ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 of 5
. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
Correct Answer: D
Rationale: The correct answer is D. A cool lower extremity can indicate impaired circulation due to the intraosseous catheter placement, leading to compartment syndrome or tissue necrosis. This finding requires immediate intervention to prevent serious complications. Choices A, B, and C are incorrect because the duration of catheter placement, poor vascular access, and the specific location of the catheter do not directly impact circulation and tissue perfusion as significantly as a cool lower extremity.
Question 2 of 5
.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
Correct Answer: D
Rationale: The correct action is to stop the infusion of intravenous fluids. Edema and tenderness above the IV site suggest infiltration, where fluid leaks into surrounding tissues. Stopping the infusion prevents further damage and helps prevent complications. Applying cold compresses (A) may not address the underlying issue. Elevating the extremity (B) is helpful for other conditions like swelling due to dependent edema, not infiltration. Flushing the catheter (C) can exacerbate the issue by pushing more fluid into the tissue.
Question 3 of 5
While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
Correct Answer: A
Rationale: The correct answer is A: Grade 3 phlebitis at IV site. This finding indicates inflammation of the vein due to irritants from the IV catheter, supported by red streak and palpable cord. Grade 3 phlebitis involves pain, redness, swelling, and palpable venous cord. Infection (B) typically presents with signs like pus, warmth, and fever. Thrombosis (C) involves a blood clot, not a palpable cord. Infiltration (D) is leakage of IV fluid into surrounding tissues, not related to palpable cord and red streak.
Question 4 of 5
1.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?
Correct Answer: D
Rationale: The correct answer is D: Place a washcloth between the skin and tourniquet. This step helps protect the client's skin by providing a barrier between the tourniquet and the skin, reducing the risk of skin irritation or damage. Lowering the extremity below the heart (A) can increase venous pressure and make it harder to insert the catheter. Warm compresses (B) can dilate blood vessels and increase the risk of bruising. Tapping the skin lightly (C) can irritate the skin and is unnecessary for skin protection.
Question 5 of 5
Place a washcloth between the skin and tourniquet
Correct Answer: D
Rationale: The correct answer is D because using a plastic bag to cover the extremity with the device helps to keep the area dry when bathing, preventing the tourniquet from becoming wet and losing its effectiveness. This technique maintains the pressure needed for venipuncture. A, providing a bed bath instead of a shower, is unrelated to the use of a tourniquet. B, using sterile technique for dressing changes, is important for wound care but not relevant to tourniquet use. C, disconnecting intravenous fluid tubing before a bath, is essential for preventing contamination but not directly related to tourniquet management.