ATI RN
Fluid and Electrolytes ATI
1. The nurse is caring for a patient who is diaphoretic from a fever. The amount of sodium excreted in the urine will:
- A. Decrease
- B. Increase
- C. Remain unchanged
- D. Fluctuate
Correct answer: A
Rationale: Increased sweating (diaphoresis) causes the loss of sodium and other electrolytes from the body. As a result, the body tries to conserve sodium, leading to a decrease in the amount of sodium excreted in the urine. Choice B is incorrect because increased sweating results in sodium loss, not retention. Choice C is incorrect because with increased sweating, there is a need to conserve sodium, leading to a decrease in its excretion. Choice D is incorrect as there is a clear physiological response to sweating that results in a more consistent decrease in sodium excretion.
2. You are preparing a patient for surgery and completing the preoperative checklist. Which of the following is not typically part of the preoperative checklist?
- A. Assessing for allergies
- B. Conducting the Time Out
- C. Ensuring that informed consent is signed
- D. Ensuring that the history and physical examination have been completed
Correct answer: B: Conducting the Time Out
Rationale: Conducting the Time Out is a crucial safety step that occurs immediately before the start of the procedure, but it is not usually part of the preoperative checklist. The Time Out involves verifying patient identity, correct procedure, correct site, and addressing any concerns or questions with the surgical team before proceeding. The other options, such as assessing for allergies, ensuring informed consent, and completing the history and physical examination, are typically included in the preoperative checklist to ensure patient safety and readiness for surgery.
3. Which of the following statements characterizes irritable bowel syndrome?
- A. Typically does not cause anemia
- B. Not generally associated with intestinal E. coli
- C. Can be associated with anxiety and/or depression
- D. Not often associated with bloody diarrhea
Correct answer: C
Rationale: Irritable bowel syndrome (IBS) is a gastrointestinal disorder characterized by abdominal pain, bloating, and changes in bowel habits. While IBS can lead to symptoms like diarrhea or constipation, it typically does not cause anemia (choice A), is not generally associated with intestinal E. coli (choice B), and is not often associated with bloody diarrhea (choice D). However, IBS can indeed be associated with anxiety and/or depression (choice C) due to the gut-brain axis, a bidirectional communication system between the gut and the brain. This association is well-documented in IBS patients, highlighting the importance of considering psychological factors in managing the condition.
4. A client is receiving opioid analgesics for pain management. Which of the following assessments is the priority?
- A. Monitor the client's blood pressure.
- B. Check the client's urinary output.
- C. Monitor the client's respiratory rate.
- D. Assess the client's pain level.
Correct answer: C
Rationale: The correct answer is C: Monitor the client's respiratory rate. When a client is receiving opioid analgesics, the priority assessment is monitoring respiratory rate. Opioids can cause respiratory depression, so it is crucial to assess the client's breathing to detect any signs of respiratory distress promptly. Checking the client's blood pressure (Choice A) and urinary output (Choice B) are important assessments too, but they are not the priority when compared to ensuring adequate respiratory function. Assessing the client's pain level (Choice D) is essential for overall care but is not the priority assessment when the client is on opioids, as respiratory status takes precedence.
5. A patient is being cared for by a nurse who has stomatitis following radiation treatment. Which of the following is an appropriate intervention for the nurse to take?
- A. Serve foods without sauces or gravies
- B. Offer mouth rinses with normal saline and water
- C. Serve foods while still at a hot temperature
- D. Instruct the client to drink liquids without a straw
Correct answer: B
Rationale: Offering mouth rinses with normal saline and water is an appropriate intervention for a nurse caring for a patient with stomatitis following radiation treatment. This intervention can help soothe and clean the mouth, promoting comfort and oral hygiene. Choice A is incorrect because serving foods without sauces or gravies does not directly address the client's stomatitis. Choice C is incorrect because serving hot foods can exacerbate discomfort in the client's mouth. Choice D is incorrect because using a straw can help in preventing further irritation in the client's mouth.
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