ATI RN
Fluid and Electrolytes ATI
1. What electrolyte value should be monitored when a patient is receiving a loop diuretic?
- A. Calcium levels
- B. Phosphorus levels
- C. Potassium levels
- D. Magnesium levels
Correct answer: C
Rationale: 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.
2. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?
- A. Place the patient in low Fowler's position and notify the physician.
- B. Increase the patient's IV fluid and auscultate the lungs.
- C. Place the patient in semi-Fowler's position and prepare to give the PRN diuretic as ordered.
- D. Discontinue the patient's IV.
Correct answer: C
Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.
3. 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.
4. The nurse is caring for a patient who is diaphoretic from a fever. The amount of sodium excreted in the urine will:
- A. Decrease
- B. Increase
- C. Remain unchanged
- D. Fluctuate
Correct answer: A
Rationale: 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.
5. What would be the best initial nursing action prior to inserting an IV?
- A. Instruct the patient to wash their hands.
- B. Prepare the IV insertion site with povidone iodine.
- C. Verify the order for IV therapy.
- D. Identify a suitable vein.
Correct answer: C
Rationale: The best initial nursing action prior to inserting an IV is to verify the order for IV therapy. This step ensures that the IV insertion is appropriate and necessary based on the physician's orders. Instructing the patient to wash their hands (Choice A) is important for infection control but not the immediate priority before IV insertion. While preparing the IV insertion site with povidone iodine (Choice B) and identifying a suitable vein (Choice D) are crucial steps in the process, confirming the order for IV therapy (Choice C) takes precedence to ensure the correct intervention is being performed.
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