Nursing Elites

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 patient's 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: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Choice A is incorrect because overhydration is not common among healthy older adults. Choice B is incorrect because dehydration leads to inelastic skin, not sponginess. Choice D is incorrect as skin turgor assessment can be done in patients of any age, including those over 70.

2. When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?

• A. Active transport of hydrogen ions across the capillary walls
• B. Pressure of the blood in the renal capillaries
• C. Action of the dissolved particles contained in a unit of blood
• D. Hydrostatic pressure resulting from the pumping action of the heart

Correct answer: D

Rationale:

3. You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?

• A. Hypertension
• B. Kussmaul respirations
• C. Increased DTRs
• D. Shallow respirations

Correct answer: D

Rationale:

4. . A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability?

• A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
• B. The kidneys buffer acids through electrolyte changes
• C. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
• D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.

Correct answer: C

Rationale:

5. Where is the largest volume of water in the body located?

• A. Plasma
• B. The fluid inside the cells
• C. Interstitial fluid
• D. Lymph

Correct answer: B

Rationale: The correct answer is B. The largest volume of water in the body is found inside the cells, known as intracellular fluid. This fluid makes up the majority of the body's total water content. Choices A, C, and D are incorrect because while plasma, interstitial fluid, and lymph are important components of the body's fluid compartments, they do not contain the largest volume of water in the body.

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