ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 of 9
You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?
Correct Answer: D
Rationale: To interpret the given ABG results: 1. pH <7.35 indicates acidosis. 2. PaCO2 <35 indicates respiratory alkalosis. 3. HCO3 <22 indicates metabolic acidosis. Therefore, the ABG results show metabolic acidosis (low pH, low HCO3) with compensatory respiratory alkalosis (low PaCO2). This means the body is trying to compensate for the metabolic acidosis by decreasing PaCO2 through hyperventilation. Option D is correct. Options A, B, and C are incorrect as they do not align with the ABG results and the principles of acid-base balance.
Question 2 of 9
A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?
Correct Answer: B
Rationale: The correct answer is B: Anxiety-induced hyperventilation. The arterial blood gas values show a pH of 7.48 (alkalosis) with low PaCO2 (respiratory alkalosis), which is consistent with hyperventilation due to anxiety. HCO3 is within normal range, ruling out metabolic causes. A: Diarrhea and vomiting would lead to metabolic acidosis with low pH and decreased HCO3. C: COPD would typically present with respiratory acidosis (high PaCO2) and normal to high HCO3. D: Diabetic ketoacidosis and emphysema would show metabolic acidosis with low pH and low HCO3.
Question 3 of 9
The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?
Correct Answer: C
Rationale: Step 1: Chvostek's sign is a facial muscle spasm induced by tapping the facial nerve in hypocalcemia. Step 2: Hypocalcemia causes increased neuromuscular excitability, leading to Chvostek's sign. Step 3: Hyperkalemia (choice D) causes muscle weakness, not muscle spasm. Step 4: Hyponatremia (choice B) affects osmolarity, not neuromuscular excitability. Step 5: Hypermagnesemia (choice A) causes muscle weakness, not muscle spasm.
Question 4 of 9
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?
Correct Answer: D
Rationale: The correct answer is D, infection. The client's symptoms of abdominal pain and feeling warm are indicative of a potential infection, which is a common complication of intraperitoneal therapy. Step-by-step rationale: 1. Abdominal pain can be a sign of peritonitis, an infection of the peritoneal cavity. 2. Feeling warm may indicate a fever, a common symptom of infection. 3. Prompt assessment and treatment of infection are crucial to prevent complications. Summary of other choices: A, allergic reaction - unlikely given the symptoms described; B, bowel obstruction - does not align with the symptoms provided; C, catheter lumen occlusion - not typically associated with abdominal pain and feeling warm.
Question 5 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 6 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.
Question 7 of 9
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
Correct Answer: D
Rationale: The correct answer is D: Presence of an ulnar pulse. This is the most important assessment to complete first because the presence of an ulnar pulse indicates adequate circulation in the hand, ensuring that the radial artery catheter is not compromising blood flow. If the ulnar pulse is absent, it may signify impaired circulation and potential complications such as ischemia. Choice A is incorrect because the amount of pressure in the fluid container is not directly related to the assessment of the radial artery catheter. Choice B is incorrect because the date of catheter tubing change is important for infection control but not the immediate priority in this situation. Choice C is incorrect as the percent of heparin in the infusion container is important for anticoagulation therapy but does not take precedence over assessing circulation in the hand.
Question 8 of 9
A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?
Correct Answer: A
Rationale: The correct answer is A: Cardiac rate and rhythm. In an acid-base imbalance, the pH is below the normal range indicating acidosis. The nurse should assess the cardiac rate and rhythm first because acidosis can have negative effects on the cardiovascular system. Acidosis can lead to arrhythmias and decreased cardiac output. Monitoring the cardiac rate and rhythm is crucial to detect any cardiac complications early. Choices B, C, and D are not the priority in this situation as they are not directly impacted by acid-base imbalances.
Question 9 of 9
You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the followin
Correct Answer: A
Rationale: Step 1: High magnesium levels can lead to hypermagnesemia, which can cause decreased neuromuscular function. Step 2: Diminished deep tendon reflexes are a sign of neuromuscular impairment, indicating potential hypermagnesemia. Step 3: Assessing for diminished deep tendon reflexes is crucial to monitor neuromuscular function in patients with high magnesium levels. Summary: A is correct because hypermagnesemia affects neuromuscular function. B, C, and D are incorrect as they do not directly relate to the effects of high magnesium levels.