1a nurse prepares to insert a peripheral venous catheter in an older adult client which action should the nurse take to protect the clients skin durin

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. 1.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?

A. Lower the extremity below the level of the heart.
B. Apply warm compresses to the extremity.
C. Tap the skin lightly and avoid slapping.
D. Place a washcloth between the skin and tourniquet

Correct answer: D

Rationale:

2. You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly?

A. Patients receiving TPN are at risk for hypercalcemia if calories are started too rapidly.
B. Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively.
C. Malnourished patients who receive fluids too rapidly are at risk for hypernatremia.
D. Patients receiving TPN need a slow initiation of treatment in order to allow digestive enzymes to accumulate

Correct answer: B

Rationale:

3. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

A. Choose a hairless site if available.
B. Consider potential effects on the patients mobility when selecting a site.
C. Have the patient briefly hold his arm over his head before insertion
D. Leave the tourniquet on for at least 3 minutes.

Correct answer: B

Rationale:

4. A 73-year-old man who slipped on a small carpet in his home and fell on his hip is alert and oriented; PERRLA (pupils equally round and reactive to light and accommodation) is intact, and he has come by ambulance to the emergency department (ED). Heart rate elevated, he is anxious and thirsty. A Foley catheter is in place and 40mL of urine is present. The nurse's most likely explanation for the urine output is:

A. The man urinated prior to his arrival in the ED and will probably not need to have the Foley catheter kept in place.
B. The man has a brain injury, lacks ADH, and needs vasopressin.
C. The man is in heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output.
D. He is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.

Correct answer: D

Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely cause of the lower urine output. Choices A, B, and C are incorrect because there is no indication of urination prior to arrival, brain injury, lack of ADH, or heart failure present in the scenario provided. The symptoms and context described point more towards a physiological response related to the sympathetic nervous system and the renin-angiotensin-aldosterone system rather than the other conditions mentioned.

5. Which negative ion is most abundant in blood plasma?

A. Bicarbonate
B. Chloride
C. Hydroxide
D. Phosphate

Correct answer: B

Rationale: Chloride (Cl-) is the most abundant anion in blood plasma. It plays a crucial role in maintaining osmotic balance and acid-base homeostasis. Bicarbonate (Choice A) is important for buffering acids in the body but is not the most abundant negative ion in blood plasma. Hydroxide (Choice C) is not typically found in high concentrations in blood plasma. Phosphate (Choice D) is an important anion in the body but is not as abundant as chloride in blood plasma.