ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
- A. Choose a hairless site if available.
- B. Consider potential effects on the patients mobility when selecting a site.
- C. Have the patient briefly hold his arm over his head before insertion
- D. Leave the tourniquet on for at least 3 minutes.
Correct answer: B
Rationale:
2. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
- A. Redness at the catheter insertion site
- B. Report of headache and stiff neck
- C. Temperature of 100.1 F (37.8 C)
- D. Pain rating of 8 on a scale of 0 to 10
Correct answer: B
Rationale:
3. The nurse assessing skin turgor in an elderly patient should remember that:
- A. Overhydration causes the skin to tent.
- B. Dehydration causes the skin to appear edematous and spongy.
- C. Inelastic skin turgor is a normal part of aging.
- D. Normal skin turgor is moist and boggy.
Correct answer: C
Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.
4. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that do not apply.)
- A. A 36-year-old who is malnourished
- B. A 42-year-old with uncontrolled diabetes
- C. A 76-year-old who is prescribed antacids
- D. 50-year-old with hyperparathyroidism
Correct answer: C
Rationale:
5. A nurse is caring for a patient who requires measurement of specific gravity every 4 hours. What does this test detect?
- A. Nutritional deficit
- B. Hyperkalemia
- C. Hypercalcemia
- D. Fluid volume status
Correct answer: D
Rationale: Specific gravity is a test used to determine the concentration of solutes in the urine, reflecting the kidney's ability to concentrate urine. Changes in specific gravity can indicate fluid volume status, such as dehydration (fluid volume deficit) or overhydration (fluid volume excess). Options A, B, and C are incorrect as specific gravity does not directly detect nutritional deficits, hyperkalemia, or hypercalcemia.
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