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 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 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
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 5 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 6 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 7 of 9
. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?
Correct Answer: D
Rationale: The correct answer is D. A cool lower extremity can indicate impaired circulation due to the intraosseous catheter placement, leading to compartment syndrome or tissue necrosis. This finding requires immediate intervention to prevent serious complications. Choices A, B, and C are incorrect because the duration of catheter placement, poor vascular access, and the specific location of the catheter do not directly impact circulation and tissue perfusion as significantly as a cool lower extremity.
Question 8 of 9
After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?
Correct Answer: C
Rationale: The correct answer is C because taking sodium bicarbonate after every meal can actually increase the risk of metabolic alkalosis due to its alkaline nature. Sodium bicarbonate can lead to an excessive build-up of bicarbonate in the bloodstream, causing alkalosis. Choice A is not directly related to metabolic alkalosis. Choice B, taking digoxin, is unrelated to metabolic alkalosis as well. Choice D, drinking six glasses of water due to sweating, does not contribute to metabolic alkalosis as it helps maintain hydration and electrolyte balance.
Question 9 of 9
. A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?
Correct Answer: D
Rationale: The correct answer is D. The man's elevated heart rate, anxiety, and low urine output indicate a sympathetic reaction. This reaction stimulates the renin-angiotensin-aldosterone system, leading to decreased urine output. The sympathetic response triggers the release of renin, which activates angiotensin II and aldosterone, causing vasoconstriction and water reabsorption in the kidneys, ultimately reducing urine output. Choice A is incorrect because low urine output is not solely due to urinating before arrival. Choice B is incorrect as there is no indication of traumatic brain injury or ADH deficiency. Choice C is incorrect as atrial natriuretic peptide in heart failure typically increases urine output.