a medical surgical nurse is concerned about the incidence of complications related to iv therapy including bloodstream infection which intervention sh
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications

Correct answer: A

Rationale:

2. The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?

Correct answer: C

Rationale: Infiltration is the administration of non-vesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the vein's wall. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort, and coolness in the area of infiltration, and a significant decrease in the flow rate. Air emboli (Choice A) involves air entering the bloodstream. Phlebitis (Choice B) is inflammation of a vein. Fluid overload (Choice D) is an excessive volume of fluid in the circulatory system.

3. Which of the following is not considered an extracellular fluid?

Correct answer: D

Rationale: The correct answer is D. Cerebrospinal fluid and the humors of the eye are not considered extracellular fluids. Extracellular fluids are fluids found outside the cells, such as interstitial fluid and lymph. Cerebrospinal fluid is found within the central nervous system, while the humors of the eye (aqueous humor and vitreous humor) are located within the eyeball, making them distinct from extracellular fluids.

4. A nurse is assessing clients on a medical-surgical unit. Which clients are at increased risk for hypophosphatemia? (Select all that do not apply.)

Correct answer: C

Rationale:

5. When does dehydration begin to occur?

Correct answer: C

Rationale: Dehydration leads to a decrease in the body's fluid levels, causing the salivary glands to produce less saliva, resulting in a dry mouth. Therefore, when dehydration begins to occur, salivary secretions decrease. Choice A is incorrect because the body does not reduce fluid output to zero during dehydration; it tries to conserve fluids. Choice B is incorrect as dehydration does not directly increase the release of ANH (Atrial Natriuretic Hormone). Choice D is incorrect because salivary secretions do not increase but decrease during dehydration.

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