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 ligh
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Nursing Elites

ATI RN

Fluid and Electrolytes ATI

1. 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:

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.

2. 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?

Correct answer: A

Rationale:

3. Which negative ion is most abundant in blood plasma?

Correct answer: B

Rationale: Chloride (Cl-) is the most abundant anion in blood plasma. It plays a crucial role in maintaining osmotic balance and acid-base homeostasis. Bicarbonate (Choice A) is important for buffering acids in the body but is not the most abundant negative ion in blood plasma. Hydroxide (Choice C) is not typically found in high concentrations in blood plasma. Phosphate (Choice D) is an important anion in the body but is not as abundant as chloride in blood plasma.

4. An increase in capillary blood pressure would tend to:

Correct answer: A

Rationale: An increase in capillary blood pressure leads to a higher force pushing fluid out of the capillaries into the interstitial space, thereby increasing interstitial fluid volume. Choice B is incorrect because capillary blood pressure affects the movement of fluid into the interstitial space, not into the plasma. Choice C is incorrect as an increase in capillary blood pressure would not decrease interstitial fluid volume. Choice D is incorrect as it combines contradictory effects when capillary blood pressure increases.

5. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

Correct answer: D

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.

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