when dehydration begins to occur

ATI RN

ATI Fluid and Electrolytes

1. When does dehydration begin to occur?

A. the body reduces fluid output to zero.
B. the body increases the release of ANH.
C. the salivary secretions decrease.
D. the salivary secretions increase.

Correct answer: C

Rationale: Dehydration leads to a decrease in the body's fluid levels, causing the salivary glands to produce less saliva, resulting in a dry mouth. Therefore, when dehydration begins to occur, salivary secretions decrease. Choice A is incorrect because the body does not reduce fluid output to zero during dehydration; it tries to conserve fluids. Choice B is incorrect as dehydration does not directly increase the release of ANH (Atrial Natriuretic Hormone). Choice D is incorrect because salivary secretions do not increase but decrease during dehydration.

2. You are working on a burns unit, and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?

A. Metabolic alkalosis
B. Hypermagnesemia
C. Hypercalcemia
D. Hypovolemia

Correct answer: D

Rationale: When a patient exhibits signs and symptoms of third-spacing, where fluid moves out of the intravascular space but not into the intracellular space, hypovolemia is expected. This leads to a decreased circulating blood volume. Increased calcium and magnesium levels are not typically associated with third-spacing fluid shift. Burns usually result in acidosis rather than alkalosis, making metabolic alkalosis an incorrect choice. Therefore, hypovolemia is the correct answer in this scenario.

3. A nurse is assessing a client with hypokalemia and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?

A. Assess the client's respiratory rate, rhythm, and depth.
B. Measure the client's pulse and blood pressure.
C. Document findings and monitor the client.
D. Call the healthcare provider.

Correct answer: A

Rationale: In a client with hypokalemia experiencing diminished handgrip strength, the priority action for the nurse is to assess the client's respiratory rate, rhythm, and depth. Hypokalemia can lead to muscle weakness, including respiratory muscles, potentially causing respiratory distress. Assessing the respiratory status is crucial to determine if immediate interventions are needed to maintain adequate oxygenation. Measuring the client's pulse and blood pressure (Choice B) is important but should come after assessing the respiratory status. Simply documenting findings and monitoring the client (Choice C) may delay necessary interventions. Calling the healthcare provider (Choice D) is not the first action indicated in this situation; assessing the client's respiratory status takes precedence.

4. The nurse in the intensive care unit receives arterial blood gases (ABG) with a patient who is complaining of being 'short of breath.' The ABG has the following values: pH = 7.21, PaCO2 = 64 mm Hg, HCO3 = 24 mmol/L. The labs reflect:

A. Respiratory acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Metabolic acidosis

Correct answer: A

Rationale: The ABG values indicate respiratory acidosis. A pH below 7.40, a PaCO2 above 40 mm Hg, and a normal HCO3 level (24 mmol/L) suggest respiratory acidosis. In this case, the patient has an acidic pH (7.21) and an elevated PaCO2 (64 mm Hg), indicating inadequate ventilation. The normal HCO3 level suggests that compensation by the kidneys has not occurred, implying an acute event. Choices B, C, and D can be ruled out based on the given ABG values and the criteria for acid-base disorders.