a home care nurse prepares to administer intravenous medication to a client the nurse assesses the site and reviews the clients chart prior to adminis

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right uppe

A. Notify the health care provider
B. . Administer the prescribed medication.
C. Discontinue the PICC
D. Switch the medication to the oral route

Correct answer: B

Rationale:

2. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand, and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

A. Hypophosphatemia
B. Hypocalcemia
C. Hypermagnesemia
D. Hyperkalemia

Correct answer: B

Rationale: The symptoms described, including tingling in the lips and fingers, intermittent spasms, and increased muscle tone, are indicative of tetany, which is a common manifestation of hypocalcemia. Hypocalcemia can lead to neuromuscular irritability, causing symptoms such as paresthesias and muscle spasms. Hypophosphatemia primarily affects the central nervous system, resulting in seizures and coma. Hypermagnesemia typically presents with hypoactive reflexes and somnolence. Hyperkalemia can cause paresthesias and anxiety, but in this case, the patient's symptoms are more suggestive of hypocalcemia.

3. A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?

A. A 34-year-old on NPO status who is receiving intravenous D5W
B. A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
C. A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
D. A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)

Correct answer: A

Rationale: The correct answer is the 34-year-old on NPO status receiving intravenous D5W because D5W is a hypotonic solution that can dilute the blood's sodium levels, leading to hyponatremia. Patients on NPO status rely solely on intravenous fluids for hydration, making them more susceptible to electrolyte imbalances. Choices B, C, and D are less likely to cause hyponatremia. Choice B, the 50-year-old with an infection on a sulfonamide antibiotic, is at risk for allergic reactions or renal issues. Choice C, the 67-year-old taking ibuprofen, is at risk for gastrointestinal bleeding or kidney problems. Choice D, the 73-year-old on digoxin with tachycardia, is more likely to experience digoxin toxicity, affecting the heart's rhythm.

4. The healthcare professional working in the PACU is aware that which of the following procedures may contribute to extracellular losses?

A. Removal of an ingrown toenail
B. Tooth extraction
C. Abdominal surgery
D. Cataract surgery

Correct answer: C

Rationale: Fluid loss from the extracellular compartment can be caused by abdominal surgery as it involves opening the abdominal cavity, potentially leading to significant fluid losses. Choices A, B, and D do not typically result in substantial extracellular losses compared to abdominal surgery.

5. Which organ has the greatest effect on fluid output?

A. Kidneys
B. Lungs
C. Skin
D. Intestines

Correct answer: A

Rationale: The correct answer is the kidneys. The kidneys are primarily responsible for regulating fluid balance by filtering blood and adjusting the volume and concentration of urine. The lungs primarily regulate gas exchange, not fluid balance. The skin plays a role in temperature regulation and protection but is not the primary organ for fluid output. The intestines are mainly involved in the absorption of nutrients and water, rather than fluid output.