ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 of 9
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
Correct Answer: D
Rationale: The correct answer is D because dangling the client on the bedside before ambulating helps prevent orthostatic hypotension and potential falls. This step allows the nurse to assess the client's tolerance to changes in position and reduces the risk of injury. A: Asking family members to speak quietly does not directly address the prevention of injury related to dehydration. B: Assessing urine parameters is important for monitoring hydration status but does not directly prevent injury. C: Encouraging fluid intake is important for rehydration but does not directly address the risk of injury during ambulation.
Question 2 of 9
You are doing discharge teaching with a patient who has hypophosphatemia during his time in hospital. The patient has a diet ordered that is high in phosphate. What foods would you teach this patient to include in his diet? Select all that do not apply
Correct Answer: B
Rationale: The correct answer is B: Beef. While beef is a good source of protein, it is not high in phosphate. Milk, poultry, and liver are high in phosphate and would be beneficial for a patient with hypophosphatemia. Beef is not typically a significant source of phosphate and therefore would not be as effective in increasing phosphate levels in the body compared to the other options. It is important for the patient to focus on consuming foods that are high in phosphate to help correct the hypophosphatemia.
Question 3 of 9
A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
Correct Answer: B
Rationale: The correct answer is B: Prepare to assist with chest tube insertion. Chest pain and difficulty breathing after subclavian central venous catheter insertion could indicate a pneumothorax, a potential complication. Chest tube insertion is indicated to help re-expand the lung and relieve the pressure in the thoracic cavity. This intervention takes priority over the other options because it addresses the potential life-threatening complication of a pneumothorax. Administering nitroglycerin (choice A) is not indicated for chest pain in this scenario. Placing a sterile dressing over the IV site (choice C) is not appropriate for managing chest pain and difficulty breathing. Re-positioning the client into the Trendelenburg position (choice D) is not effective in addressing a pneumothorax and may worsen the client's condition.
Question 4 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 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
While assessing clients on a medical-surgical unit, which client is at risk for hypokalemia?
Correct Answer: A
Rationale: The correct answer is A: Client with pancreatitis who has continuous nasogastric suctioning. Pancreatitis can lead to gastrointestinal losses of potassium, and continuous nasogastric suctioning can further exacerbate this potassium loss, putting the client at risk for hypokalemia. The other choices are incorrect because: B: ACE inhibitors can cause hyperkalemia, not hypokalemia. C: Blood transfusions can lead to hyperkalemia due to the potassium content in blood products. D: Uncontrolled diabetes and a serum pH level of 7.33 are not directly associated with hypokalemia.
Question 7 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 8 of 9
A nurse is caring for a client who is experiencing excessive diarrhea. The clients arterial blood gas values are pH 7.28, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L. Which provider order should the nurse expect to receive?
Correct Answer: B
Rationale: The correct answer is B: Sodium bicarbonate 100 mEq diluted in 1 L of D5W. In this case, the client is experiencing metabolic acidosis due to low HCO3 levels (16 mEq/L) with a low pH (7.28). Sodium bicarbonate helps correct metabolic acidosis by increasing the HCO3 levels. Furosemide (A) is a diuretic and can worsen the client's electrolyte imbalance. Mechanical ventilation (C) is not indicated for metabolic acidosis. Indwelling urinary catheter (D) does not address the underlying acid-base imbalance. Therefore, the nurse should expect the provider to order sodium bicarbonate to correct the metabolic acidosis.
Question 9 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.