ATI RN
Chapter 14 Nutrition and Fluid Balance Answer Key Questions
Question 1 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
Question 2 of 5
Because there are no IV pumps available for the immediate infusion of an IV medication, the nurse must calculate the flow rate for 500 mL to run for 4 h, using a set that delivers 15 gtt/mL. Which flow rate is correct?
Correct Answer: A
Rationale: The correct answer is A (30 gtt/min). To calculate the flow rate, first determine the total drops needed (500 mL x 15 gtt/mL = 7500 gtt) for 4 hours. Then, divide total drops by total time in minutes (4 hours x 60 min/hr = 240 min) to get 31.25 gtt/min. Since IV pumps deliver whole drops, round down to the nearest whole number, giving a flow rate of 30 gtt/min. Choice B, C, and D are incorrect as they do not reflect the accurate calculation based on the given information.
Question 3 of 5
The nurse explains to the 85-year-old patient with a temperature that, with each degree of fever, the body loses _____% of water.
Correct Answer: C
Rationale: The correct answer is C (10%). For every degree increase in body temperature, the metabolic rate increases, leading to increased water loss through perspiration and respiration. This results in dehydration. A 10% water loss is a common estimate for the body's response to fever-induced increased metabolic activity. Choices A, B, and D are incorrect as they do not accurately reflect the significant impact of fever on water loss in the body.
Question 4 of 5
A normal urine output is considered to be
Correct Answer: D
Rationale: The correct answer is D (1 to 2 L/day) because it reflects the normal range of urine output in adults, which is typically around 1 to 2 liters per day. This range ensures adequate elimination of waste products while maintaining proper hydration levels. A (80 to 125 mL/min) is incorrect because it represents an hourly output rather than a daily output, and it is too low for a normal daily urine output. B (180 L/day) is incorrect as it is an extremely high value that does not align with normal physiological urine production rates. C (80 mL/min) is also incorrect because it is too low for a normal urine output and is not representative of the typical daily volume.
Question 5 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: The correct answer is A: contact the provider and expect a prescription for a normal saline bolus. The patient is showing signs of hypovolemia, indicated by decreased urine output, tachycardia, and hypotension. Administering a normal saline bolus can help restore intravascular volume and improve perfusion. Waiting for the provider to make rounds (choice B) can delay necessary intervention. Continuing to evaluate urine output (choice C) without addressing the underlying issue of hypovolemia can worsen the patient's condition. Ignoring the urine output (choice D) is not appropriate as it can lead to serious complications.