a nurse is caring for a client who is receiving an epidural infusion for pain management which assessment finding requires immediate intervention from

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

A. Redness at the catheter insertion site
B. Report of headache and stiff neck
C. Temperature of 100.1 F (37.8 C)
D. Pain rating of 8 on a scale of 0 to 10

Correct answer: B

Rationale:

2. Which condition can result from prolonged vomiting or diarrhea?

A. Intracellular fluid
B. Interstitial fluid
C. Dehydration
D. Electrolyte

Correct answer: C

Rationale: The correct answer is C: Dehydration. Prolonged vomiting or diarrhea can lead to significant fluid loss, causing dehydration. Intracellular fluid (choice A) and interstitial fluid (choice B) refer to specific compartments of body fluid and are not conditions resulting from vomiting or diarrhea. Electrolytes (choice D) are minerals that help maintain fluid balance in the body but are not the condition directly resulting from prolonged vomiting or diarrhea.

3. Which of the following are sources of water intake?

A. Drinking fluids.
B. Consuming water from the food we eat.
C. Water from metabolic processes.
D. Drinking fluids, consuming water from the food we eat, and water from metabolic processes.

Correct answer: D

Rationale: The correct answer is D. The sources of water intake include drinking fluids, consuming water from the food we eat, and water from metabolic processes. Water intake is not solely from the liquids we drink but also from the water content present in the food we consume and the water produced during metabolic processes such as cellular respiration. Therefore, option D is the correct answer as it covers all the sources of water intake. Options A, B, and C alone do not encompass all the sources of water intake, making them incorrect choices.

4. A patient admitted with a gastrointestinal bleed and anemia is receiving a blood transfusion. Based on the patient's hypotensive blood pressure, the nurse anticipates an order for IV fluids from the physician. Which of the following IV solutions may be administered with blood products?

A. D5 and 0.45% Normal Saline
B. Lactated Ringer's
C. 5% dextrose in water
D. 0.9% NaCl

Correct answer: D

Rationale: The correct answer is D: 0.9% NaCl. The only IV solution that can be administered with blood products is normal saline (0.9% NaCl). This solution is compatible with most blood products and is commonly used during transfusions to maintain hemodynamic stability. Choices A, B, and C are incorrect. Choice A, D5 and 0.45% Normal Saline, contains dextrose and is not recommended to be given simultaneously with blood products. Choice B, Lactated Ringer's, contains calcium, which can cause coagulation and should not be mixed with blood. Choice C, 5% dextrose in water, is hypotonic and not suitable to be administered with blood products.

5. Which positive ion is most prevalent in intracellular fluid?

A. Calcium
B. Potassium
C. Sodium
D. Magnesium

Correct answer: B

Rationale: The correct answer is Potassium (K+). Potassium is the predominant cation found within cells, making it the most prevalent positive ion in intracellular fluid. Calcium, sodium, and magnesium are also essential ions in the body, but they are not as abundant in intracellular fluid. Calcium is vital for bone health and muscle function, sodium helps in maintaining fluid balance and nerve function, and magnesium is involved in numerous biochemical reactions.