Nursing Care of Clients with Altered Fluid, Electrolyte, or Acid-Base Balance

NCLEX Review
1.

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When a nurse is measuring central venous pressure (CVP) by manometer, which of the following is the correct position for accurately obtaining a measurement? [Hint] Client supine, head of bed elevated, measure at the 4th intercostal space on lateral chest wall Client supine, head of bed flat, measure at the site of the central venous catheter Client supine, head of bed flat, measure at the 4th intercostal space on lateral chest wall Client supine, head of bed elevated, measure at the site of the central venous catheter

2.

An elderly client with a history of heart disease is receiving intravenous fluids for dehydration. The client complains of shortness of breath. Physical assessment reveals tachycardia, tachypnea, and jugular vein distention. The nurse recognizes that these signs and symptoms indicate which of the following fluid volume imbalances? [Hint] Fluid overload Hypovolemia Hypernatremi a Hyponatremia

3.

The nurse is assessing a client admitted with severe diarrhea. The client has postural hypotension, muscle twitching, dry mucous membranes, tachycardia, weakness, and the family reports neurological changes since yesterday. Based on this assessment information, the nurse would suspect which of the following electrolyte imbalances? [Hint] Hypernatremi a Hyponatremia

Hypokalemia Hyperkalemia

4.

A client with crushing injuries to his lower legs complains of abdominal cramping and paresthesias. The EKG monitor reveals tall, peaked T waves. Which of the following electrolyte imbalances would the nurse suspect? [Hint] Hypokalemia Hypernatremi a Hyponatremia Hyperkalemia

5.

The nurse is admitting a client, status post radical neck dissection. In establishing a plan of care for this client, the nurse knows to carefully monitor the first 24 - 48 hours for which of the following symptoms that indicate hypocalcemia? [Hint] Laryngospasms, seizures, tetany Muscle weakness, constipation, dysrhythmias Fatigue, ataxia, nausea Vomiting, altered mental status, dysrhythmias

6.

A client being treated for hypomagnesemia is receiving an intravenous infusion of magnesium sulfate. The nurse assessing the client suspects an elevated serum magnesium level when which of the following symptoms are observed? [Hint] Hyperactive deep tendon reflexes Depressed deep tendon reflexes Muscle tremors

Dysrhythmias

7.

The nurse receives an arterial blood gas (ABGs) report for a client on continuous nasogastric suctioning. The ABG report is as follows: pH 7.48, PaCO2 46, and HCO3 28. The nurse would interpret these blood gases to be which of the following? [Hint] Metabolic acidosis Respiratory acidosis Metabolic alkalosis Metabolic acidosis

8.

A client with salicylate poisoning presents to the Emergency Department. The arterial blood gas results are pH 7.32, PaCO2 32, and HCO3 11. The nurse interprets these blood gases to be which of the following? [Hint] Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis

9.

A 32-year-old female, overdosed on an unknown sedative, presents with severe respiratory depression and decreased level of consciousness. Arterial blood gases are pH 7.31, PaCO2 47, and HCO3 24. The nurse interprets these as which acid-base disorder? [Hint] Uncompensated respiratory acidosis Compensated respiratory acidosis Uncompensated respiratory alkalosis Compensated respiratory alkalosis

10 .

An elderly male is receiving mechanical ventilation. The arterial blood gases for this morning are pH 7.48, PaCO2 33, and HCO3 24. The nurse would interpret these blood gases as which of the following? [Hint] Compensated respiratory acidosis Uncompensated respiratory acidosis Compensated respiratory alkalosis Uncompensated respiratory alkalosis
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