ATI RN
Chapter 14 Nutrition and Fluid Balance Answer Key Questions
Question 1 of 5
A patient is found unconscious with a blood pH of 7.20, PaCO₂ of 50 mmHg, and HCO₃⻠of 25 mEq/L. What is the most likely cause of this condition?
Correct Answer: C
Rationale: The correct answer is C: Diabetic ketoacidosis. In DKA, the body produces excess ketones due to lack of insulin, leading to metabolic acidosis. The low blood pH (acidosis), elevated PaCO2 (due to compensatory respiratory response), and low HCO3- levels are consistent with this condition. Sedative overdose (A) would not cause metabolic acidosis. Hyperventilation (B) would lead to respiratory alkalosis, not acidosis. Excessive vomiting (D) would result in metabolic alkalosis, not acidosis. Thus, the most likely cause in this scenario is diabetic ketoacidosis.
Question 2 of 5
The nurse uses a diagram to demonstrate how in dehydration the water is drawn into the plasma from the cells by which process?
Correct Answer: D
Rationale: In dehydration, water moves from cells to plasma to maintain osmotic balance. Osmosis is the process of water moving from an area of lower solute concentration (cells) to higher solute concentration (plasma). This maintains the body's fluid balance. Distillation involves separating substances by boiling and condensing, not relevant here. Diffusion is the movement of solutes from high to low concentration, not specific to water movement. Filtration involves passing a liquid through a filter to separate particles, not applicable to cellular water movement. Therefore, osmosis is the correct process in dehydration.
Question 3 of 5
The nurse is caring for a patient with a potassium level of 2.9 mEq/L. The nurse should carefully monitor the patient for which potential problem?
Correct Answer: B
Rationale: The correct answer is B: Abdominal distention. A low potassium level (hypokalemia) can lead to gastrointestinal issues, such as decreased bowel motility, which can result in abdominal distention. Here's the step-by-step rationale: 1. Hypokalemia can cause smooth muscle weakness, leading to decreased bowel motility. 2. Decreased bowel motility can result in the accumulation of gas and fluid in the intestines, causing abdominal distention. 3. Monitoring for abdominal distention is crucial as it can indicate potential complications like bowel obstruction or ileus. Summary: A: Excessive urinary output is more commonly associated with conditions like diabetes or diuretic use, not specifically related to hypokalemia. C: Increased reflexes are not typically associated with hypokalemia; instead, hyporeflexia may be seen in severe cases. D: Hyperactive bowel sounds are more indicative of conditions like gastroenteritis or bowel obstruction, not directly related to
Question 4 of 5
The patient with long-term obstructive pulmonary disease has a pH of 7, HCO3- of 18 mEq/L, and a PaCO2 of 40 mm Hg. These laboratory values are consistent with which acid-base imbalance?
Correct Answer: D
Rationale: The given pH, HCO3-, and PaCO2 values indicate metabolic acidosis. The low pH and HCO3- suggest acidemia and metabolic acidosis, respectively. The normal PaCO2 rules out respiratory acidosis/alkalosis. In metabolic acidosis, the kidneys cannot adequately excrete acids, leading to decreased HCO3-. Respiratory alkalosis/metabolic alkalosis involve high pH or HCO3- levels, which are not present here. Therefore, the correct answer is D: Metabolic acidosis.
Question 5 of 5
Because there are no IV pumps available for the immediate infusion of an IV medication, the nurse must calculate the flow rate for 500 mL to run for 4 h, using a set that delivers 15 gtt/mL. Which flow rate is correct?
Correct Answer: A
Rationale: The correct answer is A (30 gtt/min). To calculate the flow rate, first determine the total drops needed (500 mL x 15 gtt/mL = 7500 gtt) for 4 hours. Then, divide total drops by total time in minutes (4 hours x 60 min/hr = 240 min) to get 31.25 gtt/min. Since IV pumps deliver whole drops, round down to the nearest whole number, giving a flow rate of 30 gtt/min. Choice B, C, and D are incorrect as they do not reflect the accurate calculation based on the given information.