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

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. 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.

3. A patient with hypokalemia and heart failure is admitted to the telemetry unit. The nurse is aware that hypokalemia could cause which of the following abnormalities on an electrocardiogram (ECG)?

A. Shortened P-R interval
B. Inverted T wave
C. Depressed U wave
D. Elevated U wave

Correct answer: D

Rationale: The correct answer is D: Elevated U wave. Hypokalemia is associated with ECG changes such as an elevated U wave and flattened T waves. Choice A, a shortened P-R interval, is not typically seen in hypokalemia. Choice B, an inverted T wave, is more commonly associated with ischemia or CNS injury rather than hypokalemia. Choice C, a depressed U wave, is not a typical ECG abnormality seen in hypokalemia. Therefore, the correct ECG abnormality associated with hypokalemia is an elevated U wave.

4. Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?

A. Diminished deep tendon reflexes
B. Tachycardia
C. Cool clammy skin
D. Increased serum magnesium

Correct answer: A

Rationale: The correct answer is A: Diminished deep tendon reflexes. In a patient with hypermagnesemia, the nurse would assess for diminished deep tendon reflexes. Hypermagnesemia can lead to neuromuscular depression, causing a decrease in deep tendon reflexes. Tachycardia (choice B) is more commonly associated with hypomagnesemia. Cool clammy skin (choice C) is not typically a direct symptom of hypermagnesemia. While hypermagnesemia does involve increased serum magnesium levels (choice D), assessing serum levels is a laboratory test and not a clinical assessment like checking deep tendon reflexes.

5. Which condition can result from prolonged vomiting or diarrhea?

A. Intracellular fluid
B. Interstitial fluid
C. Dehydration
D. Electrolyte

Correct answer: C

Rationale: The correct answer is C: Dehydration. Prolonged vomiting or diarrhea can lead to significant fluid loss, causing dehydration. Intracellular fluid (choice A) and interstitial fluid (choice B) refer to specific compartments of body fluid and are not conditions resulting from vomiting or diarrhea. Electrolytes (choice D) are minerals that help maintain fluid balance in the body but are not the condition directly resulting from prolonged vomiting or diarrhea.