ATI RN
Fluid and Electrolytes ATI
1. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:
- A. Choose a proximal site.
- B. Choose a distal site.
- C. Have the patient hold their arm in a dependent position.
- D. Leave the tourniquet on for no longer than 2 minutes.
Correct answer: B
Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Opting for a distal site ensures that upper veins remain available for future cannulations. Instructing the patient to hold their arm in a dependent position can enhance blood flow, aiding in the procedure. It is crucial never to leave a tourniquet on for more than 2 minutes as prolonged restriction can lead to complications. Choice A is incorrect because a proximal site is not preferred for IV insertion. Choice C is incorrect as having the patient hold their arm over their head is not necessary and may impede proper blood flow. Choice D is incorrect as leaving the tourniquet on for at least 5 minutes is excessive and can be harmful.
2. A 73-year-old man who slipped on a small carpet in his home and fell on his hip is alert and oriented; PERRLA (pupils equally round and reactive to light and accommodation) is intact, and he has come by ambulance to the emergency department (ED). Heart rate elevated, he is anxious and thirsty. A Foley catheter is in place and 40mL of urine is present. The nurse's most likely explanation for the urine output is:
- A. The man urinated prior to his arrival in the ED and will probably not need to have the Foley catheter kept in place.
- B. The man has a brain injury, lacks ADH, and needs vasopressin.
- C. The man is in heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output.
- D. He is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.
Correct answer: D
Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely cause of the lower urine output. Choices A, B, and C are incorrect because there is no indication of urination prior to arrival, brain injury, lack of ADH, or heart failure present in the scenario provided. The symptoms and context described point more towards a physiological response related to the sympathetic nervous system and the renin-angiotensin-aldosterone system rather than the other conditions mentioned.
3. When preparing a site for the insertion of an IV catheter, how should excess hair at the site be treated?
- A. Leaving the hair intact
- B. Shaving the area
- C. Clipping the hair in the area
- D. Removing the hair with a depilatory
Correct answer: C
Rationale: The correct answer is to clip the hair in the area. Excess hair at the site of IV catheter insertion should be removed because it can be a potential source of infection. Clipping the hair is preferred over shaving because shaving can cause skin abrasions, increasing the risk of infection. Using depilatories is not recommended as they can irritate the skin, which is undesirable when preparing a clean site for an invasive procedure. Therefore, clipping the hair in the area is the most appropriate and safe method to prepare the site for IV catheter insertion.
4. A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment, the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:
- A. Hypophosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hyperkalemia
Correct answer: B
Rationale: The patient's symptoms of tingling in the lips and fingers along with the wrist and hand spasm are indicative of tetany, a characteristic manifestation of hypocalcemia. Hypocalcemia and hypomagnesemia can present with sensations of tingling in the extremities and around the mouth. The spasm in the wrist and hand when taking blood pressure could be due to slight ischemia of the ulnar nerve, further supporting the suspicion of hypocalcemia in this patient. Hypophosphatemia, hypermagnesemia, and hyperkalemia do not typically present with these specific symptoms and manifestations.
5. The healthcare provider is evaluating a patient's laboratory results. Based on the laboratory findings, what results will cause the release of an antidiuretic hormone (ADH)?
- A. Increased serum sodium
- B. Decreased serum sodium
- C. Decrease in serum osmolality
- D. Decrease in thirst
Correct answer: A
Rationale: The correct answer is A: Increased serum sodium. When serum sodium levels increase, it triggers the release of ADH by the posterior pituitary gland. ADH helps in retaining water, reducing urine output, and maintaining fluid balance. Choices B, C, and D are incorrect because decreased serum sodium, decrease in serum osmolality, and decrease in thirst do not stimulate the release of ADH.
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