ATI RN
Fluid and Electrolytes ATI Questions
Question 1 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 2 of 5
A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Electrocardiogram (ECG) results. When a patient taking spironolactone presents with a high serum potassium level of 6 mEq/L, the nurse's priority should be to assess the patient's ECG results. Hyperkalemia, indicated by elevated potassium levels, can lead to life-threatening cardiac arrhythmias, making cardiac monitoring crucial. Option A) Neuromuscular function is important in assessing electrolyte imbalances, but in this case, the priority is the potential cardiac impact of hyperkalemia. Option B) Bowel sounds are not the priority when dealing with hyperkalemia; while altered bowel function can occur, it is not an immediate concern. Option C) Respiratory rate is crucial in many situations, but in this case, the focus should be on the cardiac implications of high potassium levels. Educationally, understanding the priority assessments in patients with electrolyte imbalances is essential for nurses caring for patients on medications like spironolactone. This knowledge helps ensure timely interventions to prevent serious complications related to electrolyte disturbances, particularly in patients with cardiac comorbidities.
Question 3 of 5
The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?
Correct Answer: D
Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia.
Question 4 of 5
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: In this scenario, the correct answer is D) Hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can cause symptoms such as weakness, irregular pulse, and disorientation. The patient is taking hydrochlorothiazide, a diuretic that commonly causes potassium loss through increased urinary excretion. This medication can lead to electrolyte imbalances, specifically hypokalemia. Option A) Hypernatremia is unlikely in this case because the symptoms presented are not consistent with high sodium levels. Hypernatremia typically presents with symptoms such as thirst, dry mucous membranes, and restlessness. Option B) Hyponatremia is also less likely as it presents with symptoms like headache, confusion, seizures, and possibly coma. The symptoms of the patient in the scenario do not align with those of hyponatremia. Option C) Hyperkalemia is not the correct answer because the patient's symptoms are more indicative of low potassium levels rather than high potassium levels. Hyperkalemia usually presents with muscle weakness, cardiac arrhythmias, and potentially cardiac arrest. Understanding electrolyte imbalances is crucial in medical-surgical nursing as they can have significant impacts on a patient's health. It is essential for nurses to recognize the signs and symptoms of various electrolyte imbalances, understand the medications that can contribute to these imbalances, and be prepared to intervene appropriately to restore electrolyte balance and prevent complications.
Question 5 of 5
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.