a nurse assesses a client who has a radial artery catheter which assessment should the nurse complete first

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?

A. . Amount of pressure in fluid container
B. Date of catheter tubing change
C. Percent of heparin in infusion container
D. . Presence of an ulnar pulse

Correct answer: D

Rationale:

2. When considering overhydration:

A. occurs less often than dehydration.
B. can strain the kidneys.
C. can be caused by giving intravenous fluids too rapidly.
D. less common than dehydration.

Correct answer: C

Rationale: The correct answer is C. Overhydration can occur when intravenous fluids are administered too quickly, overwhelming the body's ability to excrete the excess fluid. Choices A, B, and D are incorrect. Choice A is incorrect because overhydration is less common than dehydration. Choice B is incorrect because while overhydration can strain the kidneys, it is not due to the burden being too heavy. Choice D is incorrect because dehydration is more common than overhydration.

3. A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?

A. Allergic reaction
B. Bowel obstruction
C. Catheter lumen occlusion
D. Infection

Correct answer: D

Rationale:

4. A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?

A. Tell the patient to rest more frequently.
B. Advise the patient to discontinue digoxin and contact the physician.
C. Contact the physician, report the symptoms, and request a blood sample to determine the patient's potassium level.
D. Instruct the patient to avoid caffeine-containing foods.

Correct answer: C

Rationale: The correct action for the nurse to take is to contact the physician, report the patient's symptoms, and request a blood sample to determine the patient's potassium level. Furosemide, a potassium-wasting diuretic, can lead to hypokalemia, causing weakness and palpitations. Therefore, checking the potassium level is crucial in this situation. Simply telling the patient to rest more frequently won't address the underlying issue of potassium depletion. While digoxin can cause adverse effects, in this case, the symptoms are more likely related to furosemide-induced potassium loss. Instructing the patient to avoid caffeine-containing foods may be beneficial in general, but it wouldn't directly address the potassium depletion that needs urgent attention.