ATI RN
Chapter 14 Nutrition and Fluid Balance Questions
Question 1 of 5
A patient with a serum calcium level of 7.8 mg/dL presents with tingling around the mouth and muscle twitching. What is the likely electrolyte imbalance?
Correct Answer: B
Rationale: The correct answer is B: Hypocalcemia. A serum calcium level of 7.8 mg/dL indicates low calcium levels. Symptoms of tingling around the mouth and muscle twitching are classic signs of hypocalcemia due to its effect on nerve and muscle function. In hypocalcemia, there is increased nerve excitability leading to these symptoms. Hypercalcemia (choice A) would present with symptoms like fatigue and confusion. Hyperkalemia (choice C) and hypokalemia (choice D) involve potassium levels, not calcium, and would present with different symptoms such as cardiac arrhythmias and muscle weakness, respectively.
Question 2 of 5
The patient taking furosemide (Lasix) to correct excess edema shows a weight loss of 5.5 pounds in 24 h. The nurse calculates that this weight loss is equivalent to how many liters (L) of fluid given that each kilogram of weight loss is equivalent to 1 L of fluid?
Correct Answer: D
Rationale: To calculate the amount of fluid loss in liters, we need to convert the weight loss from pounds to kilograms (1 kg = 2.2 lbs). 5.5 lbs ÷ 2.2 = 2.5 kg. Since each kilogram of weight loss is equivalent to 1 L of fluid, the patient lost 2.5 L of fluid in 24 hours. Therefore, the correct answer is D: 2.5 L. Choice A (1 L) is incorrect because the patient lost 2.5 kg, not just 1 kg. Choice B (1.5 L) is incorrect because the patient lost 2.5 kg, not 1.5 kg. Choice C (2.0 L) is incorrect because the patient lost 2.5 kg, not 2 kg.
Question 3 of 5
The nurse is caring for an 80-year-old patient. Which finding is the best early indicator of dehydration in this patient?
Correct Answer: B
Rationale: The correct answer is B: Constipation. Constipation is the best early indicator of dehydration in an 80-year-old patient because dehydration can lead to decreased gastrointestinal motility, resulting in constipation. Reduced skin turgor (A) is a late sign of dehydration. Increased temperature (C) can be a sign of other conditions, not specifically dehydration. Thirst (D) is a normal physiological response to dehydration but may not be the best early indicator in older adults who may have decreased thirst sensation.
Question 4 of 5
The nurse assesses the patient's IV insertion site and observes that the vein is hard, the skin is red and tender, and a blood return in the IV line. After removing the IV catheter, which action should the nurse take next?
Correct Answer: D
Rationale: The correct answer is D: Apply a warm moist pack. Rationale: 1. The symptoms described suggest phlebitis, which is inflammation of the vein. 2. Applying a warm moist pack helps to promote vasodilation and increase blood flow, aiding in the resolution of inflammation. 3. Warmth can also help to alleviate pain and discomfort associated with phlebitis. Summary: A: Obtaining an arm board is unnecessary for phlebitis and does not address the inflammation. B: Elevating the arm above the heart may help reduce swelling but does not directly address the inflammation. C: Cleaning the site and applying cool compresses are not recommended for phlebitis as cold may exacerbate the condition.
Question 5 of 5
The nurse is assessing a patient with renal failure and notes fatigue, muscle cramps, confusion, and headache. Which laboratory abnormality corresponds with these findings?
Correct Answer: B
Rationale: The correct answer is B: Sodium of 129 mEq/L. In renal failure, hyponatremia (low sodium) can cause fatigue, muscle cramps, confusion, and headache. Low sodium levels can lead to neurological symptoms and muscle weakness. Other choices are incorrect: A: Hypokalemia can cause muscle weakness but not confusion or headache. C: Hypocalcemia can cause muscle cramps but not confusion. D: Hypochloremia is not associated with the described symptoms.