a nurse is caring for a client who has just had a central venous access line inserted which action should the nurse take next
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

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

Correct answer: B

Rationale:

2. Which negative ion is most important in intracellular fluid?

Correct answer: D

Rationale: Intracellular fluid contains phosphate ions and protein molecules as essential anions. Phosphate ions play a crucial role in various cellular processes, including energy transfer. Proteins, being large molecules with negative charges, also contribute significantly to the negative ion concentration within cells. Chlorine is primarily an extracellular anion and is not as prominent as phosphate ions and proteins within intracellular fluid, making it a less important negative ion in this context. Therefore, the correct answer is D because both phosphate ions and protein molecules are crucial negative ions in intracellular fluid.

3. Third spacing occurs when fluid moves out of the intravascular space but not into the intracellular space. Based on this fluid shift, the nurse will expect the patient to demonstrate:

Correct answer: D

Rationale: In the scenario of third-spacing fluid shift, where fluid moves out of the intravascular space but not into the intracellular space, the patient is expected to demonstrate hypovolemia. Hypertension (Choice A) is unlikely as hypovolemia typically leads to decreased blood pressure. Bradycardia (Choice B) is not a common manifestation of hypovolemia, as the body often tries to compensate by increasing heart rate. Hypervolemia (Choice C) indicates an excess of fluid, which is the opposite of what occurs in third spacing.

4. The nurse assessing skin turgor in an elderly patient should remember that:

Correct answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.

5. A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?

Correct answer: A

Rationale:

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