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

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?

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. . A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?

A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.

Correct answer: D

Rationale:

3. Electrolytes:

A. do not form when glucose is added to water.
B. dissociate in water solutions, but do not form ions.
C. form ions in water solutions, but do not necessarily dissociate.
D. dissociate in water solutions and form ions in water solutions.

Correct answer: D

Rationale: The correct answer is D. Electrolytes are substances that dissociate into ions when dissolved in water, allowing the solution to conduct electricity. Choice A is incorrect because glucose does not form electrolytes when added to water. Choice B is incorrect as it states that electrolytes dissociate but do not form ions, which is inaccurate as electrolytes do form ions in water solutions. Choice C is also incorrect as it states that electrolytes form ions but may not necessarily dissociate, which goes against the definition of electrolytes that must dissociate into ions for conductivity. Therefore, choice D is the most accurate as it correctly describes that electrolytes dissociate in water solutions and form ions, highlighting the essential characteristics of electrolytes.

4. The nurse is providing care for a patient with chronic obstructive pulmonary disease. When describing the process of respiration the nurse explains how oxygen and carbon dioxide are exchanged between the pulmonary capillaries and the alveoli. The nurse is describing what process?

A. Diffusion
B. Osmosis
C. Active transport
D. Filtration

Correct answer: A

Rationale:

5. A nurse is caring for a client who has a serum calcium level of 14 mg/dL. Which provider order should the nurse implement first?

A. Encourage oral fluid intake.
B. Connect the client to a cardiac monitor.
C. Assess urinary output.
D. Administer oral calcitonin (Calcimar).

Correct answer: A

Rationale: The correct answer is to encourage oral fluid intake. With a serum calcium level of 14 mg/dL, the client is at risk of hypercalcemia. Encouraging oral fluid intake helps to promote hydration and can help prevent further elevation of calcium levels. Connecting the client to a cardiac monitor (Choice B) is important but not the first priority in this situation. Assessing urinary output (Choice C) is relevant but does not address the immediate concern of high serum calcium levels. Administering oral calcitonin (Calcimar) (Choice D) may be a treatment option later, but the first step should be to address hydration.