ATI RN
Nutrition and Fluid Balance Chapter 14 Questions
Question 1 of 5
A patient is admitted for aggressive diuretic therapy for congestive heart failure (CHF). After several doses, the patient complains of muscle cramps and weakness. What electrolyte imbalance should the nurse suspect?
Correct Answer: B
Rationale: The correct answer is B: Hypokalemia. Aggressive diuretic therapy can lead to potassium loss, causing muscle cramps and weakness. Potassium is essential for muscle function, and low levels can result in muscle-related symptoms. Hypernatremia (A) is an imbalance of high sodium levels, not typically associated with muscle cramps. Hyperkalemia (C) is high potassium levels and would not be expected with aggressive diuretic therapy. Hyponatremia (D) is low sodium levels, also not directly related to the symptoms described. Therefore, the most likely electrolyte imbalance in this scenario is hypokalemia.
Question 2 of 5
Which statement demonstrates that the patient accurately understands the nurse's teaching related to a low-sodium diet?
Correct Answer: C
Rationale: The correct answer is C because avocados and oranges are low in sodium, indicating understanding of a low-sodium diet. Dried fruits (A) are often high in sodium due to processing. Tomato juice (B) can be high in sodium unless it's low-sodium. A cheeseburger (D) typically contains high amounts of sodium, especially with extra ketchup. By choosing avocado and orange salad, the patient demonstrates good knowledge of low-sodium food choices.
Question 3 of 5
The nurse is caring for a patient with metabolic acidosis. Which assessment finding reveals that the compensatory mechanism to correct this imbalance is in effect?
Correct Answer: C
Rationale: The correct answer is C: Kussmaul respirations. In metabolic acidosis, the body compensates by increasing the respiratory rate to exhale excess CO2 and decrease acidity in the blood. Kussmaul respirations are deep, rapid breaths that help restore the acid-base balance. Increased urinary output (A) is not a compensatory mechanism for metabolic acidosis. Reduced abdominal distention (B) is unrelated to acid-base imbalances. Decreased blood pressure (D) is not a typical compensatory response to metabolic acidosis.
Question 4 of 5
The nurse is caring for a patient who has been on total parenteral nutrition (TPN) for 48 h. Which action demonstrates effective nursing care?
Correct Answer: A
Rationale: Step-by-step rationale for why choice A is correct: 1. Checking the patient's blood glucose level is crucial as TPN can significantly affect glucose levels. 2. Regular monitoring helps prevent complications like hyperglycemia or hypoglycemia. 3. Following facility protocol ensures consistency and accuracy in patient care. 4. Timely intervention based on blood glucose levels can prevent adverse effects. Summary of why other choices are incorrect: B: Increasing infusion rate without proper assessment can lead to metabolic complications. C: TPN administration method depends on patient condition, not a fixed duration. D: Monitoring peripheral IV site is irrelevant for TPN, which requires a central line.
Question 5 of 5
The nurse is caring for a patient who has sustained blunt trauma to the left flank area, and is evaluating the patient's urinalysis results. The nurse should become concerned when
Correct Answer: D
Rationale: The correct answer is D. Presence of red blood cells and albumin in the urine indicates possible kidney damage due to the blunt trauma. This is concerning as it may suggest renal impairment or injury. Choices A, B, and C are normal findings and do not necessarily indicate kidney damage. A: Similar creatinine levels in urine and blood are expected as creatinine is filtered by the kidneys. B: Sodium and chloride in urine are normal components and their presence is expected. C: Uric acid levels in urine mirroring serum levels is a normal finding.