a nurse is caring for a client who has just experienced a 90 second tonic clonic seizure the clients arterial blood gas values are ph 688 pao2 50 mm h

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?

A. . Apply oxygen by mask or nasal cannula
B. Apply a paper bag over the clients nose and mouth.
C. Administer 50 mL of sodium bicarbonate intravenously.
D. Administer 50 mL of 20% glucose and 20 units of regular insulin.

Correct answer: A

Rationale:

2. The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:

A. Daily weight
B. Serum sodium levels
C. Measured intake and output
D. Blood pressure

Correct answer: A

Rationale: Daily weight is the most sensitive indicator of body fluid balance because it can show trends over time, helping in assessing the effectiveness of interventions and medications. While serum sodium levels provide objective data on electrolyte balance, they may not accurately reflect fluid balance, especially if a patient is dehydrated. Measured intake and output are crucial for assessing fluid balance, but it can be challenging to match the two due to various ways fluid is lost from the body. Blood pressure and other vital signs may not always be reliable indicators of fluid balance as they can be influenced by other factors beyond fluid status.

3. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)

A. Urine output of 25 mL/hr
B. Serum potassium level of 5.4 mEq/L
C. Blood osmolality of 250 mOsm/L
D.

Correct answer: A

Rationale:

4. Which positive ion is most prevalent in intracellular fluid?

A. Calcium
B. Potassium
C. Sodium
D. Magnesium

Correct answer: B

Rationale: The correct answer is Potassium (K+). Potassium is the predominant cation found within cells, making it the most prevalent positive ion in intracellular fluid. Calcium, sodium, and magnesium are also essential ions in the body, but they are not as abundant in intracellular fluid. Calcium is vital for bone health and muscle function, sodium helps in maintaining fluid balance and nerve function, and magnesium is involved in numerous biochemical reactions.

5. What is the most abundant positive ion in blood plasma?

A. Potassium.
B. Calcium.
C. Sodium.
D. Both potassium and sodium are in equal concentrations.

Correct answer: C

Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.