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 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 2 of 5

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?

Correct Answer: C

Rationale: The correct answer is C: Metabolic alkalosis. Pyloric stenosis can lead to vomiting, causing loss of gastric acid and chloride ions, leading to metabolic alkalosis. Low potassium levels are common in metabolic alkalosis due to potassium shifting into cells to compensate for the alkalosis. Hypercalcemia (choice A) is not associated with pyloric stenosis. Metabolic acidosis (choice B) typically presents with low pH and bicarbonate levels. Respiratory acidosis (choice D) is caused by impaired gas exchange in the lungs, not related to pyloric stenosis.

Question 3 of 5

The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?

Correct Answer: C

Rationale: Step 1: Chvostek's sign is a facial muscle spasm induced by tapping the facial nerve in hypocalcemia. Step 2: Hypocalcemia causes increased neuromuscular excitability, leading to Chvostek's sign. Step 3: Hyperkalemia (choice D) causes muscle weakness, not muscle spasm. Step 4: Hyponatremia (choice B) affects osmolarity, not neuromuscular excitability. Step 5: Hypermagnesemia (choice A) causes muscle weakness, not muscle spasm.

Question 4 of 5

. A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?

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.

Question 5 of 5

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

Correct Answer: B

Rationale: The correct answer is B: Prepare to assist with chest tube insertion. Chest pain and difficulty breathing after subclavian central venous catheter insertion could indicate a pneumothorax, a potential complication. Chest tube insertion is indicated to help re-expand the lung and relieve the pressure in the thoracic cavity. This intervention takes priority over the other options because it addresses the potential life-threatening complication of a pneumothorax. Administering nitroglycerin (choice A) is not indicated for chest pain in this scenario. Placing a sterile dressing over the IV site (choice C) is not appropriate for managing chest pain and difficulty breathing. Re-positioning the client into the Trendelenburg position (choice D) is not effective in addressing a pneumothorax and may worsen the client's condition.

Similar Questions

A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?
A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching?
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