ATI Fluid Electrolyte and Acid-Base Regulation

ATI Fluid Electrolyte and Acid-Base Regulation Related

Review ATI Fluid Electrolyte and Acid-Base Regulation related questions and content

You are called to your patients room by a family member who voices concern about the patients status. On
assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also
find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?

  • A. Hypocalcemia
  • B. Hyponatremia
  • C. Hyperchloremia
  • D. Hypophosphatemia
Correct Answer: C

Rationale: The correct answer is C: Hyperchloremia. In this scenario, the patient's symptoms point towards fluid overload, which can lead to hyperchloremia due to excessive chloride intake. 3+ pitting edema suggests fluid retention, a common symptom of hyperchloremia. Additionally, tachypnea can occur as a compensatory mechanism for metabolic acidosis seen in hyperchloremia. Lethargy, weakness, and diminished cognitive ability can be attributed to electrolyte imbalances impacting nerve and muscle function.

Choice A: Hypocalcemia is less likely as it typically presents with neuromuscular irritability, not lethargy.
Choice B: Hyponatremia usually presents with neurological symptoms like confusion and seizures, not the symptoms described.
Choice D: Hypophosphatemia typically presents with muscle weakness, not the full constellation of symptoms described.

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

  • A. The catheter has been in place for 20 hours.
  • B. . The client has poor vascular access in the upper extremities.
  • C. The catheter is placed in the proximal tibia.
  • D. The clients left lower extremity is cool to the touch.
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.

The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The
nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at
125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift
assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates
decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom
would you expect this patient to exhibit

  • A. Diarrhea
  • B. Dilute urine
  • C. Increased muscle tone
  • D. Joint pain
Correct Answer: B

Rationale: The correct answer is B: Dilute urine. Hypokalemia can lead to kidney dysfunction, causing the kidneys to excrete more water along with electrolytes, resulting in dilute urine. This is a manifestation of the body's attempt to compensate for low potassium levels by excreting excess water. The other choices are incorrect because: A) Diarrhea is more commonly associated with hyperkalemia, not hypokalemia. C) Increased muscle tone is not a typical sign of hypokalemia; rather, hypokalemia can lead to muscle weakness or paralysis due to impaired muscle function. D) Joint pain is not a typical symptom of hypokalemia; joint pain is more commonly associated with other conditions such as arthritis or inflammation.

A nurse is caring for a client who has just had a central venous access line inserted. Which action should the nurse take next?

  • A. Begin the prescribed infusion via the new access
  • B. Ensure an x-ray is completed to confirm placement.
  • C. Check medication calculations with a second RN.
  • D. Make sure the solution is appropriate for a central line
Correct Answer: B

Rationale: The correct answer is B: Ensure an x-ray is completed to confirm placement. This is crucial to prevent complications such as pneumothorax or incorrect placement. X-ray confirmation is the gold standard to verify the central line's proper positioning before initiating any infusions. Option A is incorrect because starting the infusion without confirming placement can lead to serious complications. Option C is unnecessary for central line insertion. Option D is important but not the immediate next step as confirming placement takes precedence for patient safety.

A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial
pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for
fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which
of the following?

  • A. Hydrostatic pressure
  • B. Osmosis and osmolality
  • C. Diffusion
  • D. Active transport
Correct Answer: B

Rationale: The correct answer is B: Osmosis and osmolality. When a hypertonic solution is infused, it increases the number of dissolved particles in the blood, creating an osmotic pressure gradient. This causes fluids in the tissues to shift into the capillaries, increasing blood volume. Osmosis is the movement of solvent (water) across a semi-permeable membrane to equalize solute concentrations. Osmolality refers to the concentration of solutes in a solution.

Hydrostatic pressure (choice A) is the force exerted by a fluid against a wall when it is under pressure, not related to the movement of solutes.

Diffusion (choice C) is the movement of solute molecules from an area of high concentration to low concentration, not involving a semi-permeable membrane.

Active transport (choice D) requires energy to move molecules across a membrane against their concentration gradient, not the mechanism described in the scenario.

Place a washcloth between the skin and tourniquet

  • A. Provide a bed bath instead of letting the client take a shower
  • B. Use sterile technique when changing the dressing.
  • C. Disconnect the intravenous fluid tubing prior to the clients bath.
  • D. Use a plastic bag to cover the extremity with the device
Correct Answer: D

Rationale: The correct answer is D because using a plastic bag to cover the extremity with the device helps to keep the area dry when bathing, preventing the tourniquet from becoming wet and losing its effectiveness. This technique maintains the pressure needed for venipuncture.

A, providing a bed bath instead of a shower, is unrelated to the use of a tourniquet. B, using sterile technique for dressing changes, is important for wound care but not relevant to tourniquet use. C, disconnecting intravenous fluid tubing before a bath, is essential for preventing contamination but not directly related to tourniquet management.

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