you are performing an admission assessment on an older adult patient newly admitted for end stage liver disease what principle should guide your asses
Logo

Nursing Elites

ATI RN

ATI Fluid and Electrolytes

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?

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. The triage nurse notes upon assessment in the emergency room that the patient with anxiety is hyperventilating. The nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation is the most common cause of acute respiratory alkalosis. When a patient hyperventilates due to anxiety or other causes, they blow off excessive carbon dioxide, leading to a decrease in PaCO2 and a rise in pH. Choices A, C, and D are incorrect because hyperventilation leads to a decrease in PaCO2, causing respiratory alkalosis, not respiratory acidosis, metabolic acidosis, or metabolic alkalosis.

3. The nurse is preparing to insert a peripheral IV catheter into a patient who will require fluids and IV antibiotics. How should the nurse always start the process of insertion?

Correct answer: C

Rationale:

4. The baroreceptors, located in the left atrium and in the carotid and aortic arches, respond to changes in the circulating blood volume and regulate sympathetic and parasympathetic neural activity as well as endocrine activities. Sympathetic stimulation constricts renal arterioles, causing what effect?

Correct answer: D

Rationale:

5. While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

Correct answer: A

Rationale:

Similar Questions

The renin and angiotensin systems help to maintain the balance of sodium and water in the body. What other functions do these systems serve?
The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?
A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?
A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?
Which condition can result from prolonged vomiting or diarrhea?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses