you are the surgical nurse caring for a 65 year old female patient who is postoperative day 1 following a thyroidectomy during your shift assessment t
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

Correct answer: B

Rationale:

2. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?

Correct answer: C

Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.

3. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

Correct answer: A

Rationale:

4. After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?

Correct answer: C

Rationale:

5. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would the nurse interpret the results?

Correct answer: D

Rationale: The given arterial blood gas results show a low pH, indicating acidosis, with normal pH range being 7.35 to 7.45. The low PaCO2 suggests alkalosis, while the low bicarb level indicates acidosis. In this scenario, the primary issue is the metabolic acidosis, as the pH bicarb relationship supports this. The compensatory response to metabolic acidosis is a decrease in PaCO2, leading to a respiratory alkalosis. Therefore, the correct interpretation is 'Metabolic acidosis with a compensatory respiratory alkalosis.' Choices A, B, and C are incorrect as they do not accurately reflect the relationship between the pH, PaCO2, and HCO3 levels in the arterial blood gas results provided.

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