ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. . A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?
- A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
- B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
- C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
- D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.
Correct answer: D
Rationale:
2. What fluid is found in spaces between the cells?
- A. Intracellular fluid
- B. Interstitial fluid
- C. Plasma
- D. Electrolyte
Correct answer: B
Rationale: The correct answer is B, Interstitial fluid. Interstitial fluid is the fluid that surrounds and occupies the spaces between cells, providing them with nutrients and removing waste. Choices A, C, and D are incorrect because intracellular fluid refers to fluid inside cells, plasma refers to the liquid component of blood, and electrolyte refers to substances that dissociate into ions in solution, affecting fluid balance but not specifically found in spaces between cells.
3. While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
- A. Grade 3 phlebitis at IV site
- B. infection at IV site
- C. Thrombosed area at IV site
- D. infiltration at IV site
Correct answer: A
Rationale:
4. 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?
- A. Diarrhea and vomiting for 36 hours
- B. . Anxiety-induced hyperventilation
- C. Chronic obstructive pulmonary disease (COPD)
- D. Diabetic ketoacidosis and emphysema
Correct answer: B
Rationale:
5. A client with a serum potassium of 7.5 mEq/L and cardiovascular changes needs immediate intervention. Which prescription should the nurse implement first?
- A. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
- B. Provide a heart-healthy, low-potassium diet.
- C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
- D. Prepare the client for hemodialysis treatment.
Correct answer: C
Rationale: In a client with a serum potassium level of 7.5 mEq/L and cardiovascular changes, the priority intervention is to lower the potassium level quickly to prevent life-threatening complications like arrhythmias. The correct answer is to prepare to administer dextrose 20% and 10 units of regular insulin IV push. This combination helps shift potassium from the extracellular to the intracellular space, reducing serum potassium levels rapidly. Administering sodium polystyrene sulfate (Kayexalate) by mouth may take several hours to work, making it a less effective immediate intervention. Providing a heart-healthy, low-potassium diet is important for long-term management but is not the most urgent action in this situation. While hemodialysis is a definitive treatment for hyperkalemia, it is not the first-line intervention for acute management of high potassium levels with cardiovascular manifestations.
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