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 patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:

A. Neuromuscular function
B. Bowel sounds
C. Respiratory rate
D. Electrocardiogram (ECG) results

Correct answer: D

Rationale: In a patient with a serum potassium level of 6 mEq/L due to spironolactone use, the nurse's priority is to assess the Electrocardiogram (ECG) results. Hyperkalemia can lead to life-threatening arrhythmias, such as ventricular fibrillation, which can be detected on an ECG. While changes in neuromuscular function, bowel sounds, and respiratory rate can occur with hyperkalemia, the most critical assessment related to the patient's condition would be monitoring the ECG for signs of cardiac complications.

3. A nurse is assessing a client with hypokalemia and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?

A. Assess the client's respiratory rate, rhythm, and depth.
B. Measure the client's pulse and blood pressure.
C. Document findings and monitor the client.
D. Call the healthcare provider.

Correct answer: A

Rationale: In a client with hypokalemia experiencing diminished handgrip strength, the priority action for the nurse is to assess the client's respiratory rate, rhythm, and depth. Hypokalemia can lead to muscle weakness, including respiratory muscles, potentially causing respiratory distress. Assessing the respiratory status is crucial to determine if immediate interventions are needed to maintain adequate oxygenation. Measuring the client's pulse and blood pressure (Choice B) is important but should come after assessing the respiratory status. Simply documenting findings and monitoring the client (Choice C) may delay necessary interventions. Calling the healthcare provider (Choice D) is not the first action indicated in this situation; assessing the client's respiratory status takes precedence.

4. What is the function of aldosterone?

A. Regulates body temperature.
B. Decreases blood pressure.
C. Increases sodium reabsorption.
D. Promotes water excretion.

Correct answer: C

Rationale: Aldosterone increases the reabsorption of sodium in the kidneys, which leads to an increase in blood volume and blood pressure. Choice A is incorrect as aldosterone does not regulate body temperature. Choice B is incorrect as aldosterone increases blood pressure by increasing sodium reabsorption. Choice D is incorrect as aldosterone promotes water retention by increasing sodium reabsorption.