ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. . A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
- A. The catheter has been in place for 20 hours.
- B. . The client has poor vascular access in the upper extremities.
- C. The catheter is placed in the proximal tibia.
- D. The clients left lower extremity is cool to the touch.
Correct answer: The clients left lower extremity is cool to the touch.
Rationale:
2. Which of the following groups of vitamins are fat-soluble?
- A. vitamins B and C
- B. vitamins A and C
- C. vitamins B, E, K, D
- D. vitamins A, E, K, D
Correct answer: D
Rationale: The correct answer is D: vitamins A, E, K, and D. Fat-soluble vitamins are absorbed along with fats in the diet and can be stored in the body's fatty tissue. Vitamins B and C are water-soluble vitamins and are not stored in the body; any excess amounts are usually excreted in the urine. Therefore, choices A, B, and C are incorrect.
3. Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for this patient?
- A. Serum creatinine and BUN
- B. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
- C. Serum amylase and lipase
- D. Cardiac enzymes
Correct answer: C
Rationale: Serum amylase and lipase levels are typically elevated in patients with acute pancreatitis.
4. A client with a new diagnosis of diabetes mellitus needs instruction on foot care. What advice should the nurse provide?
- A. Soak feet in warm water daily
- B. Wear shoes at all times
- C. Cut toenails in a rounded shape
- D. Inspect the feet weekly
Correct answer: B
Rationale: The correct answer is B: 'Wear shoes at all times.' This instruction is crucial for clients with diabetes as it helps protect the feet from potential injuries. Choice A of soaking feet in warm water daily can lead to skin issues and should be avoided. Cutting toenails in a rounded shape, as mentioned in choice C, can increase the risk of ingrown toenails. While inspecting the feet weekly, as in choice D, is important, wearing shoes at all times is a more preventative measure to avoid foot injuries in diabetic clients.
5. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
- A. Evaluate chest expansion.
- B. Check pupillary response to light.
- C. Assess the capillary refill.
- D. Check the client’s response to questions about place and time.
Correct answer: A: Evaluate chest expansion.
Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client’s orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.
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