ATI RN
Fluid and Electrolytes ATI Questions
Question 1 of 9
The patient asks the nurse if he will die if air bubbles get into the IV tubing. What is the nurse's best response?
Correct Answer: B
Rationale: An air emboli is more often associated with central vein access. Usually only relatively large volumes of air administered rapidly are dangerous. It is more often a concern when air enters a central venous access line.
Question 2 of 9
The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?
Correct Answer: B
Rationale: The most common cause of acute respiratory alkalosis is hyperventilation. Extreme anxiety can lead to hyperventilation.
Question 3 of 9
The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate?
Correct Answer: C
Rationale: A brief contraction of the upper lip, nose, or side of the face indicates Chvostek's sign, which is associated with hypocalcemia.
Question 4 of 9
A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart "flutters" frequently. What action should the nurse take?
Correct Answer: C
Rationale: Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the patient to rest more often won't help the patient if she's hypokalemic. Digoxin isn't causing the patient's symptoms, so she doesn't need to stop taking it. The patient should probably avoid caffeine, but this wouldn't resolve potassium depletion.
Question 5 of 9
The nurse preparing a site for the insertion of an IV catheter should treat excess hair at the site by:
Correct Answer: C
Rationale: Hair can be a source of infection and should be removed by clipping. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.
Question 6 of 9
A patient who is hospitalized with a possible electrolyte imbalance is disoriented and weak, has an irregular pulse, and takes hydrochlorothiazide. He most likely suffers from:
Correct Answer: D
Rationale: The symptoms of hypokalemia include GI, cardiac, renal, respiratory, and neurologic disturbances. The use of potassium-wasting diuretics, such as hydrochlorothiazide, without potassium replacement therapy is a primary cause of hypokalemia.
Question 7 of 9
Your patient has alcoholism, and you may suspect during your assessment that his serum magnesium is low. What will the nurse potentially expect to assess related to hypomagnesemia?
Correct Answer: A
Rationale: Signs and symptoms of hypomagnesemia are largely confined to the neuromuscular system and include confusion, tremor, tetany, laryngeal stridor, and ataxia.
Question 8 of 9
A nurse in the medical-surgical unit has a newly admitted patient who is oliguric; the acute care nurse practitioner orders a fluid challenge of 100 to 200 mL of normal saline solution over 15 minutes. The nurse is aware this intervention will help:
Correct Answer: C
Rationale: If a patient is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid Volume deficit (FVD) or prerenal azotemia, or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a patient with FVD but normal renal function is increased urine output and increased blood pressure.
Question 9 of 9
A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:
Correct Answer: B
Rationale: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and less commonly in the feet. Taking a normal blood pressure could illicit a carpal spasm if it creates slight ischemia of the ulnar nerve.