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

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. . 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:

2. Which hormone reduces the amount of water in the body?

A. ADH
B. aldosterone
C. ANH
D. ADH and aldosterone

Correct answer: B

Rationale: The correct answer is 'aldosterone.' Aldosterone is the hormone that reduces the amount of water in the body by increasing the reabsorption of sodium and water from the kidney tubules. ANH (atrial natriuretic hormone) actually works to increase the excretion of sodium and water by the kidneys, leading to a reduction in blood volume and pressure. ADH (antidiuretic hormone) works to increase water reabsorption by the kidneys, thereby increasing blood volume. Therefore, choices A (ADH) and D (ADH and aldosterone) are incorrect in the context of reducing the amount of water in the body.

3. 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:

4. A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

A. Administer a sublingual nitroglycerin tablet
B. Prepare to assist with chest tube insertion.
C. . Place a sterile dressing over the IV site
D. Re-position the client into the Trendelenburg position.

Correct answer: B

Rationale:

5. While assessing a patient's peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?

A. Air emboli
B. Phlebitis
C. Infiltration
D. Fluid overload

Correct answer: C

Rationale: Infiltration is the administration of a nonvesicant solution or medication into the surrounding tissue, typically due to the dislodgement or perforation of the vein wall by the IV cannula. It is characterized by edema around the insertion site, leakage of IV fluid, discomfort, coolness, and a decrease in flow rate. In this scenario, the presence of edema indicates infiltration, not air emboli, phlebitis, or fluid overload. Air emboli refer to air bubbles in the bloodstream, phlebitis is inflammation of the vein, and fluid overload is an excessive volume of fluid in the circulatory system.