the nurse in the medical icu is caring for a patient who is in respiratory acidosis due to inadequate ventilation what diagnosis could the patient ha

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation. What diagnosis could the patient have that could cause inadequate ventilation?

A. Endocarditis
B. Multiple myeloma
C. Guillain-Barr syndrome
D. Overdose of amphetamines

Correct answer: C

Rationale:

2. . You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as

A. Nutritional status
B. Potassium balance
C. Calcium balance
D. Fluid volume status

Correct answer: D

Rationale:

3. A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:

A. She will need to have her medications adjusted and be readmitted to the hospital for a complete workup.
B. Limiting fluids can create imbalances in the 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. Confusion following surgery is common in the elderly due to loss of sleep.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.

4. 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?

A. . Apply oxygen by mask or nasal cannula
B. Apply a paper bag over the clients nose and mouth.
C. Administer 50 mL of sodium bicarbonate intravenously.
D. Administer 50 mL of 20% glucose and 20 units of regular insulin.

Correct answer: A

Rationale:

5. What is the most abundant positive ion in blood plasma?

A. Potassium.
B. Calcium.
C. Sodium.
D. Both potassium and sodium are in equal concentrations.

Correct answer: C

Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.