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. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.)
- A. Use a draw sheet to reposition the client in bed.
- B. . Strain all urine output and assess for urinary stones.
- C. Provide nonslip footwear for the client to use when out of bed.
- D.
Correct answer: B
Rationale:
3. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?
- A. Overhydration is common among healthy older adults.
- B. Dehydration causes the skin to appear spongy
- C. Inelastic skin turgor is a normal part of aging
- D. Skin turgor cannot be assessed in patients over 70.
Correct answer: C
Rationale:
4. Place a washcloth between the skin and tourniquet
- A. Provide a bed bath instead of letting the client take a shower
- B. Use sterile technique when changing the dressing.
- C. Disconnect the intravenous fluid tubing prior to the clients bath.
- D. Use a plastic bag to cover the extremity with the device
Correct answer: D
Rationale:
5. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:
- A. Choose a proximal site.
- B. Choose a distal site.
- C. Have the patient hold their arm in a dependent position.
- D. Leave the tourniquet on for no longer than 2 minutes.
Correct answer: B
Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Opting for a distal site ensures that upper veins remain available for future cannulations. Instructing the patient to hold their arm in a dependent position can enhance blood flow, aiding in the procedure. It is crucial never to leave a tourniquet on for more than 2 minutes as prolonged restriction can lead to complications. Choice A is incorrect because a proximal site is not preferred for IV insertion. Choice C is incorrect as having the patient hold their arm over their head is not necessary and may impede proper blood flow. Choice D is incorrect as leaving the tourniquet on for at least 5 minutes is excessive and can be harmful.
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