ATI RN
ATI Fundamental Exam Chapter 25 Candile Questions
Extract:
Question 1 of 5
The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit?
Correct Answer: A
Rationale: The client with an ileostomy is at risk for fluid volume deficit because an ileostomy is a surgical opening in the ileum, the last part of the small intestine, that allows the drainage of intestinal contents. This can result in a loss of fluids and electrolytes, especially sodium and potassium, which can lead to dehydration and hypovolemia. The client with cirrhosis is not at risk for fluid volume deficit, but rather fluid volume excess. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. This can lead to portal hypertension, which is an increase in the pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can cause ascites, which is the accumulation of fluid in the abdominal cavity, and edema, which is the swelling of the tissues due to fluid retention. The client with heart failure is not at risk for fluid volume deficit, but rather fluid volume excess. Heart failure is a condition where the heart is unable to pump enough blood to meet the body's needs. This can lead to congestion of the blood vessels, which can cause pulmonary edema, which is the accumulation of fluid in the lungs, and peripheral edema, which is the swelling of the extremities due to fluid retention. The client with decreased renal function is not at risk for fluid volume deficit, but rather fluid volume excess. Decreased renal function is a condition where the kidneys are unable to filter the blood and remove excess fluids and wastes. This can lead to oliguria, which is a decrease in urine output, and anuria, which is the absence of urine output. This can cause fluid overload, which can affect the heart and the lungs.
Question 2 of 5
An anxious adult patient is experiencing a respiratory rate of 40 breaths/min. The most appropriate intervention that the nurse could do is to instruct the patient to:
Correct Answer: B
Rationale: Panting with mouth open is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the risk of hyperventilation and respiratory alkalosis, which could worsen the anxiety and cause symptoms such as dizziness, tingling, and muscle spasms. Sitting up is an appropriate intervention for an anxious patient with a high respiratory rate. This could help the patient relax and breathe more deeply and slowly, which could reduce the anxiety and normalize the blood gas levels. Lying down is not an appropriate intervention for an anxious patient with a high respiratory rate. This could make the patient feel more claustrophobic and increase the anxiety and the respiratory rate. Breathing through a re-breather mask is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the oxygen concentration in the blood, which could reduce the stimulus for breathing and cause respiratory depression.
Question 3 of 5
The registered nurse reviews the result of the arterial blood gas values with the licensed practical nurse and tells the LPN that the client has respiratory acidosis. The LPN would expect to note which of the following on the laboratory result report?
Correct Answer: C
Rationale: This is incorrect because this represents respiratory alkalosis, not acidosis. Respiratory alkalosis is characterized by a high pH and a low PCO2. This is incorrect because this represents a mixed disorder, not a pure respiratory acidosis. A mixed disorder occurs when both the pH and the PCO2 are abnormal, but in opposite directions. This is correct because this represents respiratory acidosis. Respiratory acidosis is characterized by a low pH and a high PCO2. This is incorrect because this represents normal values, not respiratory acidosis. Normal values for pH and PCO2 are 7.35 to 7.45 and 35 to 45 mmHg, respectively.
Question 4 of 5
Lena Mason who has diabetes is admitted in a stuporous condition. Her blood gases show a pH of 7.33 PaCO2 of 40 mm Hg and HCO3- of 20 mEq/L. What type of acid-base imbalance does this patient have?
Correct Answer: D
Rationale: This is incorrect because metabolic alkalosis is characterized by a high pH and a high HCO3-. The patient's pH and HCO3- are both low, indicating acidosis, not alkalosis. This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2. The patient's pH is low and PaCO2 is normal, indicating a metabolic problem, not a respiratory one. This is incorrect because respiratory acidosis is characterized by a low pH and a high PaCO2. The patient's pH is low, but PaCO2 is normal, indicating a metabolic problem, not a respiratory one. This is correct because metabolic acidosis is characterized by a low pH and a low HCO3-. The patient's pH and HCO3- are both low, indicating a metabolic disorder. The condition is uncompensated because the PaCO2 is normal, meaning the respiratory system is not compensating for the metabolic acidosis.
Question 5 of 5
If your patient has a higher than normal pH (alkalosis) you would expect to also see:
Correct Answer: C
Rationale: This is incorrect because low HCO3- and high PaCO2 are signs of metabolic acidosis, not alkalosis. Metabolic acidosis is a condition where the blood pH is lower than the normal range of 7.35 to 7.45, due to an excess of acids or a loss of bases in the body. This is incorrect because low PaCO2 and low HCO3- are signs of respiratory acidosis, not alkalosis. Respiratory acidosis is a condition where the blood pH is lower than the normal range of 7.35 to 7.45, due to impaired gas exchange or hypoventilation, which causes carbon dioxide to accumulate in the blood. This is correct because low PaCO2 and high HCO3- are signs of alkalosis. Alkalosis is a condition where the blood pH is higher than the normal range of 7.35 to 7.45, due to a loss of acids or an excess of bases in the body. There are two types of alkalosis: respiratory and metabolic. Respiratory alkalosis is caused by hyperventilation, which lowers the PaCO2 in the blood. Metabolic alkalosis is caused by vomiting, diuretics, or excessive intake of antacids, which raises the HCO3- in the blood. This is incorrect because high PaCO2 and high HCO3- are signs of compensation, not alkalosis. Compensation is a process where the body tries to restore the normal pH by adjusting the levels of PaCO2 and HCO3- in the opposite direction of the primary disorder.