ATI Fluid Electrolyte and Acid-Base Regulation

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.

Correct Answer: D

Rationale: The correct answer is D. A cool lower extremity can indicate impaired circulation due to the intraosseous catheter placement, leading to compartment syndrome or tissue necrosis. This finding requires immediate intervention to prevent serious complications. Choices A, B, and C are incorrect because the duration of catheter placement, poor vascular access, and the specific location of the catheter do not directly impact circulation and tissue perfusion as significantly as a cool lower extremity.

Correct Answer: D

Rationale: The correct answer is D: Presence of an ulnar pulse. This is the most important assessment to complete first because the presence of an ulnar pulse indicates adequate circulation in the hand, ensuring that the radial artery catheter is not compromising blood flow. If the ulnar pulse is absent, it may signify impaired circulation and potential complications such as ischemia. Choice A is incorrect because the amount of pressure in the fluid container is not directly related to the assessment of the radial artery catheter. Choice B is incorrect because the date of catheter tubing change is important for infection control but not the immediate priority in this situation. Choice C is incorrect as the percent of heparin in the infusion container is important for anticoagulation therapy but does not take precedence over assessing circulation in the hand.

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: The correct answer is B because hyperphosphatemia can lead to paresthesia with sensations of tingling and numbness due to its effect on nerve function. A, hypokalemia causes muscle weakness but not flaccid paralysis with respiratory depression. C, hyponatremia typically presents with symptoms such as confusion and seizures, not decreased level of consciousness.