ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 of 9
A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)
Correct Answer: C
Rationale: Step 1: Fluid overload leads to increased fluid volume in the body, causing skin to appear pale, cool, and clammy due to poor circulation. Step 2: "Warm and pink skin" is not a typical manifestation of fluid overload. Step 3: Therefore, the correct answer is C. Summary: A: Increased pulse rate - Possible in fluid overload due to increased volume causing increased workload on the heart. B: Distended neck veins - Common in fluid overload due to increased venous pressure. C: Warm and pink skin - Incorrect, as skin is usually pale, cool, and clammy. D: Skeletal muscle weakness - Not directly related to fluid overload.
Question 2 of 9
. 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 3 of 9
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
Correct Answer: D
Rationale: The correct answer is D: Read food labels to determine sodium content. The nurse should assess the client's sodium level of 144 mEq/L, which is slightly above the normal range. High sodium intake can lead to fluid retention, hypertension, and other health issues. By reading food labels to determine sodium content, the nurse can identify sources of high sodium intake in the client's diet and provide appropriate dietary recommendations. This assessment is crucial in managing the client's sodium levels and overall health. Assessing the client's dietary intake of foods high in potassium (Choice A) is not the priority in this case since the client's potassium level is within the normal range. Assessing the client's neuromuscular status (Choice B) is important but not the first priority when considering the electrolyte imbalances present. Assessing the client's fluid intake and output (Choice C) is also important but does not address the immediate concern related to the client's elevated sodium level.
Question 4 of 9
A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?
Correct Answer: C
Rationale: Rationale: Option C is correct because berries, cherries, apples, and peaches are indeed low in potassium compared to other fruits. This response acknowledges the client's love for fruits while providing suitable alternatives to manage potassium levels. By choosing these low-potassium fruits, the client can continue enjoying fruits without exacerbating hyperkalemia. Incorrect options: A: Potatoes and avocados are high in potassium, so they are not suitable substitutes. B: Cooking fruit does not significantly reduce its potassium content. D: This option lacks guidance and does not offer a solution to the client's concern about high potassium levels.
Question 5 of 9
You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?
Correct Answer: C
Rationale: The correct answer is C: Inelastic skin turgor is a normal part of aging. As people age, their skin loses elasticity and becomes less turgid, which can affect skin turgor assessment. Skin turgor assessment is an important indicator of hydration status, and in older adults, it is normal for the skin to be less elastic. This is due to changes in collagen and elastin fibers in the skin with aging. Choices A, B, and D are incorrect because overhydration is not common among healthy older adults, dehydration causes the skin to appear tented rather than spongy, and skin turgor can still be assessed in patients over 70, although it may be less reliable due to natural changes in skin elasticity with aging.
Question 6 of 9
A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause
Correct Answer: B
Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation leads to excessive elimination of carbon dioxide, causing a decrease in PaCO2 levels, resulting in respiratory alkalosis. This is the most common cause of hyperventilation. Respiratory acidosis (choice A) occurs when there is retention of carbon dioxide. Increased PaCO2 (choice C) is a consequence of respiratory acidosis, not alkalosis. CNS disturbances (choice D) can lead to abnormal breathing patterns but are not the most common cause of hyperventilation.
Question 7 of 9
The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?
Correct Answer: C
Rationale: Rationale: Guillain-Barr syndrome can cause inadequate ventilation due to paralysis of the respiratory muscles. This results in respiratory acidosis. Endocarditis, multiple myeloma, and amphetamine overdose do not directly affect ventilation. Endocarditis is an infection of the heart valves, multiple myeloma is a cancer of plasma cells, and amphetamine overdose primarily affects the central nervous system and cardiovascular system, not ventilation. Therefore, Guillain-Barr syndrome is the most likely diagnosis in this case.
Question 8 of 9
. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as
Correct Answer: D
Rationale: The correct answer is D: Fluid volume status. Assessment of specific gravity helps to determine the concentration of solutes in the urine, indicating the degree of hydration or dehydration. In SIADH, there is water retention leading to diluted urine, resulting in low specific gravity. Monitoring specific gravity every 4 hours is crucial in assessing the patient's fluid volume status and response to treatment. A: Nutritional status is not directly assessed by specific gravity. B: Potassium balance is not directly assessed by specific gravity. C: Calcium balance is not directly assessed by specific gravity.
Question 9 of 9
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.