ATI RN
Fluid and Electrolytes ATI
1. 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.
2. While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
- A. Grade 3 phlebitis at IV site
- B. infection at IV site
- C. Thrombosed area at IV site
- D. infiltration at IV site
Correct answer: A
Rationale:
3. The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a positive Chvosteks sign indicate?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hypocalcemia
- D. Hyperkalemia
Correct answer: C
Rationale:
4. 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.
5. A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious administering oxygen. What is the new nurses best response?
- A. The patients calcium will rise dramatically due to pituitary stimulation.
- B. Oxygen will increase the patients intracranial pressure and create confusion.
- C. Oxygen may cause the patient to hyperventilate and become acidotic.
- D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
Correct answer: D
Rationale:
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