ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 of 5
A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause
Correct Answer: B
Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation leads to excessive elimination of carbon dioxide, causing a decrease in PaCO2 levels, resulting in respiratory alkalosis. This is the most common cause of hyperventilation. Respiratory acidosis (choice A) occurs when there is retention of carbon dioxide. Increased PaCO2 (choice C) is a consequence of respiratory acidosis, not alkalosis. CNS disturbances (choice D) can lead to abnormal breathing patterns but are not the most common cause of hyperventilation.
Question 2 of 5
You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
Correct Answer: C
Rationale: Correct Answer: C - Infiltration Rationale: 1. Infiltration occurs when IV fluid leaks into surrounding tissues, causing edema. 2. Documenting infiltration is important for appropriate management. 3. Air emboli, phlebitis, and fluid overload are unrelated to edema around IV site. Summary of Incorrect Choices: A. Air emboli: This is a serious condition caused by air entering the bloodstream, not related to edema. B. Phlebitis: Inflammation of the vein, usually presenting with redness and pain, not edema. D. Fluid overload: Excess fluid volume in the body, leading to symptoms like shortness of breath, not edema.
Question 3 of 5
You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?
Correct Answer: C
Rationale: The correct answer is C: Inelastic skin turgor is a normal part of aging. As people age, their skin loses elasticity and becomes less turgid, which can affect skin turgor assessment. Skin turgor assessment is an important indicator of hydration status, and in older adults, it is normal for the skin to be less elastic. This is due to changes in collagen and elastin fibers in the skin with aging. Choices A, B, and D are incorrect because overhydration is not common among healthy older adults, dehydration causes the skin to appear tented rather than spongy, and skin turgor can still be assessed in patients over 70, although it may be less reliable due to natural changes in skin elasticity with aging.
Question 4 of 5
The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
Correct Answer: B
Rationale: The correct answer is B because considering potential effects on the patient's mobility is crucial when selecting a site for IV insertion. Mobility can be affected if the IV is placed in a joint area or on the dominant hand. This could limit the patient's ability to move freely during and after the procedure. Therefore, it is important to choose a site that will not hinder the patient's movement. A: Choosing a hairless site is not the most important factor when selecting a site for IV insertion. C: Having the patient hold his arm over his head before insertion is not necessary and may cause discomfort for the patient. D: Leaving the tourniquet on for at least 3 minutes is not recommended as it can lead to complications such as venous stasis.
Question 5 of 5
A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?
Correct Answer: B
Rationale: The correct answer is B: Osmosis and osmolality. When a hypertonic solution is infused, it increases the number of dissolved particles in the blood, creating an osmotic pressure gradient. This causes fluids in the tissues to shift into the capillaries, increasing blood volume. Osmosis is the movement of solvent (water) across a semi-permeable membrane to equalize solute concentrations. Osmolality refers to the concentration of solutes in a solution. Hydrostatic pressure (choice A) is the force exerted by a fluid against a wall when it is under pressure, not related to the movement of solutes. Diffusion (choice C) is the movement of solute molecules from an area of high concentration to low concentration, not involving a semi-permeable membrane. Active transport (choice D) requires energy to move molecules across a membrane against their concentration gradient, not the mechanism described in the scenario.