a nurse is caring for clients with electrolyte imbalances on a medical surgical unit which clinical manifestations are correctly paired with the cont

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that do not apply.)

A. Hypokalemia Flaccid paralysis with respiratory depression
B. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
C. . Hyponatremia Decreased level of consciousness
D.

Correct answer: B

Rationale:

2. A nurse in the medical-surgical unit is giving a patient with low blood pressure a hypertonic solution, which will increase the number of dissolved particles in his blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Which of the following terms is associated with this process?

A. Hydrostatic pressure
B. Osmosis and osmolality
C. Diffusion
D. Active transport

Correct answer: B

Rationale: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. Giving a patient who has low blood pressure a hypertonic solution will increase the number of dissolved particles in the blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Option A is incorrect; hydrostatic pressure refers to changes in water or volume related to water pressure. Option C is incorrect; diffusion is the movement of solutes from an area of greater concentration to lesser concentration. The solutes in an intact vascular system are unable to move, so diffusion should not normally take place. Option D is incorrect; active transport is the movement of molecules against the concentration gradient and requires ATP as an energy source. This process typically takes place at the cellular level and is not involved in vascular volume changes.

3. . 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:

4. A patient's lab results show a slight decrease in potassium. The physician has declined to treat with drug therapy but has suggested increasing the potassium through diet. Which of the following would be a good source of potassium?

A. Apples
B. Asparagus
C. Carrots
D. Bananas

Correct answer: D

Rationale: Bananas are an excellent source of potassium, making them a good choice to increase potassium levels through diet. While apples, asparagus, and carrots are nutritious, they are not particularly high in potassium compared to bananas. Therefore, choosing bananas would be more effective in increasing the patient's potassium intake.

5. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?

A. Air emboli
B. Phlebitis
C. Infiltration
D. Fluid overload

Correct answer: C

Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the vein's wall. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort, and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli (Choice A) involves air entering the bloodstream. Phlebitis (Choice B) is inflammation of a vein. Fluid overload (Choice D) is an excessive volume of fluid in the circulatory system.