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. You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance should you first suspect?

• A. Hypophosphatemia
• B. Hypocalcemia
• C. Hypermagnesemia
• D. Hyperkalemia

Correct answer: B

Rationale:

3. A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?

• A. Allergic reaction
• B. Bowel obstruction
• C. Catheter lumen occlusion
• D. Infection

Correct answer: D

Rationale:

4. What is the most abundant positive ion in blood plasma?

• A. Potassium.
• B. Calcium.
• C. Sodium.
• D. Both potassium and sodium are in equal concentrations.

Correct answer: C

Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.

5. 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:

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