ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?
- A. Furosemide (Lasix) 40 mg intravenous push
- B. Sodium bicarbonate 100 mEq diluted in 1 L of D5W
- C. Mechanical ventilation
- D. Indwelling urinary catheter
Correct answer: Sodium bicarbonate 100 mEq diluted in 1 L of D5W
Rationale:
2. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include?
- A. Use a professional interpreter service
- B. Nurse to interpret
- C. Provide translation services for a nominal fee to clients
- D. Evaluate the clients' understanding at regular intervals
Correct answer: B: Nurse to interpret
Rationale: In situations where there is a language barrier between healthcare providers and patients, it is essential to ensure accurate communication. Using professional interpreter services is the most appropriate choice to ensure clear and precise communication. Relying on the client's children for interpretation may not guarantee accurate or confidential communication. Asking the nurse to interpret can lead to miscommunication or misunderstanding of important medical information. Providing translation services for a nominal fee to clients may not always be feasible or culturally appropriate. Regularly evaluating the client's understanding helps ensure that information is effectively communicated and comprehended.
3. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?
- A. Air emboli
- B. Phlebitis
- C. Infiltration
- D. Fluid overload
Correct answer: C
Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the vein's wall. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort, and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli (Choice A) involves air entering the bloodstream. Phlebitis (Choice B) is inflammation of a vein. Fluid overload (Choice D) is an excessive volume of fluid in the circulatory system.
4. A nurse is planning care for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include?
- A. Encourage the client to take deep breaths.
- B. Administer oxygen as needed.
- C. Teach the client pursed-lip breathing.
- D. Limit the client's fluid intake.
Correct answer: C
Rationale: The correct intervention for a client with COPD is to teach pursed-lip breathing. This technique helps improve oxygenation and reduce dyspnea by promoting better air exchange in the lungs. Encouraging deep breaths may not be suitable for clients with COPD as it can lead to air trapping. Administering oxygen is important in COPD, but teaching pursed-lip breathing is a more direct intervention to help the client manage their condition. Limiting fluid intake is not a standard intervention for COPD and may not be relevant to improving respiratory status.
5. A client who had coronary artery bypass grafting yesterday needs care. What actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (SATA)
- A. Assist the client to the chair for meals and to the bathroom.
- B. Encourage the client to use the spirometer every 4 hours.
- C. Ensure the client wears TED hose or sequential compression devices.
- D. Have the client rate pain on a 0-to-10 scale and report to the nurse.
Correct answer: A, C
Rationale: The nurse can delegate tasks such as assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs to the unlicensed assistive personnel (UAP). Using the spirometer should be encouraged every hour the day after surgery by the nurse. Assessing pain using a 0-to-10 scale is a nursing assessment. However, if the client reports pain, the UAP should inform the nurse for a more detailed assessment.
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