ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 of 9
The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at 125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom would you expect this patient to exhibit
Correct Answer: B
Rationale: The correct answer is B: Dilute urine. Hypokalemia can lead to kidney dysfunction, causing the kidneys to excrete more water along with electrolytes, resulting in dilute urine. This is a manifestation of the body's attempt to compensate for low potassium levels by excreting excess water. The other choices are incorrect because: A) Diarrhea is more commonly associated with hyperkalemia, not hypokalemia. C) Increased muscle tone is not a typical sign of hypokalemia; rather, hypokalemia can lead to muscle weakness or paralysis due to impaired muscle function. D) Joint pain is not a typical symptom of hypokalemia; joint pain is more commonly associated with other conditions such as arthritis or inflammation.
Question 2 of 9
You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?
Correct Answer: D
Rationale: The correct answer is D: Hypercalcemia. Bone metastases in lung cancer can lead to increased release of calcium into the blood, causing hypercalcemia. The patient's symptoms of weakness and abdominal pain are consistent with hypercalcemia. Hypernatremia (choice A) is unlikely as the symptoms do not align with high sodium levels. Hypomagnesemia (choice B) and hypophosphatemia (choice C) are less likely as they are not typically associated with bone metastases in lung cancer. In summary, the patient's presentation of weakness and abdominal pain in the setting of lung cancer with bone metastases points to hypercalcemia as the most likely electrolyte imbalance.
Question 3 of 9
The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?
Correct Answer: C
Rationale: Step 1: Chvostek's sign is a facial muscle spasm induced by tapping the facial nerve in hypocalcemia. Step 2: Hypocalcemia causes increased neuromuscular excitability, leading to Chvostek's sign. Step 3: Hyperkalemia (choice D) causes muscle weakness, not muscle spasm. Step 4: Hyponatremia (choice B) affects osmolarity, not neuromuscular excitability. Step 5: Hypermagnesemia (choice A) causes muscle weakness, not muscle spasm.
Question 4 of 9
A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults. What factors contribute to this phenomenon? Select all that do not apply.
Correct Answer: D
Rationale: The correct answer is D: Increased conservation of sodium. Older adults tend to have an increased conservation of sodium, leading to fluid retention and decreased fluid intake, which can contribute to dehydration. A: Decreased kidney mass is incorrect because it is a factor that can contribute to decreased kidney function but not directly linked to dehydration. B: Decreased renal blood flow can impact kidney function but is not a direct cause of dehydration in older adults. C: Decreased excretion of potassium is not a factor that directly contributes to dehydration in older adults.
Question 5 of 9
A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
Correct Answer: D
Rationale: The correct answer is D: Presence of an ulnar pulse. This is the most important assessment to complete first because the presence of an ulnar pulse indicates adequate circulation in the hand, ensuring that the radial artery catheter is not compromising blood flow. If the ulnar pulse is absent, it may signify impaired circulation and potential complications such as ischemia. Choice A is incorrect because the amount of pressure in the fluid container is not directly related to the assessment of the radial artery catheter. Choice B is incorrect because the date of catheter tubing change is important for infection control but not the immediate priority in this situation. Choice C is incorrect as the percent of heparin in the infusion container is important for anticoagulation therapy but does not take precedence over assessing circulation in the hand.
Question 6 of 9
The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?
Correct Answer: C
Rationale: Rationale: Guillain-Barr syndrome can cause inadequate ventilation due to paralysis of the respiratory muscles. This results in respiratory acidosis. Endocarditis, multiple myeloma, and amphetamine overdose do not directly affect ventilation. Endocarditis is an infection of the heart valves, multiple myeloma is a cancer of plasma cells, and amphetamine overdose primarily affects the central nervous system and cardiovascular system, not ventilation. Therefore, Guillain-Barr syndrome is the most likely diagnosis in this case.
Question 7 of 9
You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly?
Correct Answer: B
Rationale: The correct answer is B: Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. Patient with pancreatitis may have depleted levels of phosphorus due to malnutrition, and rapid initiation of TPN can further decrease phosphorus levels, leading to hypophosphatemia. This can result in respiratory failure, muscle weakness, and arrhythmias. Choice A is incorrect because patients receiving TPN are not specifically at risk for hypercalcemia due to rapid initiation of calories. Choice C is incorrect because rapid fluid infusion can lead to hypernatremia, not related to TPN initiation. Choice D is incorrect because the rationale provided for slow initiation is not related to digestive enzymes but rather to prevent hypophosphatemia in malnourished patients.
Question 8 of 9
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?
Correct Answer: D
Rationale: The correct answer is D, infection. The client's symptoms of abdominal pain and feeling warm are indicative of a potential infection, which is a common complication of intraperitoneal therapy. Step-by-step rationale: 1. Abdominal pain can be a sign of peritonitis, an infection of the peritoneal cavity. 2. Feeling warm may indicate a fever, a common symptom of infection. 3. Prompt assessment and treatment of infection are crucial to prevent complications. Summary of other choices: A, allergic reaction - unlikely given the symptoms described; B, bowel obstruction - does not align with the symptoms provided; C, catheter lumen occlusion - not typically associated with abdominal pain and feeling warm.
Question 9 of 9
The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?
Correct Answer: C
Rationale: Correct Answer: C Rationale: Asking the patient about allergies to latex or iodine is crucial before starting the IV insertion process. This step ensures patient safety and prevents potential allergic reactions. Knowing the patient's allergies allows the nurse to select appropriate materials for the procedure, reducing the risk of complications. Summary of Other Choices: A: Leaving one hand ungloved is not recommended as it compromises infection control practices. B: Cleansing the skin with normal saline is important but should come after confirming allergies to latex or iodine. D: Removing excessive hair from the site is unnecessary and not a standard practice for starting the IV insertion process.