ATI Fluid Electrolyte and Acid-Base Regulation

Correct Answer: B

Rationale: The correct answer is B: Anxiety-induced hyperventilation. The arterial blood gas values show a pH of 7.48 (alkalosis) with low PaCO2 (respiratory alkalosis), which is consistent with hyperventilation due to anxiety. HCO3 is within normal range, ruling out metabolic causes. A: Diarrhea and vomiting would lead to metabolic acidosis with low pH and decreased HCO3. C: COPD would typically present with respiratory acidosis (high PaCO2) and normal to high HCO3. D: Diabetic ketoacidosis and emphysema would show metabolic acidosis with low pH and low HCO3.

Correct Answer: D

Rationale: The correct answer is D because dangling the client on the bedside before ambulating helps prevent orthostatic hypotension and potential falls. This step allows the nurse to assess the client's tolerance to changes in position and reduces the risk of injury. A: Asking family members to speak quietly does not directly address the prevention of injury related to dehydration. B: Assessing urine parameters is important for monitoring hydration status but does not directly prevent injury. C: Encouraging fluid intake is important for rehydration but does not directly address the risk of injury during ambulation.

Correct Answer: D

Rationale: The correct answer is D: Place a washcloth between the skin and tourniquet. This step helps protect the client's skin by providing a barrier between the tourniquet and the skin, reducing the risk of skin irritation or damage. Lowering the extremity below the heart (A) can increase venous pressure and make it harder to insert the catheter. Warm compresses (B) can dilate blood vessels and increase the risk of bruising. Tapping the skin lightly (C) can irritate the skin and is unnecessary for skin protection.

Correct Answer: A

Rationale: The correct answer is A because intravenous D5W is a hypotonic solution that can lead to dilutional hyponatremia. D5W does not contain sodium, so it can cause a decrease in serum sodium levels. Clients on NPO status receiving D5W are at higher risk due to lack of sodium intake. Choices B, C, and D are incorrect because they do not directly contribute to hyponatremia. Sulfonamide antibiotics, ibuprofen, and digoxin are not typically associated with causing hyponatremia. Therefore, assessing the client on NPO status receiving D5W for potential hyponatremia is the priority.

Correct Answer: A

Rationale: The correct answer is A because electrolyte-free water, such as sterile water, can rapidly enter red blood cells due to osmotic differences, causing them to swell and potentially rupture, leading to hemolysis. This can result in severe harm to the patient. Choice B is incorrect because electrolyte-free water is not indicated for severely dehydrated patients with neurologic signs and symptoms. They require electrolytes to correct their imbalances. Choice C is incorrect as administering electrolyte-free water would not address excess calcium and/or magnesium ions in the body. Specific treatments for hypercalcemia or hypermagnesemia are needed. Choice D is incorrect because patients with fluid deficits due to renal failure require electrolyte-balanced solutions to manage their condition effectively. Electrolyte-free water would not address the electrolyte imbalances associated with renal failure.