ATI RN
Chapter 14 Nutrition and Fluid Balance Workbook Answers Questions
Question 1 of 5
The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?
Correct Answer: C
Rationale: The correct answer is C. Increasing fluids when the mouth feels dry is a reliable indicator of dehydration. Thirst sensation may be blunted in older adults, so waiting until feeling thirsty (choice B) may be too late. Drinking more fluids in the late evening (choice A) may lead to nocturia and disrupt sleep. Feeling confused (choice D) is a late sign of dehydration and not a reliable indicator for increasing fluid intake.
Question 2 of 5
A patient who has been hospitalized for 2 days, has a nasogastric tube to low suction and is receiving normal saline IV at 100 mL/hr. Which assessment finding would be a priority for the nurse to report to the health care provider?
Correct Answer: B
Rationale: The correct answer is B: Decreased alertness since admission. This finding indicates a potential neurological issue, such as electrolyte imbalance or fluid overload, which could be critical for the patient's well-being. The nurse should report this immediately to prevent further complications. A: Oral temperature of 100.1 F is a low-grade fever and may indicate infection, but it is not as urgent as a neurological issue. C: Weight gain of 2 pounds over 2 days may suggest fluid retention, but it is not as critical as a neurological change. D: Serum sodium level of 138 mEq/L is within the normal range and does not indicate an immediate threat to the patient's health.
Question 3 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 4 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 5 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.