ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?
- A. Leave one hand ungloved to assess the site.
- B. Cleanse the skin with normal saline.
- C. Ask the patient about allergies to latex or iodine.
- D. Remove excessive hair from the selected site.
Correct answer: C
Rationale:
2. The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hypocalcemia
- D. Hyperkalemia
Correct answer: C
Rationale:
3. What would be the best initial nursing action prior to inserting an IV?
- A. Instruct the patient to wash their hands.
- B. Prepare the IV insertion site with povidone iodine.
- C. Verify the order for IV therapy.
- D. Identify a suitable vein.
Correct answer: C
Rationale: The best initial nursing action prior to inserting an IV is to verify the order for IV therapy. This step ensures that the IV insertion is appropriate and necessary based on the physician's orders. Instructing the patient to wash their hands (Choice A) is important for infection control but not the immediate priority before IV insertion. While preparing the IV insertion site with povidone iodine (Choice B) and identifying a suitable vein (Choice D) are crucial steps in the process, confirming the order for IV therapy (Choice C) takes precedence to ensure the correct intervention is being performed.
4. After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?
- A. Toasted English muffin with butter and blueberry jam, and tea with sugar
- B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
- C. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
- D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
Correct answer: C
Rationale: Choice C is the correct answer as it includes foods high in potassium, such as raisins, whole wheat toast, and milk. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. Choices A, B, and D do not contain significant sources of potassium. Choice A consists mainly of carbohydrates and sugar, choice B focuses on protein and carbohydrates, and choice D provides carbohydrates and some fruit but lacks high-potassium options like in choice C.
5. After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all tha do not t apply.)
- A. Strong productive cough
- B. Active bowel sounds
- C. U waves present on the electrocardiogram (ECG)
- D.
Correct answer: C
Rationale:
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