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. The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation is the most common cause of acute respiratory alkalosis. When a patient hyperventilates due to anxiety or other causes, they blow off excessive carbon dioxide, leading to a decrease in PaCO2 and a rise in pH. Choices A, C, and D are incorrect because hyperventilation leads to a decrease in PaCO2, causing respiratory alkalosis, not respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

3. Which organ has the greatest effect on fluid output?

A. Kidneys
B. Lungs
C. Skin
D. Intestines

Correct answer: A

Rationale: The correct answer is the kidneys. The kidneys are primarily responsible for regulating fluid balance by filtering blood and adjusting the volume and concentration of urine. The lungs primarily regulate gas exchange, not fluid balance. The skin plays a role in temperature regulation and protection but is not the primary organ for fluid output. The intestines are mainly involved in the absorption of nutrients and water, rather than fluid output.

4. What is the main force that pushes fluid in blood capillaries?

A. Blood pressure.
B. Sodium in the blood plasma.
C. Sodium in the interstitial fluid.
D. Protein in the blood plasma.

Correct answer: A

Rationale: The correct answer is A, blood pressure. Blood pressure is the primary force that pushes fluid out of the capillaries into the surrounding tissues. This pressure difference is essential for the exchange of nutrients, gases, and waste products between the blood and tissues. Choices B, C, and D are incorrect as they do not represent the primary force responsible for pushing fluid in blood capillaries.

5. A nurse sees a variety of patients in the community health clinic. Which of the following patients would be at the greatest risk of dehydration?

A. An 18-year-old basketball player with a stress fracture of the right foot
B. An infant with diarrhea
C. A 45-year-old with stomach flu
D. An elderly patient living alone

Correct answer: B

Rationale: The correct answer is B. Infants are particularly vulnerable to dehydration due to diarrhea because they have a higher fluid turnover and less reserve. Option A, the 18-year-old basketball player with a stress fracture, is less likely to be at the greatest risk of dehydration compared to an infant with diarrhea. Option C, the 45-year-old with stomach flu, may experience dehydration but is not at the same level of risk as an infant with diarrhea. Option D, the elderly patient living alone, could be at risk of dehydration, but infants with diarrhea are at the greatest risk due to their unique physiological characteristics.