a nurse admitting a patient with a history of emphysema reviews her past lab reports and notes that the patients paco2 has been 56 to 64 mmhg the nurs
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Nursing Elites

ATI RN

Fluid and Electrolytes ATI

1. A nurse admitting a patient with a history of emphysema reviews her past lab reports and notes that the patient's PaCO2 has been 56 to 64 mmHg. The nurse will be cautious administering oxygen because:

Correct answer: D

Rationale: When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. Choice A is incorrect because administering oxygen does not lead to a dramatic rise in calcium due to pituitary stimulation. Choice B is incorrect because administering oxygen does not directly increase intracranial pressure or create confusion. Choice C is incorrect because administering oxygen to a patient with emphysema and high PaCO2 levels is more likely to cause respiratory depression than hyperventilation and acidosis.

2. While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

Correct answer: A

Rationale:

3. A patient who is in renal failure partially loses the ability to regulate changes in pH because the kidneys:

Correct answer: C

Rationale: The correct answer is C. In renal failure, the kidneys lose the ability to regulate pH by controlling bicarbonate levels in the extracellular fluid (ECF). The kidneys can regenerate and reabsorb bicarbonate ions to maintain a stable pH. Choices A, B, and D are incorrect because the kidneys do not primarily regulate or reabsorb carbonic acid, buffer acids through electrolyte changes, or combine carbonic acid and bicarbonate to maintain pH. The key function of the kidneys in maintaining pH balance lies in the control of bicarbonate levels.

4. When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?

Correct answer: D

Rationale:

5. When preparing a site for the insertion of an IV catheter, how should excess hair at the site be treated?

Correct answer: C

Rationale: The correct answer is to clip the hair in the area. Excess hair at the site of IV catheter insertion should be removed because it can be a potential source of infection. Clipping the hair is preferred over shaving because shaving can cause skin abrasions, increasing the risk of infection. Using depilatories is not recommended as they can irritate the skin, which is undesirable when preparing a clean site for an invasive procedure. Therefore, clipping the hair in the area is the most appropriate and safe method to prepare the site for IV catheter insertion.

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