ATI RN
Fluid and Electrolytes ATI Questions
Question 1 of 9
A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:
Correct Answer: B
Rationale: The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.
Question 2 of 9
A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:
Correct Answer: D
Rationale: Although changes in all these findings are seen in hyperkalemia, ECG changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the patient's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.
Question 3 of 9
A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:
Correct Answer: B
Rationale: The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.
Question 4 of 9
A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:
Correct Answer: B
Rationale: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and less commonly in the feet. Taking a normal blood pressure could illicit a carpal spasm if it creates slight ischemia of the ulnar nerve.
Question 5 of 9
When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:
Correct Answer: B
Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Selection of a distal site leaves the upper veins available for subsequent cannulations. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes.
Question 6 of 9
The nurse preparing a site for the insertion of an IV catheter should treat excess hair at the site by:
Correct Answer: C
Rationale: Hair can be a source of infection and should be removed by clipping. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.
Question 7 of 9
A patient with hypokalemia and heart failure is admitted to the telemetry unit. The nurse is aware that hypokalemia could cause which of the following abnormalities on an electrocardiogram (ECG)?
Correct Answer: D
Rationale: Hypokalemia often causes characteristic ECG changes, including an elevated U wave and flattened T waves.
Question 8 of 9
A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?
Correct Answer: C
Rationale: The symptoms of neck vein distention and dyspnea suggest fluid overload. Placing the patient in semi-Fowler's position and administering diuretics can help reduce fluid volume and improve breathing.
Question 9 of 9
The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?
Correct Answer: B
Rationale: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation.