the nurse assessing skin turgor in an elderly patient should remember that

ATI RN

Fluid and Electrolytes ATI

1. 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.

2. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

A. Monitor daily hemoglobin and hematocrit values.
B. Administer furosemide (Lasix) intravenously.
C. Encourage the client to take deep breaths.
D. Teach the client fall prevention measures.

Correct answer: D

Rationale:

3. The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?

A. Respiratory acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Mixed acidbase disorder

Correct answer: D

Rationale:

4. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

A. Ask family members to speak quietly to keep the client calm.
B. Assess urine color, amount, and specific gravity each day.
C. Encourage the client to drink at least 1 liter of fluids each shift.
D. Dangle the client on the bedside before ambulating.

Correct answer: D

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.