2024 ATI FLUID AND ELECTROLYTES BALANCE AND DISTURBANCE LATEST
VERSION ACTUAL EXAM QUESTION WITH QUESTION AND CORRECT
ANSWERS WITH RATIONALES RATED A GRADE.
A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis.
Which of the following statements by a unit nurse indicates the teaching has been effective?
A. "Metabolic acidosis can occur due to diabetic ketoacidosis."
B. "Metabolic acidosis can occur in a client who has myasthenia gravis."
C. "Metabolic acidosis can occur in a client who has asthma."
D. "Metabolic acidosis can occur due to cancer." - ansA; Metabolic acidosis results
from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis.
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has
dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following
findings should the nurse identify as manifestations of fluid volume deficit? (Select all that
apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea - ansA; Decreased skin turgor is a manifestation present with fluid volume
deficit. Skin turgor is decreased due to the lack of fluid within the body and results in
dryness of the skin.
B; Concentrated urine is a manifestation present with fluid volume deficit. Urine is
concentrated due to lack of fluid in the vascular system, causing a decreased profusion of
the kidneys resulting in an increased urine specific gravity.
D; Low-grade fever is a manifestation present with fluid volume deficit. Low-grade fever is
one of the body's ways to maintain homeostasis to compensate for lack of fluid within the
body.
E; Tachypnea is a manifestation present with fluid volume deficit. Increased respirations are
the body's way to obtain oxygen due to the lack of fluid volume within the body.
A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr.
Which of the following manifestations of fluid volume excess should the nurse expect?
(Select all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
D. Hypertension
E. Weakness - ansA; Dyspnea is a manifestation present with fluid volume excess. Dyspnea
is due to an excess of fluids within the body and lungs, and the client is struggling to
breathe to obtain oxygen.
B; Weight gain can be a result of edema.
D; Blood pressure rises as the heart must work harder due to the excess fluid.
E; Weakness is due to the excess fluid that is retained, which depletes energy and
increases the workload for the body.
A nurse is assessing a client for Chvostek's sign. Which of the following techniques should
the nurse use to perform this test?
A. Apply a blood pressure cuff to the client's arm
B. Place the stethoscope bell over the client's carotid artery
C. Tap lightly on the client's cheek
D. Ask the client to lower their chin to their chest - ansC; Tap the client's cheek over the
facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response
is indicated when the client exhibits facial twitching on this side of the face.
A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the
following conditions as being associated with this electrolyte imbalance?
,2024 ATI FLUID AND ELECTROLYTES BALANCE AND DISTURBANCE LATEST
VERSION ACTUAL EXAM QUESTION WITH QUESTION AND CORRECT
ANSWERS WITH RATIONALES RATED A GRADE.
A. Diabetic Ketoacidosis
B. heart failure
C. Cushing's syndrome
D. Thyroidectomy - ansA; Hyperkalemia is a lab finding associated with DKA.
A nurse is assessing a client who has pancreatitis. The client's ABG reveal metabolic
acidosis. Which of the following are expected findings? (Select all that apply.)
A. Tachycardia
B. Hypertension
C. Bounding pulse
D. Hyperreflexia
E. Dysrhythmia
F. Tachypnea - ansE; Dysrhythmia is an expected finding in a client who has pancreatitis
and metabolic acidosis.
F; Tachypnea is an expected finding in a client who has pancreatitis and metabolic acidosis.
A nurse is assessing a client who is dehydrated. Which of the following findings should the
nurse expect?
A. Moist skin
B. Distended neck veins
C. Increased urinary output
D. Tachycardia - ansD; Tachycardia is an attempt to maintain blood pressure, a
manifestation of fluid volume deficit.
A nurse is caring for a client admitted with confusion and lethargy. The client was found at
home unresponsive with an empty bottle of aspirin lying next to the bed. Vital signs reveal
blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory
rate 42/min and deep. Which of the following arterial blood gas findings should the nurse
expect?
A. pH 7.68
PaO2 96 mm Hg
PaCO2 38 mm Hg
HCO3 28 mEq/L
B. pH 7.48
PaO2 100 mm Hg
PaCO2 28 mm Hg
HCO3 23 mEq/L
C. pH 6.98
PaO2 100 mm Hg
PaCO2 30 mm Hg
HCO3 18 mEq/L
D. pH 7.58
PaO2 96 mm Hg
PaCO2 38 mm Hg
HCO3 29 mEq/L - ansC; An aspirin toxicity would result in ABG findings of metabolic
acidosis.
A nurse is caring for a client in a long-term facility who has become weak, confused, and
experienced dizziness when standing. The client's temperature is 38.3 degrees C (100.9
degrees F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of
the following actions should the nurse take?
A. Initiate fluid restrictions to limit intake
B. Check for peripheral edema
, 2024 ATI FLUID AND ELECTROLYTES BALANCE AND DISTURBANCE LATEST
VERSION ACTUAL EXAM QUESTION WITH QUESTION AND CORRECT
ANSWERS WITH RATIONALES RATED A GRADE.
C. Encourage the client to ambulate to promote oxygenation
D. Monitor for orthostatic hypotension - ansD; Monitor for orthostatic hypotension
because they have manifestations of dehydration due to decreased circulatory volume.
A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should assess
for which of the following manifestations?
A. ECG changes
B. Constipation
C. Polyuria
D. Paresthesia - ansA; Assess for ECG changes. Potassium levels can affect the heart
and result in arrhythmias.
A nurse is caring for a client who has a blood sodium level 133 mEg/L and blood potassium
level 3.4 mEq/L. The nurse should recognize that which of the following treatments can
result in these laboratory findings?
A. Three tap water enemas
B. 0.9% NaCl solution IV at 50 ml/hr
C. 5% dextrose with 0.45% NaCl solution with 20 mEq of K+ IV at 80 mL/hr
D. Antibiotic therapy - ansA; Three tap water enemas can result in a decrease in blood
sodium and potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic.
This creates an imbalance and solute dilution.
A nurse is caring for a client who has a NGT attached to low intermittent suctioning. The nurse
should monitor for which of the following electrolyte imbalances?
A. Hypercalcemia
B. Hyponatremia
C. Hyperphosphatemia
D. Hyperkalemia - ansB; Monitor the client for hyponatremia. Nasogastric losses are isotonic
and contain sodium.
A nurse is caring for a client who was in a motor-vehicle accident. The client reports chest pain
and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the
following ABG findings should the nurse expect?
A. pH 7.06
PaO2 86 mm Hg
PaCO2 52 mm Hg
HCO3 24 mEq/L
B. pH 7.42
PaO2 100 mm Hg
PaCO2 38 mm Hg
HCO3 23 mEq/L
C. pH 6.98
PaO2 100 mm Hg
PaCO2 30 mm Hg
HCO3 18 mEq/L
D. pH 7.58
PaO2 96 mm Hg
PaCO2 38 mm Hg
HCO3 29 mEq/L - ansA; A pneumothorax can cause alveolar hypoventilation and increased
carbon dioxide levels, resulting in a state of respiratory acidosis.
, 2024 ATI FLUID AND ELECTROLYTES BALANCE AND DISTURBANCE LATEST
VERSION ACTUAL EXAM QUESTION WITH QUESTION AND CORRECT
ANSWERS WITH RATIONALES RATED A GRADE.
A nurse is collecting data from a client who has hypercalcemia as a result of long-term use
of glucosteroids. Which of the following findings should the nurse expect? (Select all that
apply.)
A. Hyperreflexia
B. Confusion
C. Positive Chvostek's sign
D. Bone pain
E. Nausea and vomiting - ansB; Expect the client who has hypercalcemia to have
confusion and a possible decreased LOC,
D; Expect the pt to have bone pain.
E; Expect the pt to have N/V along with anorexia
A nurse is obtaining ABGs for a client who has vomited for 24 hr. The nurse should expect
which of the following acid-base imbalances to result from vomiting 24 hr?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - ansD; Excessive vomiting causes a loss of gastric acids and an
accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.
A nurse is performing an admission assessment on a client who has hypovolemia due to
vomiting and diarrhea. The nurse should expect which of the following findings? (Select all
that apply.)
A. Distended neck veins
B. Hyperthermia
C. Tachycardia
D. Syncope
E. Decreased skin turgor - ansC, D, E
A nurse is planning care for a client who has dehydration. Which of the following actions
should the nurse include?
A. Administer antihypertensive on schedule
B. Check the client's weight each morning
C. Notify the provider of a urine output greater than 30 mL/hr
D. Encourage independent ambulation four times a day - ansB; Include obtaining the client's
weight each day in the plan of care. To ensure accuracy the client's weight should be
obtained at the same time each day using the same scale. By determining the client's
weight gain or loss each day the nurse can evaluate the client's response to treatment.
A nurse is planning care for a client who has hypernatremia. Which of the following actions
should the nurse include in the plan of care?
A. Infuse hypotonic IV fluids
B. Implement a fluid restriction
C. Increase Na+ intake
D. Administer sodium polystyrene sulfonate - ansA; Hypotonic IV fluids are indicted for the
treatment of hypernatremia related to fluid loss to expand the ECF volume and rehydrate
the cells
A nurse is providing education for a client who has severe hypomagnesemia and is
prescribed oral magnesium sulfate. Which of the following info should the nurse include in
the teaching?
VERSION ACTUAL EXAM QUESTION WITH QUESTION AND CORRECT
ANSWERS WITH RATIONALES RATED A GRADE.
A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis.
Which of the following statements by a unit nurse indicates the teaching has been effective?
A. "Metabolic acidosis can occur due to diabetic ketoacidosis."
B. "Metabolic acidosis can occur in a client who has myasthenia gravis."
C. "Metabolic acidosis can occur in a client who has asthma."
D. "Metabolic acidosis can occur due to cancer." - ansA; Metabolic acidosis results
from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis.
A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has
dry oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following
findings should the nurse identify as manifestations of fluid volume deficit? (Select all that
apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea - ansA; Decreased skin turgor is a manifestation present with fluid volume
deficit. Skin turgor is decreased due to the lack of fluid within the body and results in
dryness of the skin.
B; Concentrated urine is a manifestation present with fluid volume deficit. Urine is
concentrated due to lack of fluid in the vascular system, causing a decreased profusion of
the kidneys resulting in an increased urine specific gravity.
D; Low-grade fever is a manifestation present with fluid volume deficit. Low-grade fever is
one of the body's ways to maintain homeostasis to compensate for lack of fluid within the
body.
E; Tachypnea is a manifestation present with fluid volume deficit. Increased respirations are
the body's way to obtain oxygen due to the lack of fluid volume within the body.
A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr.
Which of the following manifestations of fluid volume excess should the nurse expect?
(Select all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
D. Hypertension
E. Weakness - ansA; Dyspnea is a manifestation present with fluid volume excess. Dyspnea
is due to an excess of fluids within the body and lungs, and the client is struggling to
breathe to obtain oxygen.
B; Weight gain can be a result of edema.
D; Blood pressure rises as the heart must work harder due to the excess fluid.
E; Weakness is due to the excess fluid that is retained, which depletes energy and
increases the workload for the body.
A nurse is assessing a client for Chvostek's sign. Which of the following techniques should
the nurse use to perform this test?
A. Apply a blood pressure cuff to the client's arm
B. Place the stethoscope bell over the client's carotid artery
C. Tap lightly on the client's cheek
D. Ask the client to lower their chin to their chest - ansC; Tap the client's cheek over the
facial nerve just below and anterior to the ear to elicit Chvostek's sign. A positive response
is indicated when the client exhibits facial twitching on this side of the face.
A nurse is assessing a client who has hyperkalemia. The nurse should identify which of the
following conditions as being associated with this electrolyte imbalance?
,2024 ATI FLUID AND ELECTROLYTES BALANCE AND DISTURBANCE LATEST
VERSION ACTUAL EXAM QUESTION WITH QUESTION AND CORRECT
ANSWERS WITH RATIONALES RATED A GRADE.
A. Diabetic Ketoacidosis
B. heart failure
C. Cushing's syndrome
D. Thyroidectomy - ansA; Hyperkalemia is a lab finding associated with DKA.
A nurse is assessing a client who has pancreatitis. The client's ABG reveal metabolic
acidosis. Which of the following are expected findings? (Select all that apply.)
A. Tachycardia
B. Hypertension
C. Bounding pulse
D. Hyperreflexia
E. Dysrhythmia
F. Tachypnea - ansE; Dysrhythmia is an expected finding in a client who has pancreatitis
and metabolic acidosis.
F; Tachypnea is an expected finding in a client who has pancreatitis and metabolic acidosis.
A nurse is assessing a client who is dehydrated. Which of the following findings should the
nurse expect?
A. Moist skin
B. Distended neck veins
C. Increased urinary output
D. Tachycardia - ansD; Tachycardia is an attempt to maintain blood pressure, a
manifestation of fluid volume deficit.
A nurse is caring for a client admitted with confusion and lethargy. The client was found at
home unresponsive with an empty bottle of aspirin lying next to the bed. Vital signs reveal
blood pressure 104/72 mm Hg, heart rate 116/min with regular rhythm, and respiratory
rate 42/min and deep. Which of the following arterial blood gas findings should the nurse
expect?
A. pH 7.68
PaO2 96 mm Hg
PaCO2 38 mm Hg
HCO3 28 mEq/L
B. pH 7.48
PaO2 100 mm Hg
PaCO2 28 mm Hg
HCO3 23 mEq/L
C. pH 6.98
PaO2 100 mm Hg
PaCO2 30 mm Hg
HCO3 18 mEq/L
D. pH 7.58
PaO2 96 mm Hg
PaCO2 38 mm Hg
HCO3 29 mEq/L - ansC; An aspirin toxicity would result in ABG findings of metabolic
acidosis.
A nurse is caring for a client in a long-term facility who has become weak, confused, and
experienced dizziness when standing. The client's temperature is 38.3 degrees C (100.9
degrees F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of
the following actions should the nurse take?
A. Initiate fluid restrictions to limit intake
B. Check for peripheral edema
, 2024 ATI FLUID AND ELECTROLYTES BALANCE AND DISTURBANCE LATEST
VERSION ACTUAL EXAM QUESTION WITH QUESTION AND CORRECT
ANSWERS WITH RATIONALES RATED A GRADE.
C. Encourage the client to ambulate to promote oxygenation
D. Monitor for orthostatic hypotension - ansD; Monitor for orthostatic hypotension
because they have manifestations of dehydration due to decreased circulatory volume.
A nurse is caring for a client who has a blood potassium 5.4 mEq/L. The nurse should assess
for which of the following manifestations?
A. ECG changes
B. Constipation
C. Polyuria
D. Paresthesia - ansA; Assess for ECG changes. Potassium levels can affect the heart
and result in arrhythmias.
A nurse is caring for a client who has a blood sodium level 133 mEg/L and blood potassium
level 3.4 mEq/L. The nurse should recognize that which of the following treatments can
result in these laboratory findings?
A. Three tap water enemas
B. 0.9% NaCl solution IV at 50 ml/hr
C. 5% dextrose with 0.45% NaCl solution with 20 mEq of K+ IV at 80 mL/hr
D. Antibiotic therapy - ansA; Three tap water enemas can result in a decrease in blood
sodium and potassium. Tap water is hypotonic, and gastrointestinal losses are isotonic.
This creates an imbalance and solute dilution.
A nurse is caring for a client who has a NGT attached to low intermittent suctioning. The nurse
should monitor for which of the following electrolyte imbalances?
A. Hypercalcemia
B. Hyponatremia
C. Hyperphosphatemia
D. Hyperkalemia - ansB; Monitor the client for hyponatremia. Nasogastric losses are isotonic
and contain sodium.
A nurse is caring for a client who was in a motor-vehicle accident. The client reports chest pain
and difficulty breathing. A chest x-ray reveals the client has a pneumothorax. Which of the
following ABG findings should the nurse expect?
A. pH 7.06
PaO2 86 mm Hg
PaCO2 52 mm Hg
HCO3 24 mEq/L
B. pH 7.42
PaO2 100 mm Hg
PaCO2 38 mm Hg
HCO3 23 mEq/L
C. pH 6.98
PaO2 100 mm Hg
PaCO2 30 mm Hg
HCO3 18 mEq/L
D. pH 7.58
PaO2 96 mm Hg
PaCO2 38 mm Hg
HCO3 29 mEq/L - ansA; A pneumothorax can cause alveolar hypoventilation and increased
carbon dioxide levels, resulting in a state of respiratory acidosis.
, 2024 ATI FLUID AND ELECTROLYTES BALANCE AND DISTURBANCE LATEST
VERSION ACTUAL EXAM QUESTION WITH QUESTION AND CORRECT
ANSWERS WITH RATIONALES RATED A GRADE.
A nurse is collecting data from a client who has hypercalcemia as a result of long-term use
of glucosteroids. Which of the following findings should the nurse expect? (Select all that
apply.)
A. Hyperreflexia
B. Confusion
C. Positive Chvostek's sign
D. Bone pain
E. Nausea and vomiting - ansB; Expect the client who has hypercalcemia to have
confusion and a possible decreased LOC,
D; Expect the pt to have bone pain.
E; Expect the pt to have N/V along with anorexia
A nurse is obtaining ABGs for a client who has vomited for 24 hr. The nurse should expect
which of the following acid-base imbalances to result from vomiting 24 hr?
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis - ansD; Excessive vomiting causes a loss of gastric acids and an
accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.
A nurse is performing an admission assessment on a client who has hypovolemia due to
vomiting and diarrhea. The nurse should expect which of the following findings? (Select all
that apply.)
A. Distended neck veins
B. Hyperthermia
C. Tachycardia
D. Syncope
E. Decreased skin turgor - ansC, D, E
A nurse is planning care for a client who has dehydration. Which of the following actions
should the nurse include?
A. Administer antihypertensive on schedule
B. Check the client's weight each morning
C. Notify the provider of a urine output greater than 30 mL/hr
D. Encourage independent ambulation four times a day - ansB; Include obtaining the client's
weight each day in the plan of care. To ensure accuracy the client's weight should be
obtained at the same time each day using the same scale. By determining the client's
weight gain or loss each day the nurse can evaluate the client's response to treatment.
A nurse is planning care for a client who has hypernatremia. Which of the following actions
should the nurse include in the plan of care?
A. Infuse hypotonic IV fluids
B. Implement a fluid restriction
C. Increase Na+ intake
D. Administer sodium polystyrene sulfonate - ansA; Hypotonic IV fluids are indicted for the
treatment of hypernatremia related to fluid loss to expand the ECF volume and rehydrate
the cells
A nurse is providing education for a client who has severe hypomagnesemia and is
prescribed oral magnesium sulfate. Which of the following info should the nurse include in
the teaching?
