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
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. 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.)

Correct answer: C

Rationale:

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

Correct answer: C

Rationale: 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.

3. 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

Correct answer: A

Rationale:

4. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation, which can be caused by extreme anxiety, is the most common cause of acute respiratory alkalosis. This leads to a decrease in PaCO2 levels. Respiratory acidosis, choice A, occurs in conditions like hypoventilation, leading to an increase in PaCO2 levels. Choice C, Increased PaCO2, is not the correct term for an acid-base imbalance related to hyperventilation. Choice D, CNS disturbances, is not directly related to the acid-base imbalance caused by hyperventilation.

5. 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?

Correct answer: C

Rationale:

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