a nurse is caring for a client who is experiencing moderate metabolic alkalosis which action should the nurse take

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

A. Monitor daily hemoglobin and hematocrit values.
B. Administer furosemide (Lasix) intravenously.
C. Encourage the client to take deep breaths.
D. Teach the client fall prevention measures.

Correct answer: D

Rationale:

2. Which hormones increase the amount of water in the body?

A. ADH
B. Aldosterone
C. ANH
D. ADH and aldosterone

Correct answer: D

Rationale: The correct answer is D, ADH and aldosterone. Both antidiuretic hormone (ADH) and aldosterone increase water retention by the kidneys, thereby increasing blood volume. ADH acts on the kidneys to increase water reabsorption, while aldosterone acts on the kidneys to promote sodium reabsorption, leading to water retention. Choice A, ADH, is partially correct as it alone increases water retention. Choice B, aldosterone, is also partially correct as it alone increases water retention. Choice C, ANH (atrial natriuretic hormone), actually decreases water retention by promoting sodium excretion and inhibiting aldosterone release.

3. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?

A. Do you take any over-the-counter medications?
B. You appear anxious. What is causing your distress?
C. Do you have a history of anxiety attacks?
D. You are breathing fast. Is this causing you to feel light-headed?

Correct answer: B

Rationale:

4. 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?

A. Hypophosphatemia
B. Hypocalcemia
C. Hypermagnesemia
D. Hyperkalemia

Correct answer: B

Rationale:

5. You are working on a burns unit, and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

A. Metabolic alkalosis
B. Hypermagnesemia
C. Hypercalcemia
D. Hypovolemia

Correct answer: D

Rationale: When a patient exhibits signs and symptoms of third-spacing, where fluid moves out of the intravascular space but not into the intracellular space, hypovolemia is expected. This leads to a decreased circulating blood volume. Increased calcium and magnesium levels are not typically associated with third-spacing fluid shift. Burns usually result in acidosis rather than alkalosis, making metabolic alkalosis an incorrect choice. Therefore, hypovolemia is the correct answer in this scenario.