ATI RN
Fluid and Electrolytes ATI Questions
Question 1 of 5
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: The correct answer to the question is option B: "Only relatively large volumes of air administered rapidly are dangerous." This response is the best choice because it provides accurate information to the patient regarding the risk of air bubbles in IV tubing. In reality, small amounts of air bubbles in IV tubing are generally not harmful to patients as they are absorbed and eliminated by the body. It is only when a significant volume of air is rapidly infused that it can potentially cause harm by obstructing blood flow in small vessels or leading to air embolism. Option A, stating that the system is closed and it is impossible for air bubbles to enter the IV tubing, is incorrect as air bubbles can indeed form in IV tubing due to various factors such as improper priming, tubing connections, or changes in pressure. Option C, mentioning a risk of complication with IV administration, is vague and does not directly address the patient's concern about air bubbles. Option D is clearly inappropriate and unprofessional, as it dismisses the patient's question without providing any useful information. In an educational context, it is essential for nurses to be able to effectively communicate with patients and provide accurate information to address their concerns. Understanding the implications of air bubbles in IV tubing is crucial for patient safety, and nurses must be able to explain this concept clearly to patients to alleviate any fears or misconceptions. By choosing option B, the nurse can educate the patient about the actual risks associated with air bubbles in IV tubing and promote an informed understanding of the situation.
Question 2 of 5
The nurse preparing a site for the insertion of an IV catheter should treat excess hair at the site by:
Correct Answer: C
Rationale: Rationale: The correct answer is C) Clipping the hair in the area. When preparing a site for IV catheter insertion, it is essential to remove excess hair to ensure proper adhesion of the dressing and to prevent contamination during the procedure. Clipping the hair with scissors is preferred over shaving or using depilatory creams because it reduces the risk of skin irritation, micro-cuts, and infections that can occur with shaving. Leaving the hair intact (option A) can increase the risk of contamination, while shaving (option B) can cause skin trauma and increase the risk of infection. Using a depilatory (option D) is not recommended as it can cause skin irritation and allergic reactions. Educational Context: In medical-surgical nursing, proper IV catheter insertion is crucial for delivering medications, fluids, and blood products to patients. Maintaining a clean and sterile insertion site is essential to prevent infections and other complications. Clipping excess hair is a standard practice before IV catheter insertion as it helps to create a clean and smooth surface for proper dressing application and reduces the risk of introducing pathogens into the bloodstream. Nurses must follow best practices to ensure patient safety and promote positive outcomes in IV therapy.
Question 3 of 5
The nurse assessing skin turgor in an elderly patient should remember that:
Correct Answer: C
Rationale: In medical-surgical nursing, understanding fluid and electrolyte balance is crucial for patient assessment and care. In this scenario, the correct answer is C) Inelastic skin turgor is a normal part of aging. As individuals age, the skin loses elasticity due to a decrease in collagen and elastin fibers. This natural process results in skin that is less turgid and more prone to wrinkling and sagging. Option A) is incorrect because overhydration leads to skin that is puffy and edematous, not tented. Option B) is incorrect as dehydration causes the skin to lose its elasticity and become taut, not edematous and spongy. Option D) is incorrect because normal skin turgor is not moist and boggy; it should be resilient and return quickly to its original state when pinched. Educationally, it is essential for nurses to understand the normal changes that occur with aging to differentiate between expected variations and signs of pathology. By recognizing that inelastic skin turgor is a normal part of aging, nurses can provide appropriate care and interventions tailored to the individual needs of elderly patients.
Question 4 of 5
When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:
Correct Answer: B
Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Selection of a distal site leaves the upper veins available for subsequent cannulations. Instruct the patient to hold his arm in a dependent position to increase blood flow. Never leave a tourniquet in place longer than 2 minutes.
Question 5 of 5
The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:
Correct Answer: A
Rationale: Daily weights show trends and can assist medical management by indicating if interventions and medications are effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the patient with fluid balance problems. However, if a patient is dehydrated, some laboratory data can show false elevations. Intake and output is extremely important, but matching the two is difficult because fluid is also lost through breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or excess of fluids in some situations.