you are the surgical nurse caring for a 65 year old female patient who is postoperative day 1 following a thyroidectomy during your shift assessment t
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

Correct answer: B

Rationale:

2. A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications

Correct answer: A

Rationale:

3. The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation is the most common cause of acute respiratory alkalosis. When a patient hyperventilates due to anxiety or other causes, they blow off excessive carbon dioxide, leading to a decrease in PaCO2 and a rise in pH. Choices A, C, and D are incorrect because hyperventilation leads to a decrease in PaCO2, causing respiratory alkalosis, not respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

4. 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?

Correct answer: D

Rationale:

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

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.

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