ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 41 : Fluid, Electrolyte, and Acid?Base Balance Questions
Question 1 of 5
A nurse is caring for an older adult with a fluid volume deficit related to decreased thirst sensation. For which signs and symptoms of this health problem will the nurse assess?
Correct Answer: D
Rationale: Weight loss is a key indicator of fluid volume deficit due to fluid loss. Edema (
A), crackles (
B), and neck vein distention (
C) indicate fluid volume excess.
Question 2 of 5
A nurse on the IV team is making rounds to assess patients receiving IV therapy. Under which circumstance will the nurse recommend an intravenous catheter be discontinued?
Correct Answer: C
Rationale: Redness, warmth, and swelling indicate phlebitis, requiring catheter discontinuation. Bruising (
A) may be monitored. Coolness (
B) suggests infiltration, but phlebitis is more urgent. A 1 mm visible catheter (
D) is not an immediate concern if secure.
Question 3 of 5
Which action should be taken to evaluate or verify the integrity of the peripheral IV access site?
Correct Answer: D
Rationale: Assessing skin temperature and tone at the site helps evaluate for signs of infiltration, phlebitis, or infection without disrupting the securement device. Removing the securement device (
A) is unnecessary and risks dislodging the catheter. Documenting negative aspiration (
B) is not a reliable indicator of site integrity. Rotating the site every 72 hours (
C) is a maintenance action, not an evaluation method.
Question 4 of 5
A second patient problem of deficient knowledge is identified. The nurse is preparing teaching materials for the patient. Which interventions should the nurse focus on with this patient? Select all that apply.
Correct Answer: A,B,C,D
Rationale: Interventions A, B, C, and D promote effective self-management of fluid balance. Monitoring fluid intake and output (
A) helps track balance. Daily weight measurement (
B) is a reliable indicator of fluid status. Taking diuretics early (
C) minimizes nighttime urination. Tracking changes (
D) ensures timely reporting of issues. Restricting fluids excessively (E) can lead to dehydration and is not appropriate.
Question 5 of 5
Based on the identified health problem, how will the nurse and Mr. Park best know that the plan of care has been effective?
Correct Answer: B
Rationale: Stable weight and absence of dyspnea indicate effective fluid balance management, aligning with the care plan's goals. Sufficient sleep (
A) is unrelated to fluid balance. Taking diuretics every other day (
C) suggests non-compliance. Weight increase (
D) indicates potential fluid retention, suggesting ineffective management.