ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation Questions
Question 1 of 5
A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)
Correct Answer: C
Rationale: Step 1: Fluid overload leads to increased fluid volume in the body, causing skin to appear pale, cool, and clammy due to poor circulation. Step 2: "Warm and pink skin" is not a typical manifestation of fluid overload. Step 3: Therefore, the correct answer is C. Summary: A: Increased pulse rate - Possible in fluid overload due to increased volume causing increased workload on the heart. B: Distended neck veins - Common in fluid overload due to increased venous pressure. C: Warm and pink skin - Incorrect, as skin is usually pale, cool, and clammy. D: Skeletal muscle weakness - Not directly related to fluid overload.
Question 2 of 5
You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance?
Correct Answer: C
Rationale: The correct answer is C: Metabolic alkalosis. Pyloric stenosis can lead to vomiting, causing loss of gastric acid and chloride ions, leading to metabolic alkalosis. Low potassium levels are common in metabolic alkalosis due to potassium shifting into cells to compensate for the alkalosis. Hypercalcemia (choice A) is not associated with pyloric stenosis. Metabolic acidosis (choice B) typically presents with low pH and bicarbonate levels. Respiratory acidosis (choice D) is caused by impaired gas exchange in the lungs, not related to pyloric stenosis.
Question 3 of 5
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
Correct Answer: A
Rationale: The correct assessment for the nurse to complete first is A: Depth of respirations. Potassium and magnesium levels are crucial electrolytes that can affect cardiac function. Hypokalemia (low potassium) and hypomagnesemia (low magnesium) can lead to cardiac dysrhythmias. Checking the depth of respirations can provide valuable information on the client's respiratory status and potential respiratory distress due to electrolyte imbalances. This assessment takes precedence as addressing respiratory issues promptly is essential to prevent further complications. Assessing bowel sounds (B), grip strength (C), and electrocardiography (D) are important but not as immediate as assessing respiratory status in this scenario.
Question 4 of 5
The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?
Correct Answer: A
Rationale: The correct answer is A: Cimetidine. In metabolic alkalosis, the blood pH is elevated due to excess bicarbonate. Cimetidine is a histamine-2 receptor antagonist that can help decrease gastric acid production, which can contribute to alkalosis. Maalox (B) is an antacid used to treat acid-related conditions, not alkalosis. Potassium chloride elixir (C) is used to correct potassium imbalances, not directly related to alkalosis. Furosemide (D) is a loop diuretic used to treat fluid retention and edema, not specifically indicated for metabolic alkalosis.
Question 5 of 5
. A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?
Correct Answer: D
Rationale: The correct answer is D. The man's elevated heart rate, anxiety, and low urine output indicate a sympathetic reaction. This reaction stimulates the renin-angiotensin-aldosterone system, leading to decreased urine output. The sympathetic response triggers the release of renin, which activates angiotensin II and aldosterone, causing vasoconstriction and water reabsorption in the kidneys, ultimately reducing urine output. Choice A is incorrect because low urine output is not solely due to urinating before arrival. Choice B is incorrect as there is no indication of traumatic brain injury or ADH deficiency. Choice C is incorrect as atrial natriuretic peptide in heart failure typically increases urine output.
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