ATI RN
Fluid and Electrolytes ATI Questions
Question 1 of 5
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: In this scenario, the correct action for the nurse to take is option C: Place the patient in semi-Fowler's and prepare to give the PRN diuretic as ordered. This choice is the most appropriate because the patient's signs of distended neck veins and dyspnea indicate fluid volume overload, likely due to heart failure. Placing the patient in semi-Fowler's position helps improve respiratory effort, and administering a diuretic can help reduce excess fluid volume and alleviate symptoms. Option A is incorrect because placing the patient in low Fowler's may worsen respiratory distress in a patient with heart failure. Option B is incorrect as increasing IV fluid can exacerbate fluid overload, and auscultating the lungs alone does not address the underlying issue. Option D is also incorrect as discontinuing the IV without addressing the fluid overload would not be beneficial and could lead to complications. From an educational perspective, understanding the rationale behind the correct action helps nurses provide safe and effective care for patients with heart failure. Recognizing signs of fluid overload and knowing appropriate interventions, such as positioning and administering diuretics, are essential skills for managing patients with cardiac conditions. This case highlights the importance of prompt assessment and intervention in addressing fluid and electrolyte imbalances in patients with heart failure.
Question 2 of 5
A patient with diabetes insipidus is admitted to the intensive care unit after a motor vehicle accident that resulted in head trauma and damage to the pituitary gland. Diabetes insipidus can occur when there is a decreased production of which of the following?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) ADH (antidiuretic hormone). ADH, also known as vasopressin, is produced in the hypothalamus and stored in the posterior pituitary gland. Diabetes insipidus is a condition characterized by the inability to concentrate urine due to the inadequate production or release of ADH. This results in excessive urination and thirst. Option B) Estrogen is a hormone produced mainly by the ovaries and in smaller amounts by the adrenal glands and fat cells. Estrogen does not play a direct role in fluid and electrolyte balance regulation. Option C) Aldosterone is a hormone produced by the adrenal glands that plays a key role in regulating sodium and potassium balance in the body by acting on the kidneys. However, aldosterone is not directly related to the production of ADH. Option D) Renin is an enzyme produced by the kidneys in response to low blood pressure or low sodium levels. Renin plays a role in the renin-angiotensin-aldosterone system, which helps regulate blood pressure and fluid balance, but it is not responsible for the production of ADH. Understanding the role of ADH in fluid balance regulation is crucial in medical-surgical nursing, especially in managing conditions like diabetes insipidus. Nurses need to be able to recognize the signs and symptoms of fluid and electrolyte imbalances and understand the underlying pathophysiology to provide effective care for patients with such conditions.
Question 3 of 5
The nurse is caring for a patient who is diaphoretic from a fever. The amount of sodium excreted in the urine will:
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Decrease. When a patient is diaphoretic from a fever, they are losing fluids through sweating, leading to a decrease in total body fluid volume. As a compensatory mechanism, the body tries to retain as much sodium and water as possible to maintain fluid balance and prevent dehydration. Option B) Increase is incorrect because the body's response to diaphoresis is to conserve sodium, not excrete more of it. Option C) Remain unchanged is incorrect because the body needs to retain sodium to compensate for fluid loss. Option D) Fluctuate is incorrect as there is a clear physiological response to sweating and fever that leads to a decrease in sodium excretion. Educationally, understanding the relationship between fever, diaphoresis, and sodium excretion is crucial for nurses caring for patients with fluid and electrolyte imbalances. This knowledge helps nurses anticipate and manage potential complications related to fluid loss and electrolyte disturbances in various clinical settings.
Question 4 of 5
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 correct answer is B) Respiratory alkalosis. When a patient hyperventilates due to anxiety, they are exhaling more carbon dioxide (CO2) than normal. This excessive loss of CO2 leads to a decrease in PaCO2 levels in the blood, resulting in respiratory alkalosis. In respiratory alkalosis, there is an imbalance in the body's acid-base status characterized by a high pH and low PaCO2. Option A) Respiratory acidosis is incorrect because hyperventilation leads to a decrease in PaCO2, causing alkalosis, not acidosis. Option C) Increased PaCO2 is incorrect because hyperventilation actually causes a decrease in PaCO2 due to excessive CO2 exhalation. Option D) Central nervous system (CNS) disturbances is incorrect as it is not directly related to the acid-base imbalance caused by hyperventilation. Understanding the acid-base imbalances related to respiratory conditions is crucial in medical-surgical nursing as it helps nurses identify, assess, and manage patients with respiratory distress effectively. Recognizing the signs and symptoms of respiratory alkalosis, such as hyperventilation in this case, allows for timely intervention to correct the imbalance and improve patient outcomes.
Question 5 of 5
Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would the nurse interpret the results?
Correct Answer: D
Rationale: In this scenario, the correct interpretation of the arterial blood gas results provided is "D) Metabolic acidosis with a compensatory respiratory alkalosis." This interpretation is based on understanding the body's compensatory mechanisms when there is an imbalance in acid-base status. The pH of 7.26 indicates acidosis, the low PaCO2 of 28 suggests respiratory alkalosis (as it is below the normal range of 35-45 mmHg), and the low HCO3 of 11 indicates metabolic acidosis. In this case, the primary disorder is metabolic acidosis, as evidenced by the low HCO3, and the compensatory response is a decrease in PaCO2 to try to raise the pH back towards normal levels, resulting in a compensatory respiratory alkalosis. Option A is incorrect because there is evidence of metabolic acidosis in addition to the respiratory alkalosis. Option B is incorrect as there is no evidence of metabolic alkalosis. Option C is incorrect as there is evidence of both metabolic acidosis and respiratory alkalosis, indicating compensation. Understanding arterial blood gas results is crucial in medical-surgical nursing as it helps nurses identify and manage acid-base imbalances, guiding appropriate interventions and treatment plans to restore balance and improve patient outcomes. Nurses need to interpret these results accurately to provide safe and effective care to patients with complex physiological disturbances.