ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?
- A. Leave the hair intact
- B. Shave the area.
- C. Clip the hair in the area.
- D. Remove the hair with a depilatory.
Correct answer: C
Rationale:
2. You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?
- A. Respiratory acidosis with no compensation
- B. Metabolic alkalosis with a compensatory alkalosis
- C. Metabolic acidosis with no compensation
- D. Metabolic acidosis with a compensatory respiratory alkalosis
Correct answer: D
Rationale: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate more closely corresponds with a decrease in pH, making the metabolic component the primary problem. Therefore, the correct interpretation of the arterial blood gas results is metabolic acidosis with a compensatory respiratory alkalosis. Choices A, B, and C are incorrect because they do not accurately reflect the primary acid-base disturbance and the compensatory response seen in the given results.
3. A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
- A. Administer topical lidocaine to the site.
- B. Place warm compresses on the site.
- C. . Administer prescribed oral pain medication.
- D. Massage the site with scented oils.
Correct answer: B
Rationale:
4. What can cause dehydration?
- A. Prolonged vomiting.
- B. Prolonged diarrhea.
- C. Too little fluid intake.
- D. Prolonged vomiting, diarrhea, and too little fluid intake.
Correct answer: D
Rationale: Dehydration can result from significant fluid loss due to vomiting, diarrhea, or inadequate fluid intake. Prolonged vomiting and diarrhea lead to excessive fluid loss from the body, contributing to dehydration. Similarly, not consuming enough fluids can also result in dehydration. Choice A and B are too specific as they only mention one cause each, while choice C is also correct but does not encompass all the potential causes of dehydration as mentioned in choice D.
5. The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate?
- A. Hypermagnesemia
- B. Hypomagnesemia
- C. Hypocalcemia
- D. Hyperkalemia
Correct answer: C
Rationale: Chvostek's sign is characterized by a brief contraction of the upper lip, nose, or side of the face and is indicative of hypocalcemia, making choice C the correct answer. Hypomagnesemia (choice B) is associated with Trousseau's sign, not Chvostek's sign. Hypermagnesemia (choice A) is not related to Chvostek's sign. Hyperkalemia (choice D) is not typically associated with Chvostek's sign; instead, it may present with muscle weakness and cardiac arrhythmias.
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