Fluid and Electrolytes ATI

Correct Answer: A

Rationale: Daily weights show trends and can assist medical management by indicating if interventions and medications are effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the patient with fluid balance problems. However, if a patient is dehydrated, some laboratory data can show false elevations. Intake and output is extremely important, but matching the two is difficult because fluid is also lost through breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or excess of fluids in some situations.

Correct Answer: D

Rationale: Although changes in all these findings are seen in hyperkalemia, ECG changes can indicate potentially lethal arrhythmias such as ventricular fibrillation. It wouldn't be appropriate to assess the patient's neuromuscular function, bowel sounds, or respiratory rate for effects of hyperkalemia.

Correct Answer: C

Rationale: The diuretics act on the ascending loop of Henle to prevent re-absorption of water, potassium, and sodium. Because of this, potassium and sodium levels should be monitored when a patient is receiving diuretics.

Correct Answer: C

Rationale: Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in setting up for IV therapy. A local reaction could result in irritation to the IV site or, in the extreme, it could result in anaphylaxis, which can be life threatening.

Correct Answer: D

Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia.