ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?
- A. Endocarditis
- B. Multiple myeloma
- C. Guillain-Barr syndrome
- D. Overdose of amphetamines
Correct answer: C
Rationale:
2. You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?
- A. Hypertension
- B. Kussmaul respirations
- C. Increased DTRs
- D. Shallow respirations
Correct answer: D
Rationale:
3. A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?
- A. Potatoes and avocados can be substituted for fruit.
- B. If you cook the fruit, the amount of potassium will be lower.
- C. Berries, cherries, apples, and peaches are low in potassium.
- D. You are correct. Fruit is very high in potassium.
Correct answer: C
Rationale: The correct answer is C. Berries, cherries, apples, and peaches are indeed low in potassium, making them suitable choices for someone at risk for hyperkalemia. Choice A is incorrect because potatoes and avocados are high in potassium and should be avoided in this situation. Choice B is incorrect because cooking fruit does not significantly lower its potassium content. Choice D is incorrect as it provides incorrect information, as not all fruits are very high in potassium.
4. After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?
- A. Toasted English muffin with butter and blueberry jam, and tea with sugar
- B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
- C. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
- D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
Correct answer: C
Rationale: Choice C is the correct answer as it includes foods high in potassium, such as raisins, whole wheat toast, and milk. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. Choices A, B, and D do not contain significant sources of potassium. Choice A consists mainly of carbohydrates and sugar, choice B focuses on protein and carbohydrates, and choice D provides carbohydrates and some fruit but lacks high-potassium options like in choice C.
5. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
- A. Encourage oral fluid intake.
- B. Connect the client to a cardiac monitor.
- C. Assess urinary output.
- D. Administer oral calcitonin (Calcimar).
Correct answer: A
Rationale: The correct answer is to encourage oral fluid intake. With a serum calcium level of 14 mg/dL, the client is at risk of hypercalcemia. Encouraging oral fluid intake helps to promote hydration and can help prevent further elevation of calcium levels. Connecting the client to a cardiac monitor (Choice B) is important but not the first priority in this situation. Assessing urinary output (Choice C) is relevant but does not address the immediate concern of high serum calcium levels. Administering oral calcitonin (Calcimar) (Choice D) may be a treatment option later, but the first step should be to address hydration.
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