a patient is in the hospital with heart failure the nurse notes during the evening assessment that the patients neck veins are distended and the patie

ATI RN

Fluid and Electrolytes ATI

1. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?

A. Place the patient in low Fowler's position and notify the physician.
B. Increase the patient's IV fluid and auscultate the lungs.
C. Place the patient in semi-Fowler's position and prepare to give the PRN diuretic as ordered.
D. Discontinue the patient's IV.

Correct answer: C

Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.

2. What is the function of aldosterone?

A. Regulates body temperature.
B. Decreases blood pressure.
C. Increases sodium reabsorption.
D. Promotes water excretion.

Correct answer: C

Rationale: Aldosterone increases the reabsorption of sodium in the kidneys, which leads to an increase in blood volume and blood pressure. Choice A is incorrect as aldosterone does not regulate body temperature. Choice B is incorrect as aldosterone increases blood pressure by increasing sodium reabsorption. Choice D is incorrect as aldosterone promotes water retention by increasing sodium reabsorption.

3. A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?

A. The patients calcium will rise dramatically due to pituitary stimulation.
B. Oxygen will increase the patients intracranial pressure and create confusion.
C. Oxygen may cause the patient to hyperventilate and become acidotic.
D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.

Correct answer: D

Rationale:

4. Under normal circumstances, the kidneys provide the greatest means of water loss. Which organ provides the second greatest means of water loss?

A. Skin
B. Lungs
C. Intestines
D. Muscles

Correct answer: A

Rationale: The correct answer is A: Skin. After the kidneys, the skin is the second largest route of water loss through perspiration. Choice B, Lungs, is incorrect as the lungs primarily exchange gases and do not play a significant role in water loss. Choice C, Intestines, is also incorrect as water loss through the intestines is minimal since most water is reabsorbed during digestion. Choice D, Muscles, is incorrect as muscles are not a major source of water loss in the body.