Fluid and Electrolytes ATI

Questions 40

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Fluid and Electrolytes ATI Questions

Question 1 of 5

A 65-year-old male patient was admitted to a medical-surgical unit 72 hours ago with pyloric stenosis; a nasogastric tube was inserted upon admission and has been on low intermittent suction since then. The nurse taking care of the patient notices that his potassium is very low and becomes concerned that the patient may be at risk for:

Correct Answer: C

Rationale: Probably the most common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis in which only gastric fluid is lost. Vomiting, gastric suction, and pyloric stenosis all remove potassium and can cause hypokalemia.

Question 2 of 5

What would be the best initial nursing actions prior to inserting an IV?

Correct Answer: C

Rationale: Prior to initiating an IV, the nurse should verify the physician's order for IV therapy.

Question 3 of 5

The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate?

Correct Answer: C

Rationale: A brief contraction of the upper lip, nose, or side of the face indicates Chvostek's sign, which is associated with hypocalcemia.

Question 4 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 5 of 5

The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?

Correct Answer: C

Rationale: Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate.

Similar Questions

The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?
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