NUR102: Ch. 42-Fluids Electrolytes Acid/base

A patient is experiencing dehydration. While planning care, the nurse considers that the majority of the patient’s total water volume exists in with compartment?

•  Intracellular 

•  Extracellular

•  Intravascular

•  Transcellular

The nurse receives the patient’s most recent blood work results. Which laboratory value is of greatest concern?

•  Sodium of 145 mEq/L

•  Calcium of 15.5 mg/dL 

•  Potassium of 3.5 mEq/L

•  Chloride of 100 mEq/L

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first?

•  An infant with temperature of 102.2° F and diarrhea for 3 days 

•  A teenager with a sprained ankle and excessive edema

•  A middle-aged adult with abdominal pain who is moaning and holding her stomach

•  An older adult with nausea and vomiting for 3 days with blood pressure 112/60

Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?

• pH 7.60, PaCO₂ 40 mm Hg, HCO₃⁻ 30 mEq/L

• pH 7.53, PaCO₂ 30 mm Hg, HCO₃⁻ 24 mEq/L

• pH 7.35, PaCO₂ 35 mm Hg, HCO₃⁻ 26 mEq/L

• pH 7.25, PaCO₂ 48 mm Hg, HCO₃⁻ 23 mEq/L

A nurse is caring for a patient prescribed peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel?

•  Recording intake and output 

•  Regulating intravenous flow rate

•  Starting peripheral intravenous therapy

•  Changing a peripheral intravenous dressing

The nurse is caring for a diabetic patient in renal failure who is in metabolic acidosis. Which laboratory findings are consistent with metabolic acidosis?

• pH 7.3, PaCO₂ 36 mm Hg, HCO₃⁻ 19 mEq/L

• pH 7.5, PaCO₂ 35 mm Hg, HCO₃⁻ 35 mEq/L

• pH 7.32, PaCO₂ 47 mm Hg, HCO₃⁻ 23 mEq/L

• pH 7.35, PaCO₂ 40 mm Hg, HCO₃⁻ 25 mEq/L

The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient’s medical record?

•  Intake 255; output 375 

•  Intake 285; output 375

•  Intake 505; output 125

•  Intake 535; output 125

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority?

•  Gastrointestinal

•  Neurological

•  Respiratory

•  Cardiac 

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

•  Weak quadriceps muscles

•  Decreased deep tendon reflexes

•  Light-headedness when standing up

•  Tingling of extremities with possible tetany

Which assessments will alert the nurse that a patient’s IV has infiltrated? (Select all that apply.)

•  Edema of the extremity near the insertion site 

•  Reddish streak proximal to the insertion site

•  Skin discolored or pale in appearance 

•  Pain and warmth at the insertion site

•  Skin cool to the touch