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. You are caring for a patient who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. During your assessment, you note the patient complains of a new onset of weakness with abdominal pain. Further assessment suggests that the patient likely has a fluid volume deficit. You should recognize that this patient may be experiencing what electrolyte imbalance?

A. Hypernatremia
B. Hypomagnesemia
C. Hypophosphatemia
D. Hypercalcemia

Correct answer: D

Rationale:

3. When considering overhydration:

A. occurs less often than dehydration.
B. can strain the kidneys.
C. can be caused by giving intravenous fluids too rapidly.
D. less common than dehydration.

Correct answer: C

Rationale: The correct answer is C. Overhydration can occur when intravenous fluids are administered too quickly, overwhelming the body's ability to excrete the excess fluid. Choices A, B, and D are incorrect. Choice A is incorrect because overhydration is less common than dehydration. Choice B is incorrect because while overhydration can strain the kidneys, it is not due to the burden being too heavy. Choice D is incorrect because dehydration is more common than overhydration.

4. A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention should the nurse suggest to the management team to make the biggest impact on decreasing complications

A. Initiate a dedicated team to insert access devices
B. . Require additional education for all nurses.
C. Limit the use of peripheral venous access devices.
D. Perform quality control testing on skin preparation products.

Correct answer: A

Rationale:

5. Which electrolyte is important in the formation of the thyroid hormones?

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

Correct answer: B

Rationale: Iodine is the correct answer because it is essential for the synthesis of thyroid hormones. The thyroid gland incorporates iodine into thyroid hormones such as thyroxine (T4) and triiodothyronine (T3). These hormones are crucial for regulating metabolism, growth, and development. Sodium, iron, and chloride are not directly involved in the formation of thyroid hormones, making them incorrect choices.