ATI RN
Chapter 14 Nutrition and Fluid Balance Questions
Question 1 of 5
A patient with liver cirrhosis is receiving diuretic therapy. The nurse observes confusion, irritability, and muscle twitching. The serum sodium level is 118 mEq/L. What is the most likely diagnosis?
Correct Answer: C
Rationale: The correct answer is C: Hyponatremia. In liver cirrhosis, impaired liver function can lead to decreased production of plasma proteins, causing fluid to shift into the interstitial spaces and diluting the sodium concentration in the blood. This results in hyponatremia, which can present with confusion, irritability, and muscle twitching. A: Hypernatremia is incorrect as the patient's serum sodium level is low. B: Hypocalcemia is incorrect as the symptoms are more indicative of hyponatremia. D: Hyperkalemia is incorrect as the patient's symptoms are not consistent with high potassium levels.
Question 2 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 3 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 4 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.
Question 5 of 5
A normal glomerular filtration rate is
Correct Answer: B
Rationale: The correct answer is B (80 to 125 mL/min) because it falls within the normal range of glomerular filtration rate (GFR) in adults, which is typically around 90-120 mL/min. GFR represents the amount of blood filtered by the glomeruli per minute and serves as an essential indicator of kidney function. Option A is incorrect as a GFR below 60 mL/min is indicative of kidney dysfunction. Option C is incorrect as a GFR of 125-180 mL/min is considered above the normal range. Option D is incorrect as a GFR exceeding 189 mL/min could indicate hyperfiltration, often seen in conditions like diabetes.