ATI Fluid Electrolyte and Acid-Base Regulation

Questions 88

ATI RN

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ATI Fluid Electrolyte and Acid-Base Regulation Questions

Question 1 of 5

The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?

Correct Answer: B

Rationale: The correct answer is B because considering potential effects on the patient's mobility is crucial when selecting a site for IV insertion. Mobility can be affected if the IV is placed in a joint area or on the dominant hand. This could limit the patient's ability to move freely during and after the procedure. Therefore, it is important to choose a site that will not hinder the patient's movement. A: Choosing a hairless site is not the most important factor when selecting a site for IV insertion. C: Having the patient hold his arm over his head before insertion is not necessary and may cause discomfort for the patient. D: Leaving the tourniquet on for at least 3 minutes is not recommended as it can lead to complications such as venous stasis.

Question 2 of 5

A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause

Correct Answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation leads to excessive elimination of carbon dioxide, causing a decrease in PaCO2 levels, resulting in respiratory alkalosis. This is the most common cause of hyperventilation. Respiratory acidosis (choice A) occurs when there is retention of carbon dioxide. Increased PaCO2 (choice C) is a consequence of respiratory acidosis, not alkalosis. CNS disturbances (choice D) can lead to abnormal breathing patterns but are not the most common cause of hyperventilation.

Question 3 of 5

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)

Correct Answer: C

Rationale: Step 1: Fluid overload leads to increased fluid volume in the body, causing skin to appear pale, cool, and clammy due to poor circulation. Step 2: "Warm and pink skin" is not a typical manifestation of fluid overload. Step 3: Therefore, the correct answer is C. Summary: A: Increased pulse rate - Possible in fluid overload due to increased volume causing increased workload on the heart. B: Distended neck veins - Common in fluid overload due to increased venous pressure. C: Warm and pink skin - Incorrect, as skin is usually pale, cool, and clammy. D: Skeletal muscle weakness - Not directly related to fluid overload.

Question 4 of 5

. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an exam

Correct Answer: A

Rationale: The correct answer is A: Increased rate and depth of respirations. In this case, the client's arterial blood gas values show a pH within normal range (7.36), PaCO2 below normal (33 mm Hg), and HCO3 below normal (18 mEq/L), indicating a metabolic acidosis. To compensate for the acidosis, the client will hyperventilate, leading to increased rate and depth of respirations to blow off excess CO2 and attempt to normalize the pH. Options B, C, and D are incorrect because increased urinary output, thirst, hunger, and release of acids from the kidneys are not direct compensatory mechanisms for metabolic acidosis.

Question 5 of 5

You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

Correct Answer: B

Rationale: The correct answer is B: Hypocalcemia. Following a thyroidectomy, there is a risk of damaging the parathyroid glands, leading to hypocalcemia. Symptoms such as tingling in lips and fingers, muscle spasms, and increased muscle tone are classic signs of hypocalcemia. The initial concern should be hypocalcemia due to its potential to cause serious complications such as tetany and laryngospasm. Options A, C, and D are incorrect as they do not align with the symptoms described. Hypophosphatemia may present with weakness and respiratory failure, hypermagnesemia with hypotension and respiratory depression, and hyperkalemia with muscle weakness and cardiac arrhythmias.

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