ATI Fluid Electrolyte and Acid-Base Regulation

Correct Answer: C

Rationale: The correct answer is C. The client's high serum potassium level of 7.5 mEq/L can lead to serious cardiovascular complications like arrhythmias. The immediate priority is to lower potassium levels rapidly to prevent cardiac arrest. Administering dextrose 20% and regular insulin IV push helps shift potassium from extracellular to intracellular space, lowering serum levels quickly. Option A (Kayexalate) is not as rapid as insulin therapy. Option B (low-potassium diet) is not immediate. Option D (hemodialysis) is effective but not as quick as insulin therapy for urgent potassium reduction.

Correct Answer: B

Rationale: Correct Answer: B - Slow, shallow respirations Rationale: 1. Electrolyte imbalance in renal failure often leads to respiratory alkalosis, causing rapid and deep respirations, not slow and shallow. 2. Electrocardiogram changes (A) are common with electrolyte imbalances, particularly potassium and calcium. 3. Paralytic ileus (C) is a complication of electrolyte imbalances, affecting gastrointestinal motility. 4. Skeletal muscle weakness (D) is a common manifestation of electrolyte imbalances, especially potassium and magnesium deficiencies. Summary: Choice B is incorrect because slow, shallow respirations are not typically associated with electrolyte imbalances related to renal failure. Choices A, C, and D are commonly seen complications of electrolyte imbalances and should be assessed by the nurse.

Correct Answer: D

Rationale: The correct answer is D because using a plastic bag to cover the extremity with the device helps to keep the area dry when bathing, preventing the tourniquet from becoming wet and losing its effectiveness. This technique maintains the pressure needed for venipuncture. A, providing a bed bath instead of a shower, is unrelated to the use of a tourniquet. B, using sterile technique for dressing changes, is important for wound care but not relevant to tourniquet use. C, disconnecting intravenous fluid tubing before a bath, is essential for preventing contamination but not directly related to tourniquet management.

Correct Answer: D

Rationale: The correct answer is D: Increased conservation of sodium. Older adults tend to have an increased conservation of sodium, leading to fluid retention and decreased fluid intake, which can contribute to dehydration. A: Decreased kidney mass is incorrect because it is a factor that can contribute to decreased kidney function but not directly linked to dehydration. B: Decreased renal blood flow can impact kidney function but is not a direct cause of dehydration in older adults. C: Decreased excretion of potassium is not a factor that directly contributes to dehydration in older adults.

Correct Answer: C

Rationale: The correct answer is C: Help distinguish reduced renal blood flow from decreased renal function. Rationale: 1. Oliguria is a decrease in urine output. 2. Fluid challenge with normal saline can help determine the cause of oliguria by assessing the response of the kidneys. 3. If the oliguria improves after the fluid challenge, it suggests reduced renal blood flow as the cause. 4. If oliguria persists, it indicates decreased renal function. Summary: A. Fluid challenge does not directly help in distinguishing between hyponatremia and hypernatremia. B. Evaluating pituitary gland function requires specific tests, not just a fluid challenge. D. Treating hypertension-induced oliguria may involve different interventions, not just a fluid challenge.