Electrolytes
& ABGs
& ABGs
Restlessness, thirst, confusion, and rapid breathing are signs of what electrolyte imbalance
Hypernatremia
For a client with HIV, what type of precautions does ATI say are used for all clients, regardless of diagnosis?
Standard
In PACU, a sudden increase in blood pressure and heart rate with no signs of bleeding most often indicates unrelieved what?
Pain
A low-pitched heart sound immediately after S₂, best heard with the bell at the apex, is called what and indicates volume overload?
S₃ gallop
Scenario:
A 60-year-old with duodenal ulcer reports black, tarry stools and dizziness. BP 88/54, HR 118.
Question:
Based on ATI priorities, which complication is occurring?
GI bleed
A client are encouraged to eat foods like milk, beef, and liver to replace which mineral?
Phosphorus
HIV disease staging is primarily based on the level of which specific lymphocyte count?
CD4
Stimulation of the parasympathetic nervous system typically causes what change in blood pressure?
Hypotension
A patient with right-sided heart failure presents with hepatomegaly and ascites.
Which laboratory value would ATI expect to be elevated from hepatic congestion?
Bilirubin
Client with BPH reports no urine for 8 hours, suprapubic distention, and agitation.
Bladder scan > 600 mL.
Question:
What is the first nursing action?
Catheterization
Tingling around the mouth, muscle cramps, and facial twitching together strongly suggest which condition?
Hypocalcemia
HIV client with a CD4 count of 350 cells/mm³ is in which clinical stage?
Stage 2
In early surgical blood loss, the heart initially compensates with what specific change in heart rate?
Tachycardia
A client receiving IV furosemide has muscle cramps and an irregular pulse.
Which EKG change confirms the suspected electrolyte imbalance?
Flattened T waves
Post-TURP client’s irrigation bag is empty and urine output suddenly turns bright red with large clots.
Question:
What complication should the nurse suspect?
Hemorrhage
Patient has hypotension, bradycardia, very shallow respirations, and absent deep tendon reflexes is most likely experiencing which electrolyte imbalance that can progress to respiratory arrest if untreated?
Hypermagnesemia
Post-exposure prophylaxis (PEP) for HIV must be started no later than how many hours after a significant exposure?
72 hours
While recovering a client from abdominal surgery, the nurse notes sudden tachycardia, restlessness, and pallor without bleeding or pain are the earliest indicators of what postoperative complication?
Hypoxia
In acute pulmonary edema, the nurse anticipates which IV medication to reduce preload and pulmonary congestion before diuretics take effect? Hint: Also used in a condition with chest pain due to insufficient perfusion.
Nitrolgycerin
Scenario:
After a leg fracture in traction, the client reports severe unrelieved pain, pallor, and paresthesia distal to the cast.
Question:
Which emergent complication is developing?
Compartment Syndrome
Clue (Next Gen style):
A 72-year-old client is admitted with weakness and palpitations. They have been taking an ACE inhibitor and spironolactone for heart failure.
Vitals: HR 46, BP 96/58, RR 18.
Cardiac monitor: narrow QRS with tall peaked T waves.
ABG: pH 7.35, PaCO₂ 38 mm Hg, HCO₃⁻ 24 mEq/L.
Labs: Na⁺ 136 mEq/L, K⁺ 6.3 mEq/L, Mg²⁺ 1.9 mEq/L.
According to ATI and Lippincott, which electrolyte imbalance is the priority for the nurse to address?
Hyperkalemia
Clue (Next Gen style):
A 27-year-old client presents with:
Fever, sore throat, diffuse rash
Generalized lymphadenopathy
Myalgias and night sweats
He reports multiple unprotected sexual encounters 3 weeks ago.
Labs:
4th-generation HIV test: p24 antigen positive, antibody negative
HIV viral load: very high
CD4⁺ T-cell count: 720 cells/mm³
According to ATI and Lippincott, this presentation is most consistent with which phase of HIV infection?
Acute infection
Clue (Next Gen style):
A 54-year-old client is in the PACU after an open abdominal surgery.
Initial PACU vitals: BP 122/78, HR 88, RR 16, SpO₂ 97% on 2 L NC.
Two hours later, the nurse notes:
Restlessness and anxiety
Complaints of “shoulder pain” and increasing abdominal discomfort
Abdomen firm and distended
BP 86/50, HR 132, RR 24, cool clammy skin
Urine output: 15 mL in the last hour
Surgical dressing now saturated with bloody drainage.
According to ATI perioperative guidelines, the client is most likely developing which postoperative complication?
Hypovolemic shock
A 68-year-old with long-standing hypertension and coronary artery disease presents with sudden severe chest pain and dyspnea.
On assessment, the nurse finds:
BP 78/40, HR 128, RR 30, cool clammy skin
S₃ heart sound and crackles in both lung bases
Weak peripheral pulses, mottled extremities
Urine output: 10 mL/hr
ECG shows ST-segment elevation in the anterior leads.
Chest x-ray: pulmonary congestion.
Based on ATI and Lippincott shock content, this hemodynamic picture is most consistent with which type of shock?
Cardiogenic shock
Scenario:
A client with a below-knee amputation develops fever, foul odor, and redness at the incision.
Serum WBC = 17,000 / µL, ESR = 65 mm/hr.
Question:
According to ATI wound-healing principles, what is the first priority nursing intervention?
Culture wound