ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Assess the client's dietary intake of foods high in potassium.
- B. Assess the client's neuromuscular status.
- C. Assess the client's fluid intake and output.
- D. Read food labels to determine sodium content.
Correct answer: Read food labels to determine sodium content.
Rationale: The correct answer is to read food labels to determine sodium content. The client's sodium level is crucial to monitor as it is on the higher side (144 mEq/L), which can indicate hypernatremia. Excessive sodium intake can lead to fluid retention and other complications. Assessing dietary sodium intake can help the nurse and client make necessary adjustments to prevent further sodium imbalances. Choices A, B, and C are not the priority in this situation as the client's sodium level needs immediate attention to prevent potential complications.
2. When planning care for a client with ulcerative colitis who is experiencing symptoms, which client care activities can the nurse appropriately delegate to a unlicensed assistant?
- A. Assessing the client’s bowel sounds
- B. Providing skin care following bowel movements
- C. Evaluating the client’s response to antidiarrheal medications
- D. Maintaining intake and output records
Correct answer: B, D, E
Rationale: Delegating tasks such as providing skin care, maintaining intake and output records, and obtaining the client's weight are within the scope of practice for an unlicensed assistant. Assessing bowel sounds and evaluating the response to medications require nursing judgment and should not be delegated.
3. A client is in a seclusion room following violent behavior and continues to display aggressive behavior. What action should the nurse take?
- A. Confront the client about this behavior.
- B. Express sympathy for the client's situation.
- C. Speak assertively to the client.
- D. Stand within 30 cm (1 ft) of the client when speaking with them.
Correct answer: Confront the client about this behavior.
Rationale: When a client in a seclusion room following violent behavior continues to display aggression, it is essential for the nurse to confront the client about this behavior. Confrontation can help set boundaries, address the behavior, and ensure the safety of both the client and the healthcare team. Expressing sympathy (Choice B) may not address the immediate need for behavior management. Speaking assertively (Choice C) can be important but should be coupled with addressing the specific behavior. Standing within close proximity (Choice D) of an aggressive client can escalate the situation and compromise safety, so it is not the appropriate action to take.
4. A healthcare professional is assessing a client with suspected substance use disorder. Which of the following findings should the healthcare professional not expect?
- A. Neglect of responsibilities
- B. Increased tolerance to the substance
- C. Withdrawal symptoms when not using the substance
- D. Unsuccessful attempts to cut down or control use
Correct answer: B
Rationale: Findings in a client with substance use disorder typically include neglect of responsibilities, withdrawal symptoms when not using the substance, and unsuccessful attempts to cut down or control use. Increased tolerance to the substance is a common phenomenon in substance use disorder and is expected as the individual requires higher doses to achieve the same effect.
5. A client in active labor has ruptured membranes. What action should the nurse take?
- A. Apply a fetal heart rate monitor.
- B. Initiate fundal massage.
- C. Administer oxytocin IV.
- D. Insert an indwelling urinary catheter.
Correct answer: A
Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.
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