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 unchara

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. 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?

A. I will need to have your medications adjusted so you will need to be readmitted to the hospital for a complete workup
B. Limiting your fluids can create imbalances in your body that can result in confusion. Maybe we need to adjust the timing of your fluids.
C. It is normal to be a little confused following surgery, and it is safe not to urinate at night.
D. If you build up too much urine in your bladder, it can cause you to get confused, especially when your body is under stress.

Correct answer: B

Rationale:

2. What percentage of body water can be as high as in a newborn?

A. 80%.
B. 70%.
C. 60%.
D. 90%.

Correct answer: A

Rationale: The correct answer is A: 80%. Newborns can have a body water content as high as 80% due to their higher total body water compared to adults. Choice B (70%) is incorrect because newborns typically have a higher body water percentage. Choice C (60%) is also incorrect as it underestimates the body water content in newborns. Choice D (90%) is incorrect as it overestimates the body water percentage in newborns.

3. Which hormone is made in the pituitary gland and increases water absorption in the kidney?

A. Intracellular fluid
B. Interstitial fluid
C. Plasma
D. ADH

Correct answer: D

Rationale: The correct answer is D, ADH (Antidiuretic hormone). ADH is produced by the pituitary gland and functions to increase water reabsorption in the kidneys. Choices A, B, and C are incorrect as they do not refer to a hormone responsible for increasing water absorption in the kidney.

4. When preparing a site for the insertion of an IV catheter, how should excess hair at the site be treated?

A. Leaving the hair intact
B. Shaving the area
C. Clipping the hair in the area
D. Removing the hair with a depilatory

Correct answer: C

Rationale: The correct answer is to clip the hair in the area. Excess hair at the site of IV catheter insertion should be removed because it can be a potential source of infection. Clipping the hair is preferred over shaving because shaving can cause skin abrasions, increasing the risk of infection. Using depilatories is not recommended as they can irritate the skin, which is undesirable when preparing a clean site for an invasive procedure. Therefore, clipping the hair in the area is the most appropriate and safe method to prepare the site for IV catheter insertion.

5. Which organ has the greatest effect on fluid output?

A. Kidneys
B. Lungs
C. Skin
D. Intestines

Correct answer: A

Rationale: The correct answer is the kidneys. The kidneys are primarily responsible for regulating fluid balance by filtering blood and adjusting the volume and concentration of urine. The lungs primarily regulate gas exchange, not fluid balance. The skin plays a role in temperature regulation and protection but is not the primary organ for fluid output. The intestines are mainly involved in the absorption of nutrients and water, rather than fluid output.