ATI Fluid Electrolyte and Acid-Base Regulation

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.

Correct Answer: D

Rationale: The correct answer is D: Read food labels to determine sodium content. The nurse should assess the client's sodium level of 144 mEq/L, which is slightly above the normal range. High sodium intake can lead to fluid retention, hypertension, and other health issues. By reading food labels to determine sodium content, the nurse can identify sources of high sodium intake in the client's diet and provide appropriate dietary recommendations. This assessment is crucial in managing the client's sodium levels and overall health. Assessing the client's dietary intake of foods high in potassium (Choice A) is not the priority in this case since the client's potassium level is within the normal range. Assessing the client's neuromuscular status (Choice B) is important but not the first priority when considering the electrolyte imbalances present. Assessing the client's fluid intake and output (Choice C) is also important but does not address the immediate concern related to the client's elevated sodium level.

Correct Answer: C

Rationale: The correct answer is C. Reading food labels to determine sodium content is important in managing mild hypernatremia. This allows the client to monitor and control their sodium intake, which can help prevent further elevation of sodium levels. Weighing oneself or checking the pulse does not directly address sodium intake. Choosing cooking methods like baking or grilling is more about reducing fat intake, not sodium.

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: D

Rationale: The correct answer is D: Shallow respirations. Hypermagnesemia can lead to respiratory depression due to its inhibitory effect on the central nervous system. Shallow respirations are a common respiratory manifestation of hypermagnesemia. Hypertension (choice A) is not typically associated with hypermagnesemia. Kussmaul respirations (choice B) are deep, rapid breathing patterns seen in metabolic acidosis, not hypermagnesemia. Increased deep tendon reflexes (DTRs) (choice C) are more indicative of hypomagnesemia, as magnesium deficiency can lead to hyperexcitability of nerves and muscles, resulting in increased DTRs.