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. A client at risk for mild hypernatremia is being taught by a nurse. Which statement should the nurse include in this client's teaching?
- A. Weigh yourself every morning and every night
- B. Check your radial pulse twice a day
- C. Read food labels to determine sodium content
- D. Bake or grill the meat rather than frying it
Correct answer: C
Rationale: The correct answer is to 'Read food labels to determine sodium content.' This is important for a client at risk for mild hypernatremia because monitoring sodium intake is crucial in managing this condition. Choice A is not directly related to managing hypernatremia. Choice B focuses on pulse monitoring, which is not specific to managing sodium levels. Choice D addresses cooking methods, which can be beneficial but is not as directly related to sodium intake monitoring as reading food labels.
3. The term used to describe a blood sodium level of more than 145 mEq/L is:
- A. hyponatremia.
- B. hyperkalemia.
- C. hypernatremia.
- D. hypercalcemia.
Correct answer: C
Rationale: The correct answer is C: hypernatremia. Hypernatremia refers to an elevated level of sodium in the blood, specifically when it is more than 145 mEq/L. Choice A, hyponatremia, is incorrect as it refers to low sodium levels. Choice B, hyperkalemia, is incorrect as it refers to high potassium levels, not sodium. Choice D, hypercalcemia, is also incorrect as it relates to elevated calcium levels, not sodium.
4. A nurse preparing to start an IV on a newly admitted patient teaches the patient about the procedure and begins to prepare the site. The nurse should always start by:
- A. Leaving one hand ungloved to assess the site
- B. Preparing the skin with an iodine solution
- C. Asking the patient if they are allergic to latex or iodine
- D. Removing excessive hair at the selected site
Correct answer: C
Rationale: Before preparing the skin, the nurse should ask the patient if they are allergic to latex or iodine, which are commonly used in IV therapy setup. This is crucial to prevent potential allergic reactions at the IV site or even life-threatening anaphylaxis. Leaving one hand ungloved (choice A) is not a recommended practice as both hands should be gloved for infection control. While preparing the skin with an iodine solution (choice B) is a step in the process, ensuring the patient's safety by checking for allergies comes first. Removing excessive hair at the selected site (choice D) is not necessary and can lead to skin irritation.
5. .A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
- A. Apply cold compresses to the IV site.
- B. Elevate the extremity on a pillow.
- C. Flush the catheter with normal saline.
- D. . Stop the infusion of intravenous fluids.
Correct answer: D
Rationale:
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