ATI RN
Chapter 14 Nutrition and Fluid Balance Answer Key Questions
Question 1 of 5
The kidneys are the first line of defence against changes in acid-base balance because they are the most powerful mechanism for maintaining pH.
Correct Answer: B
Rationale: The correct answer is B: FALSE. The kidneys are not the first line of defense against changes in acid-base balance; they are the second line of defense. The first line of defense is the buffer systems in the body, which include bicarbonate, phosphate, and proteins. These buffer systems act quickly to prevent drastic changes in pH. The kidneys come into play as a slower but more powerful mechanism for maintaining pH by regulating the excretion or retention of hydrogen ions and bicarbonate ions. Therefore, while the kidneys are crucial in long-term regulation of acid-base balance, they are not the first line of defense.
Question 2 of 5
A patient who has a small cell cancer of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should notify the health care provider about which assessment finding?
Correct Answer: B
Rationale: The correct answer is B: Serum sodium of 120 mg/dL. In SIADH, there is excessive release of ADH, leading to water retention and dilutional hyponatremia. A serum sodium level of 120 mg/dL indicates severe hyponatremia and requires immediate intervention to prevent neurological complications. Choice A is incorrect because a serum hematocrit of 42% does not directly relate to SIADH. Choice C is incorrect because a urinary output of 280 mL in 8 hours is not a significant concern in SIADH as the condition leads to water retention and concentrated urine. Choice D is incorrect because a reported weight gain of 2.2 pounds could be related to fluid retention but is not as urgent as addressing severe hyponatremia in SIADH.
Question 3 of 5
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. Which clinical manifestation should the nurse expect?
Correct Answer: B
Rationale: The correct answer is B: Edema. In a malnourished patient with low serum protein levels, particularly albumin, there is a decreased oncotic pressure, leading to fluid shifting into interstitial spaces and causing edema. Pallor (choice A) is associated with anemia, not malnutrition. Restlessness (choice C) is not a typical manifestation of malnutrition. Confusion (choice D) is more commonly seen in severe malnutrition or certain vitamin deficiencies, but it is not the most immediate clinical manifestation in this scenario.
Question 4 of 5
An older adult patient receiving iso-osmolar continuous enteral nutrition develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
Correct Answer: C
Rationale: The correct answer is C: Na+ 154 mEq/L (154 mmol/L). High sodium levels can indicate hypernatremia, which can lead to neurological symptoms like restlessness, agitation, and weakness in older adults. This condition can be life-threatening if not promptly addressed. A: K+ 3.4 mEq/L is slightly low but not an immediate concern for neurological symptoms. B: Ca+2 7.8 mg/dL is within the normal range, and low calcium levels typically do not present with the described symptoms. D: Base balance is not a specific laboratory result and is not directly related to the symptoms described.
Question 5 of 5
The nurse notes a serum calcium level of 7.9 mg/dL for a patient who has chronic malnutrition. Which action should the nurse expect to take first?
Correct Answer: A
Rationale: The correct answer is A: Monitor ionized calcium level. Step-by-step rationale: 1. Monitoring ionized calcium level is crucial to assess the patient's current calcium status accurately. 2. In chronic malnutrition, there may be alterations in protein binding of calcium, affecting total calcium levels. 3. Ionized calcium is the physiologically active form and provides a more accurate reflection of calcium status. 4. This action helps guide further interventions and treatment based on the actual calcium levels. Summary: - Choice B: Giving oral calcium citrate tablets may not be appropriate without knowing the patient's ionized calcium level. - Choice C: Checking parathyroid hormone level may be relevant but is not the immediate priority. - Choice D: Administering vitamin D supplements may be beneficial in the long term but does not address the immediate need to assess the patient's calcium status accurately.