ATI RN
Chapter 14 Nutrition and Fluid Balance Workbook Answers Questions
Question 1 of 5
A patient who is lethargic and with deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO 88 mm Hg, PaCO 2 2
Correct Answer: D
Rationale: The correct answer is D, Respiratory Acidosis. Rationale: 1. The low pH of 7.32 indicates acidosis. 2. The PaCO2 level of 88 mm Hg is high, indicating respiratory acidosis. 3. Deep, rapid respirations are a compensatory mechanism to try to decrease CO2 levels. 4. PaO2 level is not significantly low to suggest respiratory alkalosis. Summary: A: Incorrect. The low HCO3 level and high PaCO2 suggest respiratory acidosis, not base balance. B: Incorrect. While acidosis is present, it is respiratory, not metabolic. C: Incorrect. The ABG results do not support metabolic alkalosis.
Question 2 of 5
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient's urine output has been less than 20 mL/hour for the past 2 hours. The patient's blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should
Correct Answer: A
Rationale: Step 1: The patient has signs of decreased urine output (oliguria), which can indicate inadequate kidney perfusion. Step 2: The patient's low urine output coupled with a drop in blood pressure and increased heart rate suggests hypovolemia. Step 3: Administering a normal saline bolus can help restore intravascular volume and improve kidney perfusion, addressing the underlying issue. Step 4: Contacting the provider for a prescription ensures timely intervention to prevent further complications like acute kidney injury. Summary: - Option B is incorrect because waiting for the provider may delay necessary treatment. - Option C delays immediate intervention for a potentially critical situation. - Option D is incorrect as ignoring oliguria in this context can lead to serious consequences.
Question 3 of 5
The patient is in a progressive care unit following arteriovenous fistula implantation in his left upper arm, and is due to have blood drawn with his next set of vital signs and assessment. When the nurse assesses the patient, the nurse should
Correct Answer: D
Rationale: The correct answer is D. Auscultating the left arm for a bruit and palpating for a thrill are essential post-arteriovenous fistula implantation assessments. A bruit indicates turbulent blood flow, which could suggest stenosis or occlusion. A thrill indicates the patency of the fistula. Drawing blood from the left arm (A) should be avoided to prevent damage to the fistula. Taking blood pressure from the left arm (B) could also damage the fistula. Starting a new intravenous line in the left lower arm (C) is unnecessary and could increase the risk of infection.
Question 4 of 5
The critical care nurse is responsible for monitoring the patient receiving continuous renal replacement therapy (CRRT). In doing so, the nurse should
Correct Answer: B
Rationale: The correct answer is B: assess the hemofilter every 6 hours for clotting. This is crucial in CRRT as clotting can lead to decreased efficacy or even system failure. By checking the hemofilter regularly, the nurse can detect clot formation early and prevent complications. Assessing the blood tubing for warmth (A) is not a reliable indicator of clotting or malfunction. Covering dialysis lines to protect from light (C) is not necessary for CRRT monitoring. Using clean technique during vascular access dressing changes (D) is important for infection prevention but not directly related to hemofilter clotting in CRRT.
Question 5 of 5
Complications common to patients receiving hemodialysis for acute kidney injury include which of the following? (Select all that apply.)
Correct Answer: A
Rationale: Correct Answer: A Rationale: 1. Hemodialysis involves fluid removal, which can lead to hypotension due to rapid changes in blood volume. 2. Hypotension is a common complication during hemodialysis sessions. 3. Patients on hemodialysis are at increased risk of hypotension due to decreased vascular tone. 4. Monitoring and managing hypotension is crucial to prevent further complications. Summary: B: Dysrhythmias are not commonly associated with hemodialysis for acute kidney injury. C: Muscle cramps may occur but are not as common as hypotension. D: Hemolysis is not a typical complication of hemodialysis for acute kidney injury.