ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct answer: Metabolic alkalosis
Rationale:
2. A client has a new prescription for transdermal patches. Which statement should the client make to indicate understanding of the instructions?
- A. I will clean the site with an alcohol swab before applying the patch.
- B. I will rotate the application sites weekly.
- C. I will apply the patch to an area of skin with no hair.
- D. I will place the new patch on the site of the old patch.
Correct answer: C
Rationale: The correct answer is C. Applying the patch to a hairless area of skin is essential for optimal medication absorption. Hair can interfere with the patch's adherence and effectiveness. It is important for the client to choose a site without hair to ensure proper delivery of the medication. Choices A, B, and D are incorrect because cleaning the site with an alcohol swab (Choice A) is a good practice but not the most crucial aspect for transdermal patch application. Rotating application sites weekly (Choice B) is more relevant for injections to prevent skin irritation or breakdown. Placing the new patch on the site of the old patch (Choice D) can lead to skin irritation and poor absorption due to a build-up of medication.
3. The nurse is preparing to assist in examining a Hispanic child who was brought to the clinic by the mother. During the assessment of the child, the nurse should take which action(s)?
- A. Building rapport with the child
- B. Taking the child’s temperature
- C. A, D
- D. Obtaining an interpreter if necessary
Correct answer: C
Rationale: Building rapport with the child is essential to establish trust and cooperation during the assessment. Admiring the child may not be appropriate in a professional setting and might not contribute significantly to the assessment. Taking the child's temperature is a routine part of the assessment but may not be the most critical action in this scenario. Obtaining an interpreter is crucial to ensure effective communication between the healthcare team and the child and their mother, especially considering potential language barriers.
4. Causes of acute renal failure include:
- A. chronic renal failure
- B. uncontrolled diabetes mellitus
- C. recurrent urinary tract infections
- D. severe injury such as extensive burns
Correct answer: D
Rationale: The correct answer is D. Severe injuries, like extensive burns, can cause acute renal failure due to shock, reduced blood flow to the kidneys, and tissue damage. Choices A, B, and C are incorrect because chronic renal failure, uncontrolled diabetes mellitus, and recurrent urinary tract infections are more likely to contribute to chronic kidney disease rather than acute renal failure.
5. An active 28-year-old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy?
- A. Hemoglobin A1C level 6.2%
- B. Blood pressure 146/88 mmHg
- C. Heart rate at rest 58 beats/minute
- D. High-density lipoprotein (HDL) level 65 mg/dL
Correct answer: B
Rationale: The correct answer is B. In a young adult with type 1 diabetes, a blood pressure of 146/88 mmHg may indicate the need for a change in therapy as it is above the recommended target levels. High blood pressure can increase the risk of cardiovascular complications in diabetic patients. Choices A, C, and D are within normal ranges and do not necessarily indicate the need for an immediate change in therapy. A Hemoglobin A1C level of 6.2% is generally considered good control for a diabetic patient, a resting heart rate of 58 beats/minute is normal for an active individual, and an HDL level of 65 mg/dL is considered to be in the desirable range for heart health.
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