ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance?
- A. Hypercalcemia
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct answer: C
Rationale:
2. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:
- A. Choose a proximal site.
- B. Choose a distal site.
- C. Have the patient hold their arm in a dependent position.
- D. Leave the tourniquet on for no longer than 2 minutes.
Correct answer: B
Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Opting for a distal site ensures that upper veins remain available for future cannulations. Instructing the patient to hold their arm in a dependent position can enhance blood flow, aiding in the procedure. It is crucial never to leave a tourniquet on for more than 2 minutes as prolonged restriction can lead to complications. Choice A is incorrect because a proximal site is not preferred for IV insertion. Choice C is incorrect as having the patient hold their arm over their head is not necessary and may impede proper blood flow. Choice D is incorrect as leaving the tourniquet on for at least 5 minutes is excessive and can be harmful.
3. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
- A. Assess the airway.
- B. Administer prescribed bronchodilators.
- C. Provide oxygen.
- D. Administer prescribed mucolytics
Correct answer: A
Rationale:
4. What is the most important regulator of the amount of sodium in the body?
- A. Kidneys
- B. Small intestine
- C. Large intestine
- D. Skin
Correct answer: A
Rationale: The correct answer is A: Kidneys. The kidneys play a crucial role in regulating the amount of sodium in the body. They achieve this by filtering blood and controlling the excretion or reabsorption of sodium. The small intestine is primarily responsible for nutrient absorption, not sodium regulation. The large intestine is mainly involved in water absorption and waste elimination, not sodium balance. The skin helps regulate body temperature through sweating and does not directly regulate sodium levels.
5. A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?
- A. The patients calcium will rise dramatically due to pituitary stimulation.
- B. Oxygen will increase the patients intracranial pressure and create confusion.
- C. Oxygen may cause the patient to hyperventilate and become acidotic.
- D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
Correct answer: D
Rationale:
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