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. The patient asks the nurse if he will die if air bubbles get into the IV tubing. What is the nurse's best response?

Correct answer: B

Rationale: The correct answer is B because air emboli are more commonly associated with central vein access. Usually, only relatively large volumes of air administered rapidly are dangerous. It is a significant concern when air enters a central venous access line. Choice A is incorrect as it downplays the risk and is not entirely accurate. Choice C is too general and does not specifically address the patient's concern. Choice D is dismissive and does not provide any relevant information regarding the risk of air bubbles in IV tubing.

3. The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation is the most common cause of acute respiratory alkalosis. When a patient hyperventilates due to anxiety or other causes, they blow off excessive carbon dioxide, leading to a decrease in PaCO2 and a rise in pH. Choices A, C, and D are incorrect because hyperventilation leads to a decrease in PaCO2, causing respiratory alkalosis, not respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

4. The community health nurse is performing a home visit to an 84-year-old woman recovering from hip surgery. The nurse notes that the woman seems uncharacteristically confused and has dry mucous membranes. When asked about her fluid intake, the patient states, I stop drinking water early in the day because it is just too difficult to get up during the night to go to the bathroom. What would be the nurses best response?

Correct answer: B

Rationale:

5. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

Correct answer: D

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.

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