ATI RN
Fluid and Electrolytes ATI
1. The patient asks the nurse if he will die if air bubbles get into the IV tubing. What is the nurse's best response?
- A. The system is closed, and that scenario is highly unlikely.
- B. Only relatively large volumes of air administered rapidly are dangerous.
- C. There is a risk of complications associated with IV administration.
- D. You have been influenced by movies too much.
Correct answer: B
Rationale: The correct answer is B because air emboli are more commonly associated with central vein access. Usually, only relatively large volumes of air administered rapidly are dangerous. It is a significant concern when air enters a central venous access line. Choice A is incorrect as it downplays the risk and is not entirely accurate. Choice C is too general and does not specifically address the patient's concern. Choice D is dismissive and does not provide any relevant information regarding the risk of air bubbles in IV tubing.
2. While assessing clients on a medical-surgical unit, which client is at risk for hypokalemia?
- A. Client with pancreatitis who has continuous nasogastric suctioning
- B. Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
- C. Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
- D. Client with uncontrolled diabetes and a serum pH level of 7.33
Correct answer: A
Rationale: Continuous nasogastric suctioning can lead to hypokalemia due to the loss of gastric contents rich in potassium. Therefore, a client with pancreatitis who has continuous nasogastric suctioning is at risk for hypokalemia. Option B is incorrect because ACE inhibitors may lead to hyperkalemia, not hypokalemia. Option C is incorrect as receiving packed red blood cells can lead to hyperkalemia due to the potassium content in the blood product. Option D is incorrect because a serum pH level of 7.33 indicates acidosis, which is not directly associated with hypokalemia.
3. During a visit to an 84-year-old woman recovering from hip surgery, the nurse notices signs of confusion and poor skin turgor. The woman mentions she limits water intake to avoid nighttime bathroom trips. The nurse should explain to the woman that:
- A. She will need her medications adjusted and be readmitted for a complete workup.
- B. Limiting fluids can lead to body imbalances causing confusion; perhaps adjusting fluid intake timing is necessary.
- C. Post-surgical confusion is common, and it's safe not to urinate at night.
- D. Confusion after surgery is typical in the elderly due to sleep loss.
Correct answer: B
Rationale: The correct answer is B. In elderly patients, fluid and electrolyte imbalances can manifest with subtle signs like confusion. Limiting fluids can lead to such imbalances, affecting cognitive function. Adjusting the timing of fluid intake can help maintain hydration without causing nighttime disruptions. Choices A, C, and D are incorrect. Choice A suggests unnecessary hospital readmission and medication adjustments without addressing the root cause. Choice C wrongly normalizes the confusion and fails to address the potential issue of fluid restriction. Choice D incorrectly attributes confusion solely to sleep loss without considering the impact of fluid balance.
4. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?
- A. Assess clients rate, rhythm, and depth of respiration.
- B. Measure the clients pulse and blood pressure.
- C. Document the findings and continue to monitor.
- D. Notify the physician as soon as possible.
Correct answer: A
Rationale:
5. You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that do not apply
- A. Milk
- B. Beef
- C. Poultry
- D. Liver
Correct answer: B
Rationale:
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