ATI RN
ATI Fluid and Electrolytes
1. Which organ has the greatest effect on fluid output?
- A. Kidneys
- B. Lungs
- C. Skin
- D. Intestines
Correct answer: A
Rationale: The correct answer is the kidneys. The kidneys are primarily responsible for regulating fluid balance by filtering blood and adjusting the volume and concentration of urine. The lungs primarily regulate gas exchange, not fluid balance. The skin plays a role in temperature regulation and protection but is not the primary organ for fluid output. The intestines are mainly involved in the absorption of nutrients and water, rather than fluid output.
2. What is the primary action when caring for a patient with a stage 3 pressure ulcer?
- A. Apply a hydrocolloid dressing
- B. Provide wound debridement
- C. Change the dressing daily
- D. Apply moist gauze to the ulcer
Correct answer: A
Rationale: The correct answer is to apply a hydrocolloid dressing. This type of dressing helps maintain a moist environment that is conducive to healing in stage 3 pressure ulcers. Providing wound debridement (choice B) is more suitable for higher stages of pressure ulcers where there is necrotic tissue. Changing the dressing daily (choice C) may be necessary but is not the primary action for a stage 3 pressure ulcer. Applying moist gauze (choice D) is not the recommended approach as it does not provide the same benefits as a hydrocolloid dressing.
3. Of the foods listed, the best source of phosphorus is?
- A. lettuce
- B. pears
- C. chicken
- D. noodles
Correct answer: C
Rationale: Chicken is a good source of phosphorus, which is essential for bone health and energy production in the body.
4. After surgery, your patient starts to shiver uncontrollably. What nursing intervention would you do first?
- A. Apply warm blankets & continue oxygen as prescribed
- B. Take the patient's rectal temperature
- C. Page the doctor for further orders
- D. Adjust the thermostat in the room
Correct answer: Apply warm blankets & continue oxygen as prescribed
Rationale: When a patient starts shivering uncontrollably after surgery, the priority nursing intervention is to apply warm blankets and continue oxygen as prescribed. Shivering can be a sign of hypothermia, and maintaining the patient's body temperature is crucial for their recovery. This intervention helps prevent further heat loss and supports the patient's comfort and safety. While monitoring temperature, paging the doctor, and adjusting the room temperature may be necessary, addressing the immediate need for warmth and oxygen is the priority in this situation.
5. When the client finds antiembolism stockings uncomfortably tight, what is the nurse’s best action?
- A. Remove the stockings for an hour to relieve the pressure
- B. Pull the stockings down so that they are not constricting
- C. Measure the client’s calf to ensure that they are the correct size
- D. Teach the client the purpose of wearing the stockings
Correct answer: Teach the client the purpose of wearing the stockings
Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.
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