ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 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: D
Rationale: The correct answer is D: Read food labels to determine sodium content. The nurse should assess the client's sodium level of 144 mEq/L, which is slightly above the normal range. High sodium intake can lead to fluid retention, hypertension, and other health issues. By reading food labels to determine sodium content, the nurse can identify sources of high sodium intake in the client's diet and provide appropriate dietary recommendations. This assessment is crucial in managing the client's sodium levels and overall health. Assessing the client's dietary intake of foods high in potassium (Choice A) is not the priority in this case since the client's potassium level is within the normal range. Assessing the client's neuromuscular status (Choice B) is important but not the first priority when considering the electrolyte imbalances present. Assessing the client's fluid intake and output (Choice C) is also important but does not address the immediate concern related to the client's elevated sodium level.
Question 2 of 9
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?
Correct Answer: D
Rationale: The correct answer is D: Teach the client fall prevention measures. In metabolic alkalosis, the client may experience muscle weakness and confusion, increasing the risk of falls. Teaching fall prevention measures is essential to ensure the client's safety. Monitoring hemoglobin and hematocrit values (A) is not directly related to managing metabolic alkalosis. Administering furosemide (B) is not appropriate for metabolic alkalosis. Encouraging deep breaths (C) may not address the underlying cause of the alkalosis.
Question 3 of 9
You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
Correct Answer: C
Rationale: Correct Answer: C - Infiltration Rationale: 1. Infiltration occurs when IV fluid leaks into surrounding tissues, causing edema. 2. Documenting infiltration is important for appropriate management. 3. Air emboli, phlebitis, and fluid overload are unrelated to edema around IV site. Summary of Incorrect Choices: A. Air emboli: This is a serious condition caused by air entering the bloodstream, not related to edema. B. Phlebitis: Inflammation of the vein, usually presenting with redness and pain, not edema. D. Fluid overload: Excess fluid volume in the body, leading to symptoms like shortness of breath, not edema.
Question 4 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 5 of 9
A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?
Correct Answer: C
Rationale: Rationale: Option C is correct because berries, cherries, apples, and peaches are indeed low in potassium compared to other fruits. This response acknowledges the client's love for fruits while providing suitable alternatives to manage potassium levels. By choosing these low-potassium fruits, the client can continue enjoying fruits without exacerbating hyperkalemia. Incorrect options: A: Potatoes and avocados are high in potassium, so they are not suitable substitutes. B: Cooking fruit does not significantly reduce its potassium content. D: This option lacks guidance and does not offer a solution to the client's concern about high potassium levels.
Question 6 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: D
Rationale: The correct answer is D: Read food labels to determine sodium content. The nurse should assess the client's sodium level of 144 mEq/L, which is slightly above the normal range. High sodium intake can lead to fluid retention, hypertension, and other health issues. By reading food labels to determine sodium content, the nurse can identify sources of high sodium intake in the client's diet and provide appropriate dietary recommendations. This assessment is crucial in managing the client's sodium levels and overall health. Assessing the client's dietary intake of foods high in potassium (Choice A) is not the priority in this case since the client's potassium level is within the normal range. Assessing the client's neuromuscular status (Choice B) is important but not the first priority when considering the electrolyte imbalances present. Assessing the client's fluid intake and output (Choice C) is also important but does not address the immediate concern related to the client's elevated sodium level.
Question 7 of 9
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications
Correct Answer: A
Rationale: The correct answer is A: Initiate a dedicated team to insert access devices. This intervention is the most effective in decreasing complications related to IV therapy because having a dedicated team specialized in inserting access devices ensures that the procedure is done correctly each time, reducing the risk of complications such as bloodstream infections. Choice B is not as effective because additional education for all nurses may not guarantee consistent skill levels in IV insertion. Choice C may limit access but does not address the root cause of complications. Choice D focuses on skin preparation, which is important but not as impactful as having a specialized team for IV insertion.
Question 8 of 9
You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated so you stop the infusion. What is your main concern with this infiltration?
Correct Answer: A
Rationale: The correct answer is A: Extravasation of the medication. Extravasation occurs when the infused medication leaks into surrounding tissues, potentially causing tissue damage and necrosis. This is a serious concern with vesicant medications like daunorubicin. If left untreated, it can lead to severe complications. Choice B: Discomfort to the patient is incorrect because while discomfort may occur with infiltration, the main concern is the potential for tissue damage from extravasation. Choice C: Blanching at the site is incorrect as it is a common sign of infiltration, but the main concern is the possibility of extravasation and tissue damage. Choice D: Hypersensitivity reaction to the medication is incorrect as it is a different type of reaction that is not directly related to infiltration or extravasation.
Question 9 of 9
. One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acutecare nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?
Correct Answer: C
Rationale: The correct answer is C: Help distinguish reduced renal blood flow from decreased renal function. Rationale: 1. Oliguria is a decrease in urine output. 2. Fluid challenge with normal saline can help determine the cause of oliguria by assessing the response of the kidneys. 3. If the oliguria improves after the fluid challenge, it suggests reduced renal blood flow as the cause. 4. If oliguria persists, it indicates decreased renal function. Summary: A. Fluid challenge does not directly help in distinguishing between hyponatremia and hypernatremia. B. Evaluating pituitary gland function requires specific tests, not just a fluid challenge. D. Treating hypertension-induced oliguria may involve different interventions, not just a fluid challenge.