you are performing an admission assessment on an older adult patient newly admitted for end stage liver disease what principle should guide your asse

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

A. Overhydration is common among healthy older adults.
B. Dehydration causes the skin to appear spongy
C. Inelastic skin turgor is a normal part of aging
D. Skin turgor cannot be assessed in patients over 70.

Correct answer: C

Rationale:

2. A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?

A. Depth of respirations
B. Bowel sounds
C. Grip strength
D. Electrocardiography

Correct answer: A

Rationale: The correct answer is 'Depth of respirations.' In a client with electrolyte imbalances like low potassium (hypokalemia) and low magnesium (hypomagnesemia), respiratory changes, such as shallow respirations or respiratory muscle weakness, can occur and lead to respiratory compromise. Assessing the depth of respirations is crucial to evaluate respiratory function in this client. Bowel sounds, grip strength, and electrocardiography are also important assessments in different situations, but in this case, respiratory assessment takes priority due to the potential impact of electrolyte imbalances on breathing.

3. A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which of the following?

A. Hydrostatic pressure
B. Osmosis and osmolality
C. Diffusion
D. Active transport

Correct answer: B

Rationale:

4. What is the fluid inside the cell called?

A. Plasma
B. Intracellular fluid
C. Interstitial fluid
D. Plasma and intracellular fluid

Correct answer: B

Rationale: The correct answer is 'Intracellular fluid.' Intracellular fluid refers to the fluid contained within the cells, constituting a significant portion of the body's total water content. Choices A, C, and D are incorrect. Plasma is the liquid component of blood outside the cells, interstitial fluid is the fluid surrounding cells in tissues, and the combination of plasma and intracellular fluid is not the specific term for the fluid inside the cell.