ATI Fluid Electrolyte and Acid-Base Regulation - Nurselytic

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ATI Fluid Electrolyte and Acid-Base Regulation Questions

Question 1 of 5

. One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acutecare nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?

Correct Answer: C

Rationale: The correct answer is C: Help distinguish reduced renal blood flow from decreased renal function.


Rationale:
1. Oliguria is a decrease in urine output.
2. Fluid challenge with normal saline can help determine the cause of oliguria by assessing the response of the kidneys.
3. If the oliguria improves after the fluid challenge, it suggests reduced renal blood flow as the cause.
4. If oliguria persists, it indicates decreased renal function.

Summary:
A. Fluid challenge does not directly help in distinguishing between hyponatremia and hypernatremia.
B. Evaluating pituitary gland function requires specific tests, not just a fluid challenge.
D. Treating hypertension-induced oliguria may involve different interventions, not just a fluid challenge.

Question 2 of 5

A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching?

Correct Answer: C

Rationale:
Correct Answer: C


Rationale:
1.
Choice C is correct because it emphasizes the importance of cleaning connections before accessing the device to prevent infection.
2. Sterile technique during insertion cannot guarantee no risk of infection (
Choice
B).
3. Wearing a sling is unnecessary for a central vascular access device (
Choice
A).
4. The statement about not being able to take a bath is not accurate and is not a common restriction (
Choice
D).

Question 3 of 5

A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that do not apply.)

Correct Answer: C

Rationale: The correct answer is C because antacids contain aluminum or magnesium, which can bind with phosphorus and decrease its absorption, leading to hypophosphatemia. Malnourishment (choice
A) can cause hypophosphatemia due to inadequate intake, uncontrolled diabetes (choice
B) is associated with hyperphosphatemia, and hyperparathyroidism (choice
D) can lead to hyperphosphatemia due to increased calcium levels.

Question 4 of 5

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?

Correct Answer: C

Rationale: The correct answer is C: Metabolic alkalosis. Pyloric stenosis can lead to vomiting, causing loss of gastric acid and chloride ions, leading to metabolic alkalosis. Low potassium levels are common in metabolic alkalosis due to potassium shifting into cells to compensate for the alkalosis. Hypercalcemia (choice
A) is not associated with pyloric stenosis. Metabolic acidosis (choice
B) typically presents with low pH and bicarbonate levels. Respiratory acidosis (choice
D) is caused by impaired gas exchange in the lungs, not related to pyloric stenosis.

Question 5 of 5

A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

Correct Answer: A

Rationale: The correct answer is A: Assess clients rate, rhythm, and depth of respiration. The arterial blood gas values indicate a respiratory acidosis due to low pH and low PaCO2. The nurse should assess the respiratory status to determine if the client is hypoventilating, which is causing the retention of CO2 and subsequent acidosis. Assessing the rate, rhythm, and depth of respiration will help determine if the client requires immediate intervention such as oxygen therapy, mechanical ventilation, or respiratory treatment.


Choice B is incorrect because measuring pulse and blood pressure does not directly address the underlying cause of the acid-base imbalance.
Choice C is incorrect as the nurse should take immediate action to address the imbalance rather than passively monitoring.
Choice D is incorrect as immediate intervention is needed to address the respiratory acidosis.

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