ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 41 Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The patient with which problem will the nurse suspect may have developed respiratory alkalosis?
Correct Answer: A
Rationale: Patients experiencing hypoxia breathe rapidly, 'blowing off' CO2, which drives pH up, causing respiratory alkalosis. Atelectasis (
B) may cause hypoxia but not necessarily alkalosis. Chronic respiratory illness (
C) often leads to respiratory acidosis. Sedative overdose (
D) causes hypoventilation, leading to respiratory acidosis.
Question 5 of 5
The patient with which problem would the nurse identify is at high risk for fluid volume excess?
Correct Answer: A
Rationale: Patients with renal failure are unable to excrete fluids, leading to oliguria and fluid volume excess. Vomiting (
B), hypernatremia (
C), and NPO status (
D) typically cause fluid volume deficit.