ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 16 : Caring for Clients With Fluid, Electrolyte, and Acid? Base Imbalances Questions
Question 1 of 5
The client's lab values are sodium $166 \mathrm{mEq} / \mathrm{L}$, potassium $5.0 \mathrm{mEq} / \mathrm{L}$, chloride $115 \mathrm{mEq} / \mathrm{L}$, and bicarbonate $35 \mathrm{mEq} / \mathrm{L}$. What condition is this client likely to have, judging by anion gap?
Correct Answer: A
Rationale: The anion gap is the difference between sodium and potassium cations and the sum of chloride and bicarbonate anions. An anion gap that exceeds $16 \mathrm{mEq} / \mathrm{L}$ indicates metabolic acidosis. In this case, the anion gap is $(166+5)-(115+35)$, yielding $21 \mathrm{mEq} / \mathrm{L}$, which suggests metabolic acidosis. Anion gap is not used to check for respiratory alkalosis, metabolic alkalosis, or respiratory acidosis.
Question 2 of 5
The emergency department (ED) nurse is caring for a client with a possible acid- base imbalance. The physician has prescribed an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG?
Correct Answer: D
Rationale: Arterial blood gas (ABG) results are the main tool for measuring blood $\mathrm{pH}, \mathrm{CO}_2$ content $\left(\mathrm{PaCO}_2\right)$, and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. $\mathrm{PaO}_2$ and $\mathrm{PO}_2$ are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.
Question 3 of 5
The nursing instructor is talking with the nursing class about fluid and electrolyte balance. What would the instructor tell the students that the average daily fluid intake for an adult is?
Correct Answer: B
Rationale: In healthy adults, oral fluid intake averages about $2500 \mathrm{~mL} /$ day; however, it can range between 1800 and $3000 \mathrm{~mL} /$ day, with a similar volume of fluid loss. $2000 \mathrm{~mL}, 3000 \mathrm{~mL}$, and $3500 \mathrm{~mL}$ are not the average amounts of fluid a healthy adult takes in daily.
Question 4 of 5
The nurse is instructing on the body's negative feedback loop to ensure homeostasis to a group of students. Which action by bases keeps the blood $\mathrm{pH}$ nearly neutral?
Correct Answer: B
Rationale: Acids are substances that release hydrogen into fluid, bases are substances that bind with hydrogen. The delicate balance between acids and bases, as well as fluids and electrolytes, maintains the nearly neutral blood $\mathrm{pH}$.
Question 5 of 5
The nurse is caring for an older adult client in the home setting who is experiencing decreased thirst. Which type of fluid imbalance should the nurse anticipate?
Correct Answer: A
Rationale: The nurse should anticipate the presence of dehydration, which is the most common fluid imbalance in older adult clients that results from decreased thirst. Hypovolemia is a condition in which only the blood volume is low. Hypervolemia is when the intravascular fluid volume is too high. Third spacing describes the translocation of fluid from the intravascular or intercellular space to tissue compartments, where it becomes trapped and useless. It is associated with the loss of colloids.