ATI Fluid Electrolyte and Acid-Base Regulation

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ATI Fluid Electrolyte and Acid-Base Regulation Questions

Question 1 of 5

A nurse assesses a client who is prescribed furosemide (Lasix) for hypertension. For which acid-base imbalance should the nurse assess to prevent complications of this therapy?

Correct Answer: D

Rationale: The correct answer is D: Metabolic alkalosis. Furosemide, a loop diuretic, can lead to potassium depletion and metabolic alkalosis due to excessive loss of chloride and hydrogen ions. The nurse should assess for signs of metabolic alkalosis such as confusion, muscle weakness, and dysrhythmias to prevent complications. Respiratory acidosis and alkalosis are not directly related to furosemide therapy. Metabolic acidosis is less likely due to furosemide's mechanism of action.

Question 2 of 5

You are caring for a patient with a diagnosis of pancreatitis. The patient was admitted from a homeless shelter and is a vague historian. The patient appears malnourished and on day 3 of the patients admission total parenteral nutrition (TPN) has been started. Why would you know to start the infusion of TPN slowly?

Correct Answer: B

Rationale: The correct answer is B: Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. Patient with pancreatitis may have depleted levels of phosphorus due to malnutrition, and rapid initiation of TPN can further decrease phosphorus levels, leading to hypophosphatemia. This can result in respiratory failure, muscle weakness, and arrhythmias. Choice A is incorrect because patients receiving TPN are not specifically at risk for hypercalcemia due to rapid initiation of calories. Choice C is incorrect because rapid fluid infusion can lead to hypernatremia, not related to TPN initiation. Choice D is incorrect because the rationale provided for slow initiation is not related to digestive enzymes but rather to prevent hypophosphatemia in malnourished patients.

Question 3 of 5

A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, which action should the nurse take to relieve pain?

Correct Answer: B

Rationale: The correct answer is B: Place warm compresses on the site. Warm compresses can help increase blood flow, reduce pain, and promote healing at the site of inflammation. The warmth can help dilate blood vessels, increasing circulation to the area and promoting the removal of inflammatory substances. This can help alleviate pain and reduce swelling. Administering topical lidocaine (choice A) may not address the underlying cause of pain and redness. Administering oral pain medication (choice C) may be necessary for severe pain but may not directly address the local inflammation. Massaging the site with scented oils (choice D) can potentially introduce more irritants and should be avoided in cases of inflammation.

Question 4 of 5

While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

Correct Answer: A

Rationale: The correct answer is A: Grade 3 phlebitis at IV site. This finding indicates inflammation of the vein due to irritants from the IV catheter, supported by red streak and palpable cord. Grade 3 phlebitis involves pain, redness, swelling, and palpable venous cord. Infection (B) typically presents with signs like pus, warmth, and fever. Thrombosis (C) involves a blood clot, not a palpable cord. Infiltration (D) is leakage of IV fluid into surrounding tissues, not related to palpable cord and red streak.

Question 5 of 5

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

Correct Answer: C

Rationale: The correct answer is C: Inelastic skin turgor is a normal part of aging. As people age, their skin loses elasticity and becomes less turgid, which can affect skin turgor assessment. Skin turgor assessment is an important indicator of hydration status, and in older adults, it is normal for the skin to be less elastic. This is due to changes in collagen and elastin fibers in the skin with aging. Choices A, B, and D are incorrect because overhydration is not common among healthy older adults, dehydration causes the skin to appear tented rather than spongy, and skin turgor can still be assessed in patients over 70, although it may be less reliable due to natural changes in skin elasticity with aging.

Similar Questions

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that do mot apply.)
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?
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)

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