ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 of 9
A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A: Assess the airway. The nurse should prioritize airway assessment as the client's ABGs indicate respiratory acidosis (low pH, high PaCO2). This suggests potential airway obstruction or inadequate ventilation. Ensuring a patent airway is crucial for adequate oxygenation. Administering bronchodilators (B) or mucolytics (D) may help with airway clearance but should come after ensuring a clear airway. Providing oxygen (C) is important, but addressing the underlying respiratory acidosis by first assessing the airway is the priority in this situation to prevent further deterioration.
Question 2 of 9
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?
Correct Answer: B
Rationale: The correct answer is B: Place warm compresses on the site. Warm compresses can help increase blood flow, reduce pain, and promote healing at the site of inflammation. The warmth can help dilate blood vessels, increasing circulation to the area and promoting the removal of inflammatory substances. This can help alleviate pain and reduce swelling. Administering topical lidocaine (choice A) may not address the underlying cause of pain and redness. Administering oral pain medication (choice C) may be necessary for severe pain but may not directly address the local inflammation. Massaging the site with scented oils (choice D) can potentially introduce more irritants and should be avoided in cases of inflammation.
Question 3 of 9
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)
Correct Answer: A
Rationale: Step-by-step rationale for why option A is correct: 1. Inhibition of aldosterone secretion leads to decreased sodium reabsorption and increased water excretion. 2. Decreased aldosterone can result in decreased blood volume and BP, leading to decreased urine output. 3. Monitoring urine output is crucial to assess renal function and fluid balance. 4. A urine output of 25 mL/hr is considered inadequate and can indicate renal impairment or dehydration. Summary: Option A is correct as it directly relates to the mechanism of action of inhibiting aldosterone secretion. Options B, C, and D are incorrect as they do not align with the expected complications of aldosterone inhibition.
Question 4 of 9
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.
Question 5 of 9
After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?
Correct Answer: C
Rationale: The correct answer is C because it includes foods high in potassium. Raisins, whole wheat toast, and milk are good sources of potassium. Sausage might contain some potassium as well. A: This option lacks potassium-rich foods. B: While strawberries have some potassium, the overall meal lacks a sufficient amount. D: While oatmeal and peaches have potassium, coffee can actually inhibit potassium absorption.
Question 6 of 9
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
Correct Answer: B
Rationale: The correct answer is B: Report of headache and stiff neck. This finding indicates a potential complication of epidural anesthesia called a post-dural puncture headache, which can lead to serious consequences like meningitis or subdural hematoma. The nurse should act immediately by notifying the healthcare provider for further evaluation and management. Redness at the catheter insertion site (A) may indicate local inflammation but doesn't require immediate intervention. Temperature elevation (C) could be a sign of infection but isn't as urgent as a headache and stiff neck. Pain rating of 8 (D) is important but doesn't indicate an immediate threat to the client's health like a post-dural puncture headache.
Question 7 of 9
A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?
Correct Answer: B
Rationale: The correct answer is B: "You appear anxious. What is causing your distress?" because hyperventilation can be triggered by emotional distress or anxiety. By addressing the underlying cause of the hyperventilation, the nurse can provide appropriate interventions to help the client manage their anxiety and subsequently reduce the hyperventilation episodes. A: "Do you take any over-the-counter medications?" - This question is not directly related to addressing the client's anxiety or distress, which is the primary concern in hyperventilation. C: "Do you have a history of anxiety attacks?" - While relevant to understanding the client's medical history, this question does not address the immediate cause of hyperventilation in this specific situation. D: "You are breathing fast. Is this causing you to feel light-headed?" - This question focuses on the physical symptoms of hyperventilation rather than exploring the emotional or psychological triggers, which are essential in managing hyperventilation caused by anxiety.
Question 8 of 9
The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?
Correct Answer: A
Rationale: The correct answer is A: Diffusion. In respiration, oxygen and carbon dioxide are exchanged between the alveoli and pulmonary capillaries through the process of diffusion. Here's the rationale: 1. Diffusion is the movement of molecules from an area of high concentration to an area of low concentration. 2. In the alveoli, oxygen moves from the air (higher concentration) into the blood (lower concentration) and carbon dioxide moves from the blood (higher concentration) into the air (lower concentration). 3. This exchange occurs passively, without the need for energy input, which is characteristic of diffusion. Summary of other choices: B: Osmosis involves the movement of water across a semi-permeable membrane, not gas exchange. C: Active transport requires energy input to move molecules against their concentration gradient, not seen in gas exchange. D: Filtration involves the movement of molecules through a membrane under pressure, not the passive movement of gases in respiration.
Question 9 of 9
A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct answer is A: Apply oxygen by mask or nasal cannula. The client is experiencing respiratory acidosis due to inadequate ventilation and oxygenation during the seizure. Providing oxygen will help improve oxygenation and correct the respiratory acidosis. This is the priority to address the immediate physiological need. Choice B is incorrect as applying a paper bag can lead to rebreathing of carbon dioxide, worsening the respiratory acidosis. Choice C is incorrect as sodium bicarbonate is not indicated in this situation and can potentially worsen the acid-base imbalance. Choice D is incorrect as administering glucose and insulin is not relevant to correcting the respiratory acidosis.