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. 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:
3. You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?
- A. Increased serum sodium
- B. Decreased serum potassium
- C. Decreased hemoglobin
- D. Increased platelets
Correct answer: A
Rationale:
4. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Assess the client's dietary intake of foods high in potassium.
- B. Assess the client's neuromuscular status.
- C. Assess the client's fluid intake and output.
- D. Read food labels to determine sodium content.
Correct answer: D
Rationale: The correct answer is to read food labels to determine sodium content. The client's sodium level is crucial to monitor as it is on the higher side (144 mEq/L), which can indicate hypernatremia. Excessive sodium intake can lead to fluid retention and other complications. Assessing dietary sodium intake can help the nurse and client make necessary adjustments to prevent further sodium imbalances. Choices A, B, and C are not the priority in this situation as the client's sodium level needs immediate attention to prevent potential complications.
5. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
- A. Air emboli
- B. Phlebitis
- C. Infiltration
- D. Fluid overload
Correct answer: C
Rationale:
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