hg and hco3 2

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?

A. Do you take any over-the-counter medications?
B. You appear anxious. What is causing your distress?
C. Do you have a history of anxiety attacks?
D. You are breathing fast. Is this causing you to feel light-headed?

Correct answer: B

Rationale:

2. . A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?

A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.

Correct answer: D

Rationale:

3. When does dehydration begin to occur?

A. the body reduces fluid output to zero.
B. the body increases the release of ANH.
C. the salivary secretions decrease.
D. the salivary secretions increase.

Correct answer: C

Rationale: Dehydration leads to a decrease in the body's fluid levels, causing the salivary glands to produce less saliva, resulting in a dry mouth. Therefore, when dehydration begins to occur, salivary secretions decrease. Choice A is incorrect because the body does not reduce fluid output to zero during dehydration; it tries to conserve fluids. Choice B is incorrect as dehydration does not directly increase the release of ANH (Atrial Natriuretic Hormone). Choice D is incorrect because salivary secretions do not increase but decrease during dehydration.

4. A nurse in the medical-surgical unit is giving a patient with low blood pressure a hypertonic solution, which will increase the number of dissolved particles in his blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Which of the following terms is associated with this process?

A. Hydrostatic pressure
B. Osmosis and osmolality
C. Diffusion
D. Active transport

Correct answer: B

Rationale: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. Giving a patient who has low blood pressure a hypertonic solution will increase the number of dissolved particles in the blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Option A is incorrect; hydrostatic pressure refers to changes in water or volume related to water pressure. Option C is incorrect; diffusion is the movement of solutes from an area of greater concentration to lesser concentration. The solutes in an intact vascular system are unable to move, so diffusion should not normally take place. Option D is incorrect; active transport is the movement of molecules against the concentration gradient and requires ATP as an energy source. This process typically takes place at the cellular level and is not involved in vascular volume changes.