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. Which substance dissociates into ions in a water solution?

A. Intracellular fluid
B. Interstitial fluid
C. Plasma
D. Electrolyte

Correct answer: D

Rationale: The correct answer is 'Electrolyte.' Electrolytes are substances that dissociate into ions when dissolved in water. Intracellular fluid, interstitial fluid, and plasma are not substances that dissociate into ions in a water solution. Intracellular fluid is the fluid inside cells, interstitial fluid is the fluid between cells, and plasma is the liquid component of blood. These choices do not dissociate into ions in a water solution, unlike electrolytes.

3. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values?

A. . Diabetic ketoacidosis in a person with emphysema
B. Bronchial obstruction related to aspiration of a hot dog
C. Anxiety-induced hyperventilation in an adolescen
D. Diarrhea for 36 hours in an older, frail woman

Correct answer: A

Rationale:

4. 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:

5. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health?

A. Nutritional status
B. Potassium balance
C. Calcium balance
D. Fluid volume status

Correct answer: D

Rationale: Assessing the specific gravity in a patient with SIADH helps the nurse evaluate the patient's fluid volume status. Specific gravity indicates the concentration of solutes in the urine and can detect if the patient has a fluid volume deficit or excess. Nutritional status, potassium balance, and calcium balance are not directly assessed through specific gravity testing. Nutritional status is typically evaluated through dietary intake and anthropometric measurements. Potassium balance is assessed through blood tests and ECG monitoring. Calcium balance is evaluated through blood tests and bone density scans. Therefore, the correct answer is assessing fluid volume status through specific gravity testing.