1. The nurse is caring for a client who has a diagnosis of syndrome of inappropriate antidiuretic
hormone secretion. The plan of care includes assessment of specific gravity every four hours. The
results of this test will allow the nurse to assess which aspect of the client’s health?
1. Nutritional status
2. Potassium balance
3. Calcium balance
4. Fluid volume status
ANS: D Rationale: Specific gravity measures the density of urine compared with water and can
assess the ability of the kidneys to excrete or conserve water. Therefore, specific gravity will
detect if the client has a fluid volume deficit or fluid volume excess. Nutrition, potassium, and
calcium levels are not directly indicated. REF:p.230
2. The nurse is caring for a client admitted with a diagnosis of acute kidney injury. When reviewing
the client’s most recent laboratory reports, the nurse notes that the client’s magnesium levels are
high. The nurse should prioritize assessment for what health problem?
1. Diminished deep tendon reflexes
2. Tachycardia
3. Cool, clammy skin
4. Acuteflankpain
ANS: A Rationale: To gauge a client’s magnesium status, the nurse should check deep tendon
reflexes. If the reflex is absent, this may indicate high serum magnesium. Tachycardia, flank pain,
and cool, clammy skin are not typically associated with hypermagnesemia. REF:p.254
3. The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of
third spacing. Based on this change in status, the nurse should expect the client to exhibit signs
and symptoms of which imbalance?
1. Metabolic alkalosis
2. Hypermagnesemia
3. Hypercalcemia
4. Hypovolemia
ANS: D Rationale: Third-spacing fluid shift, which occurs when fluid moves out of the
intravascular space but not into the intracellular space, can cause hypovolemia. Increased calcium
and magnesium levels are not indicators of third-spacing fluid shift. Burns typically cause
acidosis, not alkalosis. REF:p.226
4. A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency
room. The triage nurse notes upon assessment that the client is hyperventilating. The triage nurse
is aware that hyperventilation is the most common cause of which acid–base imbalance?
1. Respiratory acidosis
lOMoARcPSD|4292290
ATI Med Surg test questions Fluid and Electrolytes Balance and Disturbance 100%
Correct Answers Newest Version 2024
2. Respiratory alkalosis
3. Increased PaCO2
4. Metabolicacidosis
ANS: B Rationale: Extreme anxiety can lead to hyperventilation, the most common cause of
acute respiratory alkalosis. During hyperventilation, CO2 is lost through the lungs, creating an
alkalotic state and a low PaCO2. Acute respiratory acidosis occurs in emergency situations, such
as pulmonary edema, and is exhibited by hypoventilation and decreased PaCO2. Metabolic
acidosis results from the loss of bicarbonate, not CO2. REF:p.255
5. The emergency-room nurse is caring for a trauma client who has the following arterial blood gas
results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How should the nurse interpret these results?
1. Respiratory acidosis with no compensation
2. Metabolic alkalosis with compensatory alkalosis
3. Metabolic acidosis with no compensation
4. Metabolic acidosis with compensatory respiratory alkalosis
ANS: D Rationale: A low pH indicates acidosis (normal pH is 7.35 to 7.45). The PaCO2 is also
low, which causes alkalosis. The bicarbonate is low, which causes acidosis. The pH bicarbonate
more closely corresponds with a decrease in pH, making the metabolic component the primary
problem. REF: p.261
While assessing a client’s peripheral IV site, the nurse observes edema and coolness around the
insertion site. How should the nurse document this observation?
5. Air embolism
6. Phlebitis
7. Infiltration D. Fluidoverload
ANS: C Rationale: Infiltration is the administration of non-vesicant solution or medication into the
surrounding tissue when the IV cannula dislodges or perforates the wall of the vein. Infiltration is
characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort
and coolness, and a significant decrease in the flow rate. An air embolism occurs when air enters the vein;
it does not have any local manifestations at the IV site but may produce palpitations, dyspnea,
hypotension, and chest pain. Phlebitis, an inflammation of the vein, is characterized by redness, warmth,
and tenderness at the IV site. Fluid volume overload produces systemic manifestations and is not apparent
at the IV site. REF:p.268
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