ATI RN
Chapter 14 Nutrition and Fluid Balance Answer Key Questions
Question 1 of 5
A patient presents with confusion, muscle cramps, and a serum potassium of 2.9 mEq/L. What is the most appropriate intervention?
Correct Answer: A
Rationale: The correct answer is A: Administer IV potassium chloride. The patient has hypokalemia (low potassium levels) which can lead to serious complications like cardiac arrhythmias. IV potassium chloride is the fastest way to increase potassium levels in severe cases. Choice B is not appropriate as oral potassium may be too slow. Choice C, calcium gluconate, is used for hyperkalemia, not hypokalemia. Choice D, sodium bicarbonate, does not address the potassium deficiency. Administering IV potassium chloride is the most appropriate and urgent intervention to quickly correct the low potassium levels and prevent further complications.
Question 2 of 5
A patient is admitted with a serum phosphate level of 2.1 mg/dL and reports muscle weakness. Which intervention should the nurse prioritize?
Correct Answer: A
Rationale: The correct answer is A: Administer calcium supplements. In hypophosphatemia, low phosphate levels can lead to low calcium levels due to reciprocal relationship between the two minerals. This can cause muscle weakness. Administering calcium supplements helps maintain calcium-phosphate balance, improving muscle function. Administering potassium or phosphate supplements can worsen the imbalance. Encouraging sodium intake is unrelated to correcting the issue.
Question 3 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 4 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 5 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.