Free ATI Fluid and Electrolytes practice for ATI Fluid and Electrolytes (ATI RN). Answer 58 nursing exam-style questions with rationales, exam mode, and progres

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Question 1 of 58
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A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)

Select the best answer.

Correct Answer: C. Warm and pink skin

Explanation:

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The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?

Select the best answer.

Correct Answer: D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Explanation:

Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. Monitoring for an elevated thyroid-stimulating hormone (choice A) is not relevant in assessing for hypocalcemia. Observing for swelling of the neck, tracheal deviation, and severe pain (choice B) are more related to airway compromise. Evaluating the quality of the patient's voice postoperatively (choice C) is important but not a primary sign of hypocalcemia.

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The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

Select the best answer.

Correct Answer: B. Consider potential effects on the patient's mobility when selecting a site.

Explanation:

When selecting a site for IV insertion on the hand or arm, it is important to consider the potential effects on the patient's mobility. The chosen site should not interfere with the patient's movement. Instructing the patient to hold his arm in a dependent position helps increase blood flow, aiding in vein visualization and insertion. It is advisable to choose a site with minimal hair if possible for better adhesion of the dressing. Removing the tourniquet after 2 minutes is recommended to prevent complications like hemoconcentration and potential vein damage. Therefore, option B is the correct choice as it aligns with best practices for IV insertion.

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A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Select the best answer.

Correct Answer: A. Respiratory acidosis

Explanation:

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A nurse preparing to start an IV on a newly admitted patient teaches the patient about the procedure and begins to prepare the site. The nurse should always start by:

Select the best answer.

Correct Answer: C. Asking the patient if they are allergic to latex or iodine

Explanation:

Before preparing the skin, the nurse should ask the patient if they are allergic to latex or iodine, which are commonly used in IV therapy setup. This is crucial to prevent potential allergic reactions at the IV site or even life-threatening anaphylaxis. Leaving one hand ungloved (choice A) is not a recommended practice as both hands should be gloved for infection control. While preparing the skin with an iodine solution (choice B) is a step in the process, ensuring the patient's safety by checking for allergies comes first. Removing excessive hair at the selected site (choice D) is not necessary and can lead to skin irritation.

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Who would have the greatest percentage of body water?

Select the best answer.

Correct Answer: D. a newborn

Explanation:

Newborns have a higher percentage of body water compared to adults due to their higher body fluid content. Factors such as the higher ratio of body surface area to body volume and lower body fat content contribute to this. This is why a newborn would have the greatest percentage of body water. Choices A, B, and C are incorrect because obesity and gender do not determine the percentage of body water in individuals. Therefore, the correct answer is a newborn.

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The healthcare provider is evaluating a patient's laboratory results. Based on the laboratory findings, what results will cause the release of an antidiuretic hormone (ADH)?

Select the best answer.

Correct Answer: A. Increased serum sodium

Explanation:

The correct answer is A: Increased serum sodium. When serum sodium levels increase, it triggers the release of ADH by the posterior pituitary gland. ADH helps in retaining water, reducing urine output, and maintaining fluid balance. Choices B, C, and D are incorrect because decreased serum sodium, decrease in serum osmolality, and decrease in thirst do not stimulate the release of ADH.

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Third spacing occurs when fluid moves out of the intravascular space but not into the intracellular space. Based on this fluid shift, the nurse will expect the patient to demonstrate:

Select the best answer.

Correct Answer: D. Hypovolemia

Explanation:

In the scenario of third-spacing fluid shift, where fluid moves out of the intravascular space but not into the intracellular space, the patient is expected to demonstrate hypovolemia. Hypertension (Choice A) is unlikely as hypovolemia typically leads to decreased blood pressure. Bradycardia (Choice B) is not a common manifestation of hypovolemia, as the body often tries to compensate by increasing heart rate. Hypervolemia (Choice C) indicates an excess of fluid, which is the opposite of what occurs in third spacing.

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.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?

Select the best answer.

Correct Answer: D. . Stop the infusion of intravenous fluids.

Explanation:

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The term used to describe a blood sodium level of more than 145 mEq/L is:

Select the best answer.

Correct Answer: C. hypernatremia.

Explanation:

The correct answer is C: hypernatremia. Hypernatremia refers to an elevated level of sodium in the blood, specifically when it is more than 145 mEq/L. Choice A, hyponatremia, is incorrect as it refers to low sodium levels. Choice B, hyperkalemia, is incorrect as it refers to high potassium levels, not sodium. Choice D, hypercalcemia, is also incorrect as it relates to elevated calcium levels, not sodium.

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A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:

Select the best answer.

Correct Answer: B. Limiting fluids can create imbalances in the body that can result in confusion; maybe we need to adjust the timing of your fluids.

Explanation:

The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.

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A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

Select the best answer.

Correct Answer: B. Prepare to assist with chest tube insertion.

Explanation:

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What electrolyte value should be monitored when a patient is receiving a loop diuretic?

Select the best answer.

Correct Answer: C. Potassium levels

Explanation:

When a patient is receiving a loop diuretic like furosemide (Lasix), potassium levels should be monitored closely. Loop diuretics act on the ascending loop of Henle to inhibit the reabsorption of sodium and water, leading to potassium loss. Monitoring potassium levels is crucial to prevent hypokalemia, which can result in serious complications such as cardiac arrhythmias. Calcium levels (Choice A), phosphorus levels (Choice B), and magnesium levels (Choice D) are not typically affected directly by loop diuretics and do not require routine monitoring in this context.

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The nurse is caring for a patient who is diaphoretic from a fever. The amount of sodium excreted in the urine will:

Select the best answer.

Correct Answer: A. Decrease

Explanation:

Increased sweating (diaphoresis) causes the loss of sodium and other electrolytes from the body. As a result, the body tries to conserve sodium, leading to a decrease in the amount of sodium excreted in the urine. Choice B is incorrect because increased sweating results in sodium loss, not retention. Choice C is incorrect because with increased sweating, there is a need to conserve sodium, leading to a decrease in its excretion. Choice D is incorrect as there is a clear physiological response to sweating that results in a more consistent decrease in sodium excretion.

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While assessing clients on a medical-surgical unit, which client is at risk for hypokalemia?

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Correct Answer: A. Client with pancreatitis who has continuous nasogastric suctioning

Explanation:

Continuous nasogastric suctioning can lead to hypokalemia due to the loss of gastric contents rich in potassium. Therefore, a client with pancreatitis who has continuous nasogastric suctioning is at risk for hypokalemia. Option B is incorrect because ACE inhibitors may lead to hyperkalemia, not hypokalemia. Option C is incorrect as receiving packed red blood cells can lead to hyperkalemia due to the potassium content in the blood product. Option D is incorrect because a serum pH level of 7.33 indicates acidosis, which is not directly associated with hypokalemia.

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A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that do mot apply.)

Select the best answer.

Correct Answer: B. Slow, shallow respirations

Explanation:

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Where is the largest volume of water in the body located?

Select the best answer.

Correct Answer: B. The fluid inside the cells

Explanation:

The correct answer is B. The largest volume of water in the body is found inside the cells, known as intracellular fluid. This fluid makes up the majority of the body's total water content. Choices A, C, and D are incorrect because while plasma, interstitial fluid, and lymph are important components of the body's fluid compartments, they do not contain the largest volume of water in the body.

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What percentage of body water can be as high as in a newborn?

Select the best answer.

Correct Answer: A. 80%.

Explanation:

The correct answer is A: 80%. Newborns can have a body water content as high as 80% due to their higher total body water compared to adults. Choice B (70%) is incorrect because newborns typically have a higher body water percentage. Choice C (60%) is also incorrect as it underestimates the body water content in newborns. Choice D (90%) is incorrect as it overestimates the body water percentage in newborns.

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What is the main water-holding force in the blood capillaries?

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Correct Answer: C. Protein in the blood plasma

Explanation:

The correct answer is C: Protein in the blood plasma. Plasma proteins, especially albumin, create oncotic pressure, which is the main force responsible for holding water within the blood capillaries. Capillary blood pressure (Choice A) is involved in pushing blood through the capillaries, while sodium and chloride in the blood plasma (Choices B and D) are electrolytes and do not play a significant role in the water-holding force within capillaries.

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Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would the nurse interpret the results?

Select the best answer.

Correct Answer: D. Metabolic acidosis with a compensatory respiratory alkalosis

Explanation:

The given arterial blood gas results show a low pH, indicating acidosis, with normal pH range being 7.35 to 7.45. The low PaCO2 suggests alkalosis, while the low bicarb level indicates acidosis. In this scenario, the primary issue is the metabolic acidosis, as the pH bicarb relationship supports this. The compensatory response to metabolic acidosis is a decrease in PaCO2, leading to a respiratory alkalosis. Therefore, the correct interpretation is 'Metabolic acidosis with a compensatory respiratory alkalosis.' Choices A, B, and C are incorrect as they do not accurately reflect the relationship between the pH, PaCO2, and HCO3 levels in the arterial blood gas results provided.

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The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

Select the best answer.

Correct Answer: B. Respiratory alkalosis

Explanation:

The correct answer is B: Respiratory alkalosis. Hyperventilation is the most common cause of acute respiratory alkalosis. When a patient hyperventilates due to anxiety or other causes, they blow off excessive carbon dioxide, leading to a decrease in PaCO2 and a rise in pH. Choices A, C, and D are incorrect because hyperventilation leads to a decrease in PaCO2, causing respiratory alkalosis, not respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

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The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect?

Select the best answer.

Correct Answer: D. Decrease in glomerular filtration

Explanation:

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You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that do not apply

Select the best answer.

Correct Answer: B. Beef

Explanation:

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Which electrolyte is important in the formation of the thyroid hormones?

Select the best answer.

Correct Answer: B. Iodine

Explanation:

Iodine is the correct answer because it is essential for the synthesis of thyroid hormones. The thyroid gland incorporates iodine into thyroid hormones such as thyroxine (T4) and triiodothyronine (T3). These hormones are crucial for regulating metabolism, growth, and development. Sodium, iron, and chloride are not directly involved in the formation of thyroid hormones, making them incorrect choices.

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An increase in capillary blood pressure would tend to:

Select the best answer.

Correct Answer: A. increase interstitial fluid volume.

Explanation:

An increase in capillary blood pressure leads to a higher force pushing fluid out of the capillaries into the interstitial space, thereby increasing interstitial fluid volume. Choice B is incorrect because capillary blood pressure affects the movement of fluid into the interstitial space, not into the plasma. Choice C is incorrect as an increase in capillary blood pressure would not decrease interstitial fluid volume. Choice D is incorrect as it combines contradictory effects when capillary blood pressure increases.

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A patient who is hospitalized with a possible electrolyte imbalance is disoriented and weak, has an irregular pulse, and takes hydrochlorothiazide. He most likely suffers from:

Select the best answer.

Correct Answer: D. Hypokalemia

Explanation:

The patient is displaying symptoms of hypokalemia, including weakness, disorientation, irregular pulse, which can lead to cardiac disturbances. Hydrochlorothiazide is a potassium-wasting diuretic that can cause hypokalemia if not accompanied by potassium replacement therapy. Hypernatremia (choice A) is characterized by high sodium levels, not potassium. Hyponatremia (choice B) is low sodium levels. Hyperkalemia (choice C) is high potassium levels, which is not consistent with the symptoms described in the question.

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A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?

Select the best answer.

Correct Answer: C. Contact the physician, report the symptoms, and request a blood sample to determine the patient's potassium level.

Explanation:

The correct action for the nurse to take is to contact the physician, report the patient's symptoms, and request a blood sample to determine the patient's potassium level. Furosemide, a potassium-wasting diuretic, can lead to hypokalemia, causing weakness and palpitations. Therefore, checking the potassium level is crucial in this situation. Simply telling the patient to rest more frequently won't address the underlying issue of potassium depletion. While digoxin can cause adverse effects, in this case, the symptoms are more likely related to furosemide-induced potassium loss. Instructing the patient to avoid caffeine-containing foods may be beneficial in general, but it wouldn't directly address the potassium depletion that needs urgent attention.

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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?

Select the best answer.

Correct Answer: B. Hypocalcemia

Explanation:

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The nurse in the intensive care unit receives arterial blood gases (ABG) with a patient who is complaining of being 'short of breath.' The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mmol/L. The labs reflect:

Select the best answer.

Correct Answer: A. Respiratory acidosis

Explanation:

The ABG values indicate respiratory acidosis. A pH below 7.40, a PaCO2 above 40 mm Hg, and a normal HCO3 level (24 mmol/L) suggest respiratory acidosis. In this case, the patient has an acidic pH (7.21) and an elevated PaCO2 (64 mm Hg), indicating inadequate ventilation. The normal HCO3 level suggests that compensation by the kidneys has not occurred, implying an acute event. Choices B, C, and D can be ruled out based on the given ABG values and the criteria for acid-base disorders.

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Place a washcloth between the skin and tourniquet

Select the best answer.

Correct Answer: D. Use a plastic bag to cover the extremity with the device

Explanation:

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A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

Select the best answer.

Correct Answer: A. Encourage oral fluid intake.

Explanation:

The correct answer is to encourage oral fluid intake. With a serum calcium level of 14 mg/dL, the client is at risk of hypercalcemia. Encouraging oral fluid intake helps to promote hydration and can help prevent further elevation of calcium levels. Connecting the client to a cardiac monitor (Choice B) is important but not the first priority in this situation. Assessing urinary output (Choice C) is relevant but does not address the immediate concern of high serum calcium levels. Administering oral calcitonin (Calcimar) (Choice D) may be a treatment option later, but the first step should be to address hydration.

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. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?

Select the best answer.

Correct Answer: D. The clients left lower extremity is cool to the touch.

Explanation:

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Which hormone is made in the pituitary gland and increases water absorption in the kidney?

Select the best answer.

Correct Answer: D. ADH

Explanation:

The correct answer is D, ADH (Antidiuretic hormone). ADH is produced by the pituitary gland and functions to increase water reabsorption in the kidneys. Choices A, B, and C are incorrect as they do not refer to a hormone responsible for increasing water absorption in the kidney.

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A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications

Select the best answer.

Correct Answer: A. Initiate a dedicated team to insert access devices

Explanation:

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A nurse is assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

Select the best answer.

Correct Answer: D. Upper extremity swelling is noted.

Explanation:

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. One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acutecare nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?

Select the best answer.

Correct Answer: C. Help distinguish reduced renal blood flow from decreased renal function

Explanation:

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You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?

Select the best answer.

Correct Answer: D. Metabolic acidosis with a compensatory respiratory alkalosis

Explanation:

A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem. Therefore, the correct interpretation of the arterial blood gas results is metabolic acidosis with a compensatory respiratory alkalosis. Choices A, B, and C are incorrect because they do not accurately reflect the primary acid-base disturbance and the compensatory response seen in the given results.

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What is the main force that pushes fluid in blood capillaries?

Select the best answer.

Correct Answer: A. Blood pressure.

Explanation:

The correct answer is A, blood pressure. Blood pressure is the primary force that pushes fluid out of the capillaries into the surrounding tissues. This pressure difference is essential for the exchange of nutrients, gases, and waste products between the blood and tissues. Choices B, C, and D are incorrect as they do not represent the primary force responsible for pushing fluid in blood capillaries.

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Which of the following organs does not contribute to fluid output from the body?

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Correct Answer: D. Lungs, skin, and intestine

Explanation:

The correct answer is D. All the listed organs (lungs, skin, and intestines) contribute to fluid loss from the body. Lungs contribute to fluid loss through respiration, skin through sweating, and intestines through excretion. Therefore, none of the organs listed in the options retain fluids within the body. Choices A, B, and C are incorrect because all of these organs play a role in fluid output from the body.

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A patient with hypokalemia and heart failure is admitted to the telemetry unit. The nurse is aware that hypokalemia could cause which of the following abnormalities on an electrocardiogram (ECG)?

Select the best answer.

Correct Answer: D. Elevated U wave

Explanation:

The correct answer is D: Elevated U wave. Hypokalemia is associated with ECG changes such as an elevated U wave and flattened T waves. Choice A, a shortened P-R interval, is not typically seen in hypokalemia. Choice B, an inverted T wave, is more commonly associated with ischemia or CNS injury rather than hypokalemia. Choice C, a depressed U wave, is not a typical ECG abnormality seen in hypokalemia. Therefore, the correct ECG abnormality associated with hypokalemia is an elevated U wave.

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Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?

Select the best answer.

Correct Answer: A. Diminished deep tendon reflexes

Explanation:

The correct answer is A: Diminished deep tendon reflexes. In a patient with hypermagnesemia, the nurse would assess for diminished deep tendon reflexes. Hypermagnesemia can lead to neuromuscular depression, causing a decrease in deep tendon reflexes. Tachycardia (choice B) is more commonly associated with hypomagnesemia. Cool clammy skin (choice C) is not typically a direct symptom of hypermagnesemia. While hypermagnesemia does involve increased serum magnesium levels (choice D), assessing serum levels is a laboratory test and not a clinical assessment like checking deep tendon reflexes.

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Which negative ion is most important in intracellular fluid?

Select the best answer.

Correct Answer: D. Phosphate ions and protein molecules.

Explanation:

Intracellular fluid contains phosphate ions and protein molecules as essential anions. Phosphate ions play a crucial role in various cellular processes, including energy transfer. Proteins, being large molecules with negative charges, also contribute significantly to the negative ion concentration within cells. Chlorine is primarily an extracellular anion and is not as prominent as phosphate ions and proteins within intracellular fluid, making it a less important negative ion in this context. Therefore, the correct answer is D because both phosphate ions and protein molecules are crucial negative ions in intracellular fluid.

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You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patient's most recent laboratory reports, you note that the patient's magnesium levels are high. You should prioritize assessment for which of the following health problems?

Select the best answer.

Correct Answer: A. Diminished deep tendon reflexes

Explanation:

Corrected Rationale: To assess a patient's magnesium status, the nurse should check deep tendon reflexes. Diminished deep tendon reflexes may indicate high serum magnesium levels, as hypermagnesemia can lead to neuromuscular effects. Tachycardia, cool clammy skin, and acute flank pain are not typically associated with high magnesium levels and are not priority assessments in this situation.

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The chief mechanism for maintaining fluid balance is to:

Select the best answer.

Correct Answer: C. adjust fluid output so it equals fluid input.

Explanation:

The correct answer is C: 'adjust fluid output so it equals fluid input.' Maintaining fluid balance involves ensuring that the amount of fluid lost through processes like urination, sweating, and respiration equals the amount of fluid taken in. This ensures that the body stays properly hydrated. Choices A, B, and D are incorrect because they do not focus on the balance between fluid input and output, which is crucial for maintaining proper fluid balance. By adjusting fluid output to equal fluid input, the body can regulate hydration levels effectively, preventing dehydration or overhydration.

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A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?

Select the best answer.

Correct Answer: B. . Anxiety-induced hyperventilation

Explanation:

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

Select the best answer.

Correct Answer: D. Teach the client fall prevention measures.

Explanation:

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A nurse in the medical-surgical unit is giving a patient with low blood pressure a hypertonic solution, which will increase the number of dissolved particles in his blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Which of the following terms is associated with this process?

Select the best answer.

Correct Answer: B. Osmosis and osmolality

Explanation:

Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. Giving a patient who has low blood pressure a hypertonic solution will increase the number of dissolved particles in the blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Option A is incorrect; hydrostatic pressure refers to changes in water or volume related to water pressure. Option C is incorrect; diffusion is the movement of solutes from an area of greater concentration to lesser concentration. The solutes in an intact vascular system are unable to move, so diffusion should not normally take place. Option D is incorrect; active transport is the movement of molecules against the concentration gradient and requires ATP as an energy source. This process typically takes place at the cellular level and is not involved in vascular volume changes.

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. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an exam

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Correct Answer: A. Increased rate and depth of respirations

Explanation:

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A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

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Correct Answer: A. Assess clients rate, rhythm, and depth of respiration.

Explanation:

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The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?

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Correct Answer: A. Diffusion

Explanation:

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You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

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Correct Answer: C. Inelastic skin turgor is a normal part of aging

Explanation:

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You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

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Correct Answer: C. Infiltration

Explanation:

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Which mineral is important in hemoglobin production?

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Correct Answer: C. Iron

Explanation:

Iron (Fe) is a critical mineral in hemoglobin production. Hemoglobin is a protein found in red blood cells that is essential for transporting oxygen throughout the body. Sodium (Choice A), Iodine (Choice B), and Chloride (Choice D) are not directly involved in hemoglobin production. Sodium is an electrolyte that helps maintain fluid balance, Iodine is essential for thyroid hormone production, and Chloride is an electrolyte that helps regulate fluid balance and acidity in the body.

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What is the function of aldosterone?

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Correct Answer: C. Increases sodium reabsorption.

Explanation:

Aldosterone increases the reabsorption of sodium in the kidneys, which leads to an increase in blood volume and blood pressure. Choice A is incorrect as aldosterone does not regulate body temperature. Choice B is incorrect as aldosterone increases blood pressure by increasing sodium reabsorption. Choice D is incorrect as aldosterone promotes water retention by increasing sodium reabsorption.

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Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill patient. What health problem typically precedes normal anion gap acidosis?

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Correct Answer: D. Excessive administration of chloride

Explanation:

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Which condition can result from prolonged vomiting or diarrhea?

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Correct Answer: C. Dehydration

Explanation:

The correct answer is C: Dehydration. Prolonged vomiting or diarrhea can lead to significant fluid loss, causing dehydration. Intracellular fluid (choice A) and interstitial fluid (choice B) refer to specific compartments of body fluid and are not conditions resulting from vomiting or diarrhea. Electrolytes (choice D) are minerals that help maintain fluid balance in the body but are not the condition directly resulting from prolonged vomiting or diarrhea.

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A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?

Select the best answer.

Correct Answer: D. Read food labels to determine sodium content.

Explanation:

The correct answer is to read food labels to determine sodium content. The client's sodium level is crucial to monitor as it is on the higher side (144 mEq/L), which can indicate hypernatremia. Excessive sodium intake can lead to fluid retention and other complications. Assessing dietary sodium intake can help the nurse and client make necessary adjustments to prevent further sodium imbalances. Choices A, B, and C are not the priority in this situation as the client's sodium level needs immediate attention to prevent potential complications.

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A nurse in the medical-surgical unit has a newly admitted patient who is oliguric; the acute care nurse practitioner orders a fluid challenge of 100 to 200 mL of normal saline solution over 15 minutes. The nurse is aware this intervention will help:

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Correct Answer: C. Distinguish reduced renal blood flow from decreased renal function

Explanation:

Administering a fluid challenge in oliguric patients helps to distinguish reduced renal blood flow from decreased renal function. This intervention aids in determining whether the oliguria is due to reduced renal blood flow (such as in fluid volume deficit or prerenal azotemia) or decreased renal function (such as in acute tubular necrosis). The response to this challenge can indicate the underlying cause. Choices A, B, and D are incorrect as they do not align with the purpose of a fluid challenge in oliguric patients.

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