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 assessing clients who have intravenous therapy prescribed. Which assessment finding for a client with a peripherally inserted central catheter (PICC) requires immediate attention?

A. The initial site dressing is 3 days old.
B. The PICC was inserted 4 weeks ago.
C. A securement device is absent.
D. Upper extremity swelling is noted.

Correct answer: D

Rationale:

3. What can cause dehydration?

A. Prolonged vomiting.
B. Prolonged diarrhea.
C. Too little fluid intake.
D. Prolonged vomiting, diarrhea, and too little fluid intake.

Correct answer: D

Rationale: Dehydration can result from significant fluid loss due to vomiting, diarrhea, or inadequate fluid intake. Prolonged vomiting and diarrhea lead to excessive fluid loss from the body, contributing to dehydration. Similarly, not consuming enough fluids can also result in dehydration. Choice A and B are too specific as they only mention one cause each, while choice C is also correct but does not encompass all the potential causes of dehydration as mentioned in choice D.

4. A nurse is caring for a client who is having a subclavian central venous catheter inserted. The client begins to report chest pain and difficulty breathing. After administering oxygen, which action should the nurse take next?

A. Administer a sublingual nitroglycerin tablet
B. Prepare to assist with chest tube insertion.
C. . Place a sterile dressing over the IV site
D. Re-position the client into the Trendelenburg position.

Correct answer: B

Rationale:

5. Which mineral is important in hemoglobin production?

A. Sodium
B. Iodine
C. Iron
D. Chloride

Correct answer: C

Rationale: Iron (Fe) is a critical mineral in hemoglobin production. Hemoglobin is a protein found in red blood cells that is essential for transporting oxygen throughout the body. Sodium (Choice A), Iodine (Choice B), and Chloride (Choice D) are not directly involved in hemoglobin production. Sodium is an electrolyte that helps maintain fluid balance, Iodine is essential for thyroid hormone production, and Chloride is an electrolyte that helps regulate fluid balance and acidity in the body.