ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 of 9
A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?
Correct Answer: C
Rationale: The correct answer is C: Clip the hair in the area. Clipping the hair is the most appropriate option as it reduces the risk of infection during IV insertion by minimizing the presence of bacteria that may be trapped in the hair. Shaving (B) can cause micro-abrasions leading to increased infection risk. Leaving the hair intact (A) can also trap bacteria. Using a depilatory (D) can cause skin irritation and should be avoided. In summary, clipping the hair is the best option to maintain a clean and safe environment for IV insertion.
Question 2 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: A
Rationale: The correct assessment for the nurse to complete first is A: Depth of respirations. Potassium and magnesium levels are crucial electrolytes that can affect cardiac function. Hypokalemia (low potassium) and hypomagnesemia (low magnesium) can lead to cardiac dysrhythmias. Checking the depth of respirations can provide valuable information on the client's respiratory status and potential respiratory distress due to electrolyte imbalances. This assessment takes precedence as addressing respiratory issues promptly is essential to prevent further complications. Assessing bowel sounds (B), grip strength (C), and electrocardiography (D) are important but not as immediate as assessing respiratory status in this scenario.
Question 3 of 9
The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect?
Correct Answer: D
Rationale: The correct answer is D: Decrease in glomerular filtration. Sympathetic stimulation constricts renal arterioles, leading to decreased blood flow to the kidneys. This reduction in blood flow decreases the glomerular filtration rate, impacting the kidney's ability to filter blood and produce urine. The constriction of renal arterioles does not directly affect the release of aldosterone (choice A), filtration in the Loop of Henle (choice B), or the reabsorption of sodium (choice C). The primary effect of sympathetic stimulation on renal arterioles is to decrease glomerular filtration by reducing blood flow to the kidneys.
Question 4 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 5 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 6 of 9
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that do not apply.)
Correct Answer: B
Rationale: The correct answer is B because hyperphosphatemia can lead to paresthesia with sensations of tingling and numbness due to its effect on nerve function. A, hypokalemia causes muscle weakness but not flaccid paralysis with respiratory depression. C, hyponatremia typically presents with symptoms such as confusion and seizures, not decreased level of consciousness.
Question 7 of 9
You are the nurse evaluating a newly admitted patients laboratory results, which include several values that are outside of reference ranges. Which of the following would cause the release of antidiuretic hormone (ADH)?
Correct Answer: A
Rationale: The correct answer is A: Increased serum sodium. High serum sodium levels trigger the release of antidiuretic hormone (ADH) from the pituitary gland to help retain water in the body and maintain fluid balance. This is a physiological response to prevent further dehydration. Decreased serum potassium (choice B), decreased hemoglobin (choice C), and increased platelets (choice D) do not directly stimulate the release of ADH. Hence, they are incorrect choices in this scenario.
Question 8 of 9
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that do mot apply.)
Correct Answer: B
Rationale: Correct Answer: B - Slow, shallow respirations Rationale: 1. Electrolyte imbalance in renal failure often leads to respiratory alkalosis, causing rapid and deep respirations, not slow and shallow. 2. Electrocardiogram changes (A) are common with electrolyte imbalances, particularly potassium and calcium. 3. Paralytic ileus (C) is a complication of electrolyte imbalances, affecting gastrointestinal motility. 4. Skeletal muscle weakness (D) is a common manifestation of electrolyte imbalances, especially potassium and magnesium deficiencies. Summary: Choice B is incorrect because slow, shallow respirations are not typically associated with electrolyte imbalances related to renal failure. Choices A, C, and D are commonly seen complications of electrolyte imbalances and should be assessed by the nurse.
Question 9 of 9
A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
Correct Answer: A
Rationale: The correct answer is A: Encourage oral fluid intake. When a client has hypercalcemia (serum calcium level of 14 mg/dL), the priority is to increase fluid intake to promote renal calcium excretion. This helps prevent complications such as renal calculi. The first step is to dilute the serum calcium by increasing fluid intake, which can help lower the serum calcium level. Connecting the client to a cardiac monitor (B) is not the priority as hypercalcemia affects the kidneys more than the heart. Assessing urinary output (C) is important but encouraging fluid intake is more immediate. Administering oral calcitonin (Calcimar) (D) is not the first action as it is a medication used for long-term management of hypercalcemia, not the immediate priority.