ATI Fluid Electrolyte and Acid-Base Regulation

Correct Answer: D

Rationale: The correct answer is D because upper extremity swelling could indicate a potential complication such as deep vein thrombosis, which is a serious condition requiring immediate attention to prevent further complications. Swelling can impede blood flow and lead to clot formation. A: The initial site dressing being 3 days old is concerning for infection but not an immediate threat. B: The PICC being inserted 4 weeks ago may increase infection risk but does not require immediate attention. C: A missing securement device may increase the risk of dislodgement but is not an immediate threat compared to potential vascular compromise indicated by upper extremity swelling.

Correct Answer: A

Rationale: The correct action for the nurse to take first is to assess the client's respiratory rate, rhythm, and depth (Choice A). Diminished handgrip strength in a client with hypokalemia could indicate potential respiratory muscle weakness, which can lead to respiratory distress or failure. By assessing the client's respiratory status, the nurse can determine if immediate intervention is needed to support breathing. Choice B is incorrect because measuring the client's pulse and blood pressure may not address the underlying issue of respiratory muscle weakness. Choice C is incorrect as it delays potential life-saving interventions by simply documenting findings. Choice D is incorrect as calling the healthcare provider should come after addressing the client's immediate respiratory needs.

Correct Answer: D

Rationale: The correct answer is D: Excessive administration of chloride. Normal anion gap acidosis is commonly caused by an excessive intake of chloride-containing solutions like normal saline during treatment. This leads to an increase in the plasma chloride concentration, causing a decrease in the anion gap. Metastases (A) are not typically associated with normal anion gap acidosis. Excessive potassium intake (B) would not lead to normal anion gap acidosis but rather hyperkalemia. Water intoxication (C) can lead to dilutional hyponatremia but not normal anion gap acidosis.

Correct Answer: A

Rationale: The correct answer is A: "I will drink at least three glasses of milk each day." Milk is a good source of calcium and bicarbonate, which can help buffer excess acids in the body and prevent metabolic acidosis. Calcium also plays a role in maintaining the acid-base balance. Option B is incorrect because while eating well-balanced meals is important for overall health, it does not specifically address the prevention of metabolic acidosis. Option C is irrelevant to the prevention of metabolic acidosis. Option D is incorrect because avoiding salting food does not directly address the underlying issue of metabolic acidosis related to malnutrition.

Correct Answer: A

Rationale: The correct answer is A: Client with pancreatitis who has continuous nasogastric suctioning. Pancreatitis can lead to gastrointestinal losses of potassium, and continuous nasogastric suctioning can further exacerbate this potassium loss, putting the client at risk for hypokalemia. The other choices are incorrect because: B: ACE inhibitors can cause hyperkalemia, not hypokalemia. C: Blood transfusions can lead to hyperkalemia due to the potassium content in blood products. D: Uncontrolled diabetes and a serum pH level of 7.33 are not directly associated with hypokalemia.