ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L. Which clinical situation should the nurse correlate with these values?
- A. . Diabetic ketoacidosis in a person with emphysema
- B. Bronchial obstruction related to aspiration of a hot dog
- C. Anxiety-induced hyperventilation in an adolescen
- D. Diarrhea for 36 hours in an older, frail woman
Correct answer: A
Rationale:
2. What happens first in dehydration?
- A. Intercellular fluid volume drops first.
- B. Plasma volume drops first.
- C. Interstitial fluid drops first.
- D. Neither interstitial nor intracellular fluid volume are affected.
Correct answer: C
Rationale: In dehydration, the body first draws fluid from the interstitial space to maintain blood volume, leading to a decrease in interstitial fluid volume. This is why choice C is correct. Choice A is incorrect because intracellular fluid is not the first to be affected. Choice B is also incorrect as plasma volume reduction typically occurs after interstitial fluid loss. Choice D is incorrect as dehydration impacts both interstitial and intracellular fluid volumes.
3. Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?
- A. Diminished deep tendon reflexes
- B. Tachycardia
- C. Cool clammy skin
- D. Increased serum magnesium
Correct answer: A
Rationale: The correct answer is A: Diminished deep tendon reflexes. In a patient with hypermagnesemia, the nurse would assess for diminished deep tendon reflexes. Hypermagnesemia can lead to neuromuscular depression, causing a decrease in deep tendon reflexes. Tachycardia (choice B) is more commonly associated with hypomagnesemia. Cool clammy skin (choice C) is not typically a direct symptom of hypermagnesemia. While hypermagnesemia does involve increased serum magnesium levels (choice D), assessing serum levels is a laboratory test and not a clinical assessment like checking deep tendon reflexes.
4. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?
- A. Agitation
- B. Kussmaul respirations
- C. Seizures
- D. Positive Chvosteks sign
Correct answer: B
Rationale:
5. Place a washcloth between the skin and tourniquet
- A. Provide a bed bath instead of letting the client take a shower
- B. Use sterile technique when changing the dressing.
- C. Disconnect the intravenous fluid tubing prior to the clients bath.
- D. Use a plastic bag to cover the extremity with the device
Correct answer: D
Rationale:
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