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: Place a washcloth between the skin and tourniquet
Rationale:
2. A healthcare provider reviews the laboratory data for an older patient. The healthcare provider would be most concerned about which finding?
- A. Hematocrit of 35%
- B. Hemoglobin of 11.8 g/dL
- C. Platelet count of 400,000/μL
- D. White blood cell (WBC) count of 2800/μL
Correct answer: D
Rationale: A low white blood cell (WBC) count in an older patient is concerning as it indicates a potential compromise in the patient's immune function. White blood cells are crucial for fighting infections and a low count could lead to an increased risk of infections. Hematocrit, hemoglobin, and platelet count are important parameters to assess, but a low WBC count takes priority in this case due to its direct impact on immune health.
3. A client has a nasogastric tube for gastric decompression. Which of the following actions should the nurse take?
- A. Check for the presence of bowel sounds every 8 hours.
- B. Flush the NG tube every 24 hours.
- C. Provide the client with sips of water every 2 hours.
- D. Keep the client's head of the bed elevated to 45 degrees.
Correct answer: D
Rationale: The correct answer is to keep the client's head of the bed elevated to 45 degrees. This position helps prevent aspiration in clients with a nasogastric tube for gastric decompression by reducing the risk of reflux and promoting proper drainage. Choice A is incorrect because checking for bowel sounds is not directly related to the care of a nasogastric tube. Choice B is incorrect as flushing the NG tube every 24 hours is not a standard nursing practice and may lead to complications. Choice C is incorrect because providing sips of water may interfere with the purpose of gastric decompression, which is to keep the stomach empty.
4. How many diet-related major risk factors for coronary heart disease does Mrs. Winslow have?
- A. 1
- B. 4
- C. 2
- D. 3
Correct answer: B
Rationale: Mrs. Winslow has four major diet-related risk factors for coronary heart disease: high total cholesterol, high LDL cholesterol, high triglycerides, and low HDL cholesterol. Choice A is incorrect because there are more than one risk factor present. Choices C and D are incorrect as they do not account for the total number of diet-related major risk factors identified.
5. The client is discussing sources of carbohydrates with a nurse recently diagnosed with diabetes. Which food(s) identified by the client indicate understanding? (SATA)
- A. Starch
- B. Fiber
- C. Sugar
- D. All of the above
Correct answer: D
Rationale: The correct answer is D because starch, fiber, and sugar are all sources of carbohydrates. Starchy foods like bread, rice, and potatoes contain starch; fruits, vegetables, and whole grains provide fiber; and sugars are found in sweet foods like fruits, honey, and desserts. Fatty acids and amino acids are not sources of carbohydrates, so choices A, B, and C are correct while choices A and B are incorrect.
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