ATI RN
ATI Fluid Electrolyte and Acid-Base Regulation
1. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?
- A. I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup
- B. Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.
- C. It is normal to be a little confused following surgery, and it is safe not to urinate at night.
- D. If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.
Correct answer: B
Rationale:
2. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
- A. Assess the airway.
- B. Administer prescribed bronchodilators.
- C. Provide oxygen.
- D. Administer prescribed mucolytics
Correct answer: A
Rationale:
3. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?
- A. Encourage oral fluid intake.
- B. Connect the client to a cardiac monitor.
- C. Assess urinary output.
- D. Administer oral calcitonin (Calcimar).
Correct answer: A
Rationale: The correct answer is to encourage oral fluid intake. With a serum calcium level of 14 mg/dL, the client is at risk of hypercalcemia. Encouraging oral fluid intake helps to promote hydration and can help prevent further elevation of calcium levels. Connecting the client to a cardiac monitor (Choice B) is important but not the first priority in this situation. Assessing urinary output (Choice C) is relevant but does not address the immediate concern of high serum calcium levels. Administering oral calcitonin (Calcimar) (Choice D) may be a treatment option later, but the first step should be to address hydration.
4. A nurse is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?
- A. Agitation
- B. Kussmaul respirations
- C. Seizures
- D. Positive Chvosteks sign
Correct answer: B
Rationale:
5. A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?
- A. . Cardiac rate and rhythm
- B. Skin and mucous membranes
- C. Musculoskeletal strength
- D. Level of orientation
Correct answer: A
Rationale:
Similar Questions
Access More Features
ATI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $149.99