ATI RN
ATI Fluid and Electrolytes
1. What is the most abundant positive ion in blood plasma?
- A. Potassium.
- B. Calcium.
- C. Sodium.
- D. Both potassium and sodium are in equal concentrations.
Correct answer: C
Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.
2. You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
- A. Air emboli
- B. Phlebitis
- C. Infiltration
- D. Fluid overload
Correct answer: C
Rationale:
3. A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?
- A. Tell the patient to rest more often.
- B. Tell the patient to stop taking the digoxin and call the physician.
- C. Call the physician, report the symptoms, and request to draw a blood sample to determine the patient's potassium level.
- D. Tell the patient to avoid foods that contain caffeine.
Correct answer: C
Rationale: The correct action for the nurse to take is to call the physician, report the symptoms, and request to draw a blood sample to determine the patient's potassium level. Furosemide is a potassium-wasting diuretic, and low potassium levels can lead to weakness and palpitations. Resting more often won't address the underlying issue of hypokalemia caused by furosemide. While digoxin can have side effects, it is not causing the symptoms described by the patient. Avoiding caffeine may be beneficial, but addressing the potassium level is more critical in this situation.
4. The healthcare professional working in the PACU is aware that which of the following procedures may contribute to extracellular losses?
- A. Removal of an ingrown toenail
- B. Tooth extraction
- C. Abdominal surgery
- D. Cataract surgery
Correct answer: C
Rationale: Fluid loss from the extracellular compartment can be caused by abdominal surgery as it involves opening the abdominal cavity, potentially leading to significant fluid losses. Choices A, B, and D do not typically result in substantial extracellular losses compared to abdominal surgery.
5. A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:
- A. Neuromuscular function
- B. Bowel sounds
- C. Respiratory rate
- D. Electrocardiogram (ECG) results
Correct answer: D
Rationale: In a patient with a serum potassium level of 6 mEq/L due to spironolactone use, the nurse's priority is to assess the Electrocardiogram (ECG) results. Hyperkalemia can lead to life-threatening arrhythmias, such as ventricular fibrillation, which can be detected on an ECG. While changes in neuromuscular function, bowel sounds, and respiratory rate can occur with hyperkalemia, the most critical assessment related to the patient's condition would be monitoring the ECG for signs of cardiac complications.
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