ATI Fluid Electrolyte and Acid-Base Regulation

Correct Answer: D

Rationale: The correct action is to stop the infusion of intravenous fluids. Edema and tenderness above the IV site suggest infiltration, where fluid leaks into surrounding tissues. Stopping the infusion prevents further damage and helps prevent complications. Applying cold compresses (A) may not address the underlying issue. Elevating the extremity (B) is helpful for other conditions like swelling due to dependent edema, not infiltration. Flushing the catheter (C) can exacerbate the issue by pushing more fluid into the tissue.

Correct Answer: C

Rationale: Step 1: Fluid overload leads to increased fluid volume in the body, causing skin to appear pale, cool, and clammy due to poor circulation. Step 2: "Warm and pink skin" is not a typical manifestation of fluid overload. Step 3: Therefore, the correct answer is C. Summary: A: Increased pulse rate - Possible in fluid overload due to increased volume causing increased workload on the heart. B: Distended neck veins - Common in fluid overload due to increased venous pressure. C: Warm and pink skin - Incorrect, as skin is usually pale, cool, and clammy. D: Skeletal muscle weakness - Not directly related to fluid overload.

Correct Answer: B

Rationale: The correct answer is B: Administer the prescribed medication. The nurse has assessed the client's site and reviewed the chart, indicating readiness to administer the medication. It is crucial to follow the healthcare provider's order and administer the prescribed medication as planned. Notifying the provider (A) is unnecessary if all assessments are normal. Discontinuing the PICC line (C) without a valid reason can lead to complications. Switching to oral route (D) should only be considered if there are specific contraindications for the intravenous route. It's important to prioritize safe and effective medication administration based on the client's condition and healthcare provider's orders.

Correct Answer: B

Rationale: The correct answer is B: Beef. While beef is a good source of protein, it is not high in phosphate. Milk, poultry, and liver are high in phosphate and would be beneficial for a patient with hypophosphatemia. Beef is not typically a significant source of phosphate and therefore would not be as effective in increasing phosphate levels in the body compared to the other options. It is important for the patient to focus on consuming foods that are high in phosphate to help correct the hypophosphatemia.

Correct Answer: B

Rationale: The correct answer is B: Report of headache and stiff neck. This finding indicates a potential complication of epidural anesthesia called a post-dural puncture headache, which can lead to serious consequences like meningitis or subdural hematoma. The nurse should act immediately by notifying the healthcare provider for further evaluation and management. Redness at the catheter insertion site (A) may indicate local inflammation but doesn't require immediate intervention. Temperature elevation (C) could be a sign of infection but isn't as urgent as a headache and stiff neck. Pain rating of 8 (D) is important but doesn't indicate an immediate threat to the client's health like a post-dural puncture headache.