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 flushing a patient's peripheral venous access device. The nurse finds that the access size is leaking fluid during flushing. What action will the nurse take next?
Correct Answer: A
Rationale: Leaking fluid indicates infiltration, requiring removal of the IV and restarting at a new site. Notifying the provider (
B) is unnecessary unless complications arise. Outlining the area (
C) is a follow-up action after removal. Aspirating and flushing again (
D) risks further tissue damage.
Question 2 of 5
A nurse is monitoring a patient who is receiving an IV infusion of normal saline at 250 mL/hr. The patient is apprehensive and presents with a pounding headache, rapid pulse, chills, and dyspnea. What would be the nurse's priority intervention related to these symptoms?
Correct Answer: A
Rationale: Symptoms suggest speed shock from rapid infusion. Discontinuing the infusion, monitoring vital signs, and reporting to the provider are priority actions. Slowing the infusion (
B) is insufficient. Pinching the catheter (
C) addresses air embolism, not speed shock. Warm compresses (
D) are irrelevant to speed shock.
Question 3 of 5
A nurse carefully assesses the acid-base balance of a patient whose bicarbonate (HCO3-) level is decreased on the ABG results. This typically occurs in patients with damage to which organ?
Correct Answer: A
Rationale: The kidneys regulate bicarbonate levels, and damage can lead to decreased HCO3-, causing metabolic acidosis. Lungs (
B) regulate CO2. Adrenal glands (
C) affect hormones, not bicarbonate directly. The brain (
D) regulates respiration, not bicarbonate.
Question 4 of 5
A nurse is monitoring a patient who is diagnosed with hypokalemia. Which nursing intervention would be appropriate for this patient?
Correct Answer: B
Rationale: Hypokalemia requires potassium replacement, such as oral supplements as prescribed. High sodium (
A) is for hyponatremia. Cautioning against potassium-rich foods (
C) is for hyperkalemia. Calcium loss (
D) is unrelated to hypokalemia.
Question 5 of 5
A nurse has begun administering an intravenous antibiotic via the patient's peripheral venous access. Immediately, the nurse observes that the fluid does not flow easily into the vein and the skin around the insertion site is edematous and cool to the touch. What would be the nurse's next action related to these findings?
Correct Answer: D
Rationale: Edema and coolness indicate infiltration, requiring catheter removal. Repositioning (
A) or raising the pole (
B) worsens infiltration. Applying pressure (
C) is inappropriate. Pulling and reinserting (
D) risks further tissue damage.