Fluid and Electrolytes ATI

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.

Correct Answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm.

Correct Answer: C

Rationale: Hair can be a source of infection and should be removed by clipping. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.

Correct Answer: C

Rationale: The symptoms of neck vein distention and dyspnea suggest fluid overload. Placing the patient in semi-Fowler's position and administering diuretics can help reduce fluid volume and improve breathing.

Correct Answer: D

Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely cause of the lower urine output.