you are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases during your assessment you

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?

A. Hypernatremia
B. Hypomagnesemia
C. Hypophosphatemia
D. Hypercalcemia

Correct answer: D

Rationale:

2. 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:

3. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?

A. Place the patient in low Fowler's position and notify the physician.
B. Increase the patient's IV fluid and auscultate the lungs.
C. Place the patient in semi-Fowler's position and prepare to give the PRN diuretic as ordered.
D. Discontinue the patient's IV.

Correct answer: C

Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.

4. Extracellular fluid includes:

A. plasma and intracellular fluid.
B. interstitial and intracellular fluids.
C. plasma and interstitial fluid.
D. plasma, interstitial fluid, and intracellular fluid.

Correct answer: C

Rationale: The correct answer is C: 'plasma and interstitial fluid.' Extracellular fluid consists of all body fluids outside the cells, primarily including plasma (the liquid component of blood) and interstitial fluid (the fluid between cells). Choices A, B, and D are incorrect because intracellular fluid is located within the cells, not in the extracellular fluid compartment.

5. When preparing a site for the insertion of an IV catheter, how should excess hair at the site be treated?

A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory

Correct answer: C

Rationale: The correct answer is to clip the hair in the area. Excess hair at the site of IV catheter insertion should be removed because it can be a potential source of infection. Clipping the hair is preferred over shaving because shaving can cause skin abrasions, increasing the risk of infection. Using depilatories is not recommended as they can irritate the skin, which is undesirable when preparing a clean site for an invasive procedure. Therefore, clipping the hair in the area is the most appropriate and safe method to prepare the site for IV catheter insertion.