ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. 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.
2. What is the most abundant positive ion in blood plasma?
- A. Potassium.
- B. Calcium.
- C. Sodium.
- D. Both potassium and sodium are in equal concentrations.
Correct answer: C
Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.
3. After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?
- A. . I dont drink milk because it gives me gas and diarrhea
- B. I have been taking digoxin every day for the last 15 years
- C. . I take sodium bicarbonate after every meal to prevent heartburn
- D. In hot weather, I sweat so much that I drink six glasses of water each day.
Correct answer: C
Rationale:
4. A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
- A. Administer topical lidocaine to the site.
- B. Place warm compresses on the site.
- C. . Administer prescribed oral pain medication.
- D. Massage the site with scented oils.
Correct answer: B
Rationale:
5. What is the fluid inside the cell called?
- A. Plasma
- B. Intracellular fluid
- C. Interstitial fluid
- D. Plasma and intracellular fluid
Correct answer: B
Rationale: The correct answer is 'Intracellular fluid.' Intracellular fluid refers to the fluid contained within the cells, constituting a significant portion of the body's total water content. Choices A, C, and D are incorrect. Plasma is the liquid component of blood outside the cells, interstitial fluid is the fluid surrounding cells in tissues, and the combination of plasma and intracellular fluid is not the specific term for the fluid inside the cell.
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