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 nurse is caring for four clients on a medical unit. Which client's laboratory reports does the nurse review first for an electrolyte imbalance?
Correct Answer: C
Rationale: Electrolytes are in both intracellular and extracellular water. Electrolyte deficiency occurs from an inadequate intake of food, conditions that deplete water such as nausea and vomiting, or disease processes that cause an excess of electrolyte amounts. The 52-year-old with diarrhea would be the client most likely to have an electrolyte imbalance. The orthopedic client will not likely have an electrolyte imbalance. Myocardial infarction clients will occasionally have electrolyte imbalance, but this is the exception rather than the rule.
Question 2 of 5
The nurse is reviewing client lab work for a critical lab value. Which value is called to the health care provider for additional prescriptions?
Correct Answer: A
Rationale: Normal potassium level is 3.5 to $5.5 \mathrm{mEq} / \mathrm{L}$. Elevated potassium levels can lead to muscle weakness, paresthesias, and cardiac dysrhythmias.
Question 3 of 5
The nurse is assigned a client with calcium level of $4.0 \mathrm{mg} / \mathrm{dL}$. Which system assessment would the nurse ask detailed questions?
Correct Answer: C
Rationale: A client with a calcium level of $4.0 \mathrm{mg} / \mathrm{dL}$ has hypocalcemia. The nurse closely monitors the client with hypocalcemia for neurological manifestations such as tetany, seizures, and spasms. If the calcium level continues to decrease, seizure precautions are necessary. Cardiac dysrhythmias and airway obstruction may also occur.
Question 4 of 5
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?
Correct Answer: C
Rationale: The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving $\mathrm{CO}_2$ by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.
Question 5 of 5
The nurse receives report that a client's $\mathrm{pH}$ level is 7.4. Which nursing action would be most appropriate?
Correct Answer: C
Rationale: The nurse realizes that a $\mathrm{pH}$ level of 7.4 is within normal limits. No additional measures need obtained and the nurse would perform a usual head-to-toe assessment.