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 assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?

A. The catheter has been in place for 20 hours.
B. . The client has poor vascular access in the upper extremities.
C. The catheter is placed in the proximal tibia.
D. The clients left lower extremity is cool to the touch.

Correct answer: D

Rationale:

3. A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:

A. Neuromuscular function
B. Bowel sounds
C. Respiratory rate
D. Electrocardiogram (ECG) results

Correct answer: D

Rationale: In a patient with a serum potassium level of 6 mEq/L due to spironolactone use, the nurse's priority is to assess the Electrocardiogram (ECG) results. Hyperkalemia can lead to life-threatening arrhythmias, such as ventricular fibrillation, which can be detected on an ECG. While changes in neuromuscular function, bowel sounds, and respiratory rate can occur with hyperkalemia, the most critical assessment related to the patient's condition would be monitoring the ECG for signs of cardiac complications.

4. The nurse assessing skin turgor in an elderly patient should remember that:

A. Overhydration causes the skin to tent.
B. Dehydration causes the skin to appear edematous and spongy.
C. Inelastic skin turgor is a normal part of aging.
D. Normal skin turgor is moist and boggy.

Correct answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.