ATI RN
Fluid and Electrolytes ATI
1. What would be the best initial nursing action prior to inserting an IV?
- A. Instruct the patient to wash their hands.
- B. Prepare the IV insertion site with povidone iodine.
- C. Verify the order for IV therapy.
- D. Identify a suitable vein.
Correct answer: C
Rationale: The best initial nursing action prior to inserting an IV is to verify the order for IV therapy. This step ensures that the IV insertion is appropriate and necessary based on the physician's orders. Instructing the patient to wash their hands (Choice A) is important for infection control but not the immediate priority before IV insertion. While preparing the IV insertion site with povidone iodine (Choice B) and identifying a suitable vein (Choice D) are crucial steps in the process, confirming the order for IV therapy (Choice C) takes precedence to ensure the correct intervention is being performed.
2. A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right uppe
- A. Notify the health care provider
- B. . Administer the prescribed medication.
- C. Discontinue the PICC
- D. Switch the medication to the oral route
Correct answer: B
Rationale:
3. You are caring for a 65-year-old male patient admitted to your medical unit 72 hours ago with pyloric stenosis. A nasogastric tube placed upon admission has been on low intermittent suction ever since. Upon review of the mornings blood work, you notice that the patients potassium is below reference range. You should recognize that the patient may be at risk for what imbalance?
- A. Hypercalcemia
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct answer: C
Rationale:
4. 1.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?
- A. Lower the extremity below the level of the heart.
- B. Apply warm compresses to the extremity.
- C. Tap the skin lightly and avoid slapping.
- D. Place a washcloth between the skin and tourniquet
Correct answer: D
Rationale:
5. Your patient has alcoholism, and you may suspect during your assessment that his serum magnesium is low. What will the nurse potentially expect to assess related to hypomagnesemia?
- A. Tremor
- B. Pruritus
- C. Edema
- D. Decreased blood pressure
Correct answer: A
Rationale: The correct answer is A: Tremor. Signs and symptoms of hypomagnesemia primarily affect the neuromuscular system and can include tremors, confusion, tetany, laryngeal stridor, and ataxia. Pruritus (choice B) refers to itching and is not typically associated with hypomagnesemia. Edema (choice C) is swelling caused by fluid retention and is not a common manifestation of hypomagnesemia. Decreased blood pressure (choice D) is not a typical sign of hypomagnesemia; instead, low magnesium levels are more likely to cause hypertension.
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