ATI RN
Chapter 14 Nutrition and Fluid Balance Answer Key Questions
Question 1 of 5
If a patient has a serum sodium of 150 mEq/L, which fluid imbalance do they have?
Correct Answer: B
Rationale: The correct answer is B: Hypernatremia. A serum sodium level of 150 mEq/L indicates an elevated sodium concentration in the blood, which signifies hypernatremia. Hypernatremia occurs when there is an excess of sodium relative to water in the body, leading to dehydration and increased serum sodium levels. Hyponatremia (choice A) is characterized by low sodium levels, while choices C and D (Hypokalemia and Hyperkalemia) refer to imbalances in potassium levels, not sodium. Hypernatremia is the appropriate diagnosis based on the given serum sodium level.
Question 2 of 5
A patient is found unconscious with a blood pH of 7.20, PaCO₂ of 50 mmHg, and HCO₃⻠of 25 mEq/L. What is the most likely cause of this condition?
Correct Answer: C
Rationale: The correct answer is C: Diabetic ketoacidosis. In DKA, the body produces excess ketones due to lack of insulin, leading to metabolic acidosis. The low blood pH (acidosis), elevated PaCO2 (due to compensatory respiratory response), and low HCO3- levels are consistent with this condition. Sedative overdose (A) would not cause metabolic acidosis. Hyperventilation (B) would lead to respiratory alkalosis, not acidosis. Excessive vomiting (D) would result in metabolic alkalosis, not acidosis. Thus, the most likely cause in this scenario is diabetic ketoacidosis.
Question 3 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 4 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 5 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