ATI RN
ATI Fluid and Electrolytes
1. Which of the following are sources of water intake?
- A. Drinking fluids.
- B. Consuming water from the food we eat.
- C. Water from metabolic processes.
- D. Drinking fluids, consuming water from the food we eat, and water from metabolic processes.
Correct answer: D
Rationale: The correct answer is D. The sources of water intake include drinking fluids, consuming water from the food we eat, and water from metabolic processes. Water intake is not solely from the liquids we drink but also from the water content present in the food we consume and the water produced during metabolic processes such as cellular respiration. Therefore, option D is the correct answer as it covers all the sources of water intake. Options A, B, and C alone do not encompass all the sources of water intake, making them incorrect choices.
2. The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
- B. Observe for swelling of the neck, tracheal deviation, and severe pain.
- C. Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
Correct answer: D
Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. Monitoring for an elevated thyroid-stimulating hormone (choice A) is not relevant in assessing for hypocalcemia. Observing for swelling of the neck, tracheal deviation, and severe pain (choice B) are more related to airway compromise. Evaluating the quality of the patient's voice postoperatively (choice C) is important but not a primary sign of hypocalcemia.
3. . A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?
- A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
- B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
- C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
- D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.
Correct answer: D
Rationale:
4. A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications
- A. Initiate a dedicated team to insert access devices
- B. . Require additional education for all nurses.
- C. Limit the use of peripheral venous access devices.
- D. Perform quality control testing on skin preparation products.
Correct answer: A
Rationale:
5. A patient with diabetes insipidus is admitted to the intensive care unit after a motor vehicle accident that resulted in head trauma and damage to the pituitary gland. Diabetes insipidus can occur when there is a decreased production of which of the following?
- A. ADH
- B. Estrogen
- C. Aldosterone
- D. Renin
Correct answer: A
Rationale: The correct answer is A: ADH. Diabetes insipidus is characterized by a deficiency in antidiuretic hormone (ADH), leading to excessive urine output and thirst. In this scenario, the head trauma and damage to the pituitary gland can result in decreased production or release of ADH. Estrogen (Choice B) is not directly related to diabetes insipidus. Aldosterone (Choice C) is a hormone that regulates sodium and potassium levels, not water balance like ADH. Renin (Choice D) is an enzyme involved in the regulation of blood pressure and fluid balance but not directly related to diabetes insipidus.
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