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
The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?
Correct Answer: B
Rationale: The correct answer is B because limiting fluids can lead to dehydration, which can cause confusion and dry mucous membranes. Adjusting the timing of fluids can help maintain hydration without causing frequent nighttime bathroom trips. Choice A is incorrect because hospital readmission is not necessary at this point. Choice C is incorrect as it normalizes confusion post-surgery and dangerous practice of avoiding urination at night. Choice D is incorrect because urine accumulation in the bladder does not directly cause confusion; dehydration is the primary concern.
Question 3 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 4 of 9
A nurse is assessing a client with hypokalemia and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
Correct Answer: A
Rationale: The correct action for the nurse to take first is to assess the client's respiratory rate, rhythm, and depth (Choice A). Diminished handgrip strength in a client with hypokalemia could indicate potential respiratory muscle weakness, which can lead to respiratory distress or failure. By assessing the client's respiratory status, the nurse can determine if immediate intervention is needed to support breathing. Choice B is incorrect because measuring the client's pulse and blood pressure may not address the underlying issue of respiratory muscle weakness. Choice C is incorrect as it delays potential life-saving interventions by simply documenting findings. Choice D is incorrect as calling the healthcare provider should come after addressing the client's immediate respiratory needs.
Question 5 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 6 of 9
You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly?
Correct Answer: B
Rationale: The correct answer is B: Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. Patient with pancreatitis may have depleted levels of phosphorus due to malnutrition, and rapid initiation of TPN can further decrease phosphorus levels, leading to hypophosphatemia. This can result in respiratory failure, muscle weakness, and arrhythmias. Choice A is incorrect because patients receiving TPN are not specifically at risk for hypercalcemia due to rapid initiation of calories. Choice C is incorrect because rapid fluid infusion can lead to hypernatremia, not related to TPN initiation. Choice D is incorrect because the rationale provided for slow initiation is not related to digestive enzymes but rather to prevent hypophosphatemia in malnourished patients.
Question 7 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 8 of 9
The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit
Correct Answer: B
Rationale: The correct answer is B: Dilute urine. Hypokalemia can lead to kidney dysfunction, causing the kidneys to excrete more water along with electrolytes, resulting in dilute urine. This is a manifestation of the body's attempt to compensate for low potassium levels by excreting excess water. The other choices are incorrect because: A) Diarrhea is more commonly associated with hyperkalemia, not hypokalemia. C) Increased muscle tone is not a typical sign of hypokalemia; rather, hypokalemia can lead to muscle weakness or paralysis due to impaired muscle function. D) Joint pain is not a typical symptom of hypokalemia; joint pain is more commonly associated with other conditions such as arthritis or inflammation.
Question 9 of 9
You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?
Correct Answer: D
Rationale: The correct answer is D: Hypercalcemia. Bone metastases in lung cancer can lead to increased release of calcium into the blood, causing hypercalcemia. The patient's symptoms of weakness and abdominal pain are consistent with hypercalcemia. Hypernatremia (choice A) is unlikely as the symptoms do not align with high sodium levels. Hypomagnesemia (choice B) and hypophosphatemia (choice C) are less likely as they are not typically associated with bone metastases in lung cancer. In summary, the patient's presentation of weakness and abdominal pain in the setting of lung cancer with bone metastases points to hypercalcemia as the most likely electrolyte imbalance.