ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?
- A. Hypertension
- B. Kussmaul respirations
- C. Increased DTRs
- D. Shallow respirations
Correct answer: Shallow respirations
Rationale:
2. 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: Metabolic alkalosis
Rationale:
3. You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?
- A. Extravasation of the medication
- B. Discomfort to the patient
- C. Blanching at the site
- D. Hypersensitivity reaction to the medication
Correct answer: Extravasation of the medication
Rationale:
4. The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?
- A. Cimetidine
- B. Maalox
- C. Potassium chloride elixir
- D. ) Furosemide
Correct answer: Cimetidine
Rationale:
5. A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment, the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:
- A. Hypophosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hyperkalemia
Correct answer: B
Rationale: The patient's symptoms of tingling in the lips and fingers along with the wrist and hand spasm are indicative of tetany, a characteristic manifestation of hypocalcemia. Hypocalcemia and hypomagnesemia can present with sensations of tingling in the extremities and around the mouth. The spasm in the wrist and hand when taking blood pressure could be due to slight ischemia of the ulnar nerve, further supporting the suspicion of hypocalcemia in this patient. Hypophosphatemia, hypermagnesemia, and hyperkalemia do not typically present with these specific symptoms and manifestations.
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