ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?
- A. I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup
- B. Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.
- C. It is normal to be a little confused following surgery, and it is safe not to urinate at night.
- D. If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.
Correct answer: Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.
Rationale:
2. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include?
- A. Stay in bed for at least 1 hour if unable to fall asleep.
- B. Take a 1-hour nap during the day.
- C. Perform exercise before bed.
- D. Eat a light snack before bedtime.
Correct answer: D
Rationale: The correct answer is to eat a light snack before bedtime. Consuming a light snack can help promote sleep by preventing discomfort from hunger. Choice A is incorrect because staying in bed for too long when unable to fall asleep can lead to frustration and worsen insomnia. Choice B is incorrect as taking a nap during the day can interfere with nighttime sleep. Choice C is incorrect as exercising before bed can increase alertness and make falling asleep more difficult.
3. Which of the following is not a symptom of a panic attack?
- A. Chest pain
- B. Shortness of breath
- C. Dizziness
- D. Hot flashes
Correct answer: A
Rationale: Symptoms of a panic attack include shortness of breath, dizziness, and hot flashes. Chest pain is not a common symptom of a panic attack but can be present in some cases. Euphoria is not typically associated with panic attacks.
4. 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: Prepare to assist with chest tube insertion.
Rationale:
5. Why is a precise amount of oxygen necessary for a patient with COPD to prevent which complication?
- A. Cardiac arrest related to increased partial pressure of carbon dioxide in arterial blood (PaCO2)
- B. Circulatory overload due to hypervolemia
- C. Respiratory excitement
- D. Inhibition of the respiratory hypoxic stimulus
Correct answer: D
Rationale: In patients with COPD, the respiratory drive is often stimulated by low oxygen levels. Administering too much oxygen can inhibit this hypoxic drive, leading to respiratory depression and potential respiratory failure. Therefore, it is crucial to carefully regulate the oxygen therapy to prevent the inhibition of the respiratory hypoxic stimulus in COPD patients.
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