a nurse in the medical surgical unit has a newly admitted patient who is oliguric the acute care nurse practitioner orders a fluid challenge of 100 to

ATI RN

Fluid and Electrolytes ATI

1. A nurse in the medical-surgical unit has a newly admitted patient who is oliguric; the acute care nurse practitioner orders a fluid challenge of 100 to 200 mL of normal saline solution over 15 minutes. The nurse is aware this intervention will help:

A. Distinguish hyponatremia from hypernatremia
B. Evaluate pituitary gland function
C. Distinguish reduced renal blood flow from decreased renal function
D. Provide an effective treatment for hypertension-induced oliguria

Correct answer: C

Rationale: Administering a fluid challenge in oliguric patients helps to distinguish reduced renal blood flow from decreased renal function. This intervention aids in determining whether the oliguria is due to reduced renal blood flow (such as in fluid volume deficit or prerenal azotemia) or decreased renal function (such as in acute tubular necrosis). The response to this challenge can indicate the underlying cause. Choices A, B, and D are incorrect as they do not align with the purpose of a fluid challenge in oliguric patients.

2. 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.

3. A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right uppe

A. Notify the health care provider
B. . Administer the prescribed medication.
C. Discontinue the PICC
D. Switch the medication to the oral route

Correct answer: B

Rationale:

4. 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.

5. Your patient has alcoholism, and you may suspect during your assessment that his serum magnesium is low. What will the nurse potentially expect to assess related to hypomagnesemia?

A. Tremor
B. Pruritus
C. Edema
D. Decreased blood pressure

Correct answer: A

Rationale: The correct answer is A: Tremor. Signs and symptoms of hypomagnesemia primarily affect the neuromuscular system and can include tremors, confusion, tetany, laryngeal stridor, and ataxia. Pruritus (choice B) refers to itching and is not typically associated with hypomagnesemia. Edema (choice C) is swelling caused by fluid retention and is not a common manifestation of hypomagnesemia. Decreased blood pressure (choice D) is not a typical sign of hypomagnesemia; instead, low magnesium levels are more likely to cause hypertension.