ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
- A. Administer a sublingual nitroglycerin tablet
- B. Prepare to assist with chest tube insertion.
- C. . Place a sterile dressing over the IV site
- D. Re-position the client into the Trendelenburg position.
Correct answer: B
Rationale:
2. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
- A. Monitor daily hemoglobin and hematocrit values.
- B. Administer furosemide (Lasix) intravenously.
- C. Encourage the client to take deep breaths.
- D. Teach the client fall prevention measures.
Correct answer: D
Rationale:
3. When preparing a site for the insertion of an IV catheter, how should excess hair at the site be treated?
- A. Leaving the hair intact
- B. Shaving the area
- C. Clipping the hair in the area
- D. Removing the hair with a depilatory
Correct answer: C
Rationale: The correct answer is to clip the hair in the area. Excess hair at the site of IV catheter insertion should be removed because it can be a potential source of infection. Clipping the hair is preferred over shaving because shaving can cause skin abrasions, increasing the risk of infection. Using depilatories is not recommended as they can irritate the skin, which is undesirable when preparing a clean site for an invasive procedure. Therefore, clipping the hair in the area is the most appropriate and safe method to prepare the site for IV catheter insertion.
4. Which positive ion is most prevalent in intracellular fluid?
- A. Calcium
- B. Potassium
- C. Sodium
- D. Magnesium
Correct answer: B
Rationale: The correct answer is Potassium (K+). Potassium is the predominant cation found within cells, making it the most prevalent positive ion in intracellular fluid. Calcium, sodium, and magnesium are also essential ions in the body, but they are not as abundant in intracellular fluid. Calcium is vital for bone health and muscle function, sodium helps in maintaining fluid balance and nerve function, and magnesium is involved in numerous biochemical reactions.
5. 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:
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