a patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room the triage nurse notes upon assessment that the
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Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause

Correct answer: B

Rationale:

2. Who would have the greatest percentage of body water?

Correct answer: D

Rationale: Newborns have a higher percentage of body water compared to adults due to their higher body fluid content. Factors such as the higher ratio of body surface area to body volume and lower body fat content contribute to this. This is why a newborn would have the greatest percentage of body water. Choices A, B, and C are incorrect because obesity and gender do not determine the percentage of body water in individuals. Therefore, the correct answer is a newborn.

3. Which hormone reduces the amount of water in the body?

Correct answer: B

Rationale: The correct answer is 'aldosterone.' Aldosterone is the hormone that reduces the amount of water in the body by increasing the reabsorption of sodium and water from the kidney tubules. ANH (atrial natriuretic hormone) actually works to increase the excretion of sodium and water by the kidneys, leading to a reduction in blood volume and pressure. ADH (antidiuretic hormone) works to increase water reabsorption by the kidneys, thereby increasing blood volume. Therefore, choices A (ADH) and D (ADH and aldosterone) are incorrect in the context of reducing the amount of water in the body.

4. What electrolyte value should be monitored when a patient is receiving a loop diuretic?

Correct answer: C

Rationale: When a patient is receiving a loop diuretic like furosemide (Lasix), potassium levels should be monitored closely. Loop diuretics act on the ascending loop of Henle to inhibit the reabsorption of sodium and water, leading to potassium loss. Monitoring potassium levels is crucial to prevent hypokalemia, which can result in serious complications such as cardiac arrhythmias. Calcium levels (Choice A), phosphorus levels (Choice B), and magnesium levels (Choice D) are not typically affected directly by loop diuretics and do not require routine monitoring in this context.

5. 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.

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