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

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

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 patients skin turgor?

Correct answer: C

Rationale:

2. A nurse preparing to start an IV on a newly admitted patient teaches the patient about the procedure and begins to prepare the site. The nurse should always start by:

Correct answer: C

Rationale: Before preparing the skin, the nurse should ask the patient if they are allergic to latex or iodine, which are commonly used in IV therapy setup. This is crucial to prevent potential allergic reactions at the IV site or even life-threatening anaphylaxis. Leaving one hand ungloved (choice A) is not a recommended practice as both hands should be gloved for infection control. While preparing the skin with an iodine solution (choice B) is a step in the process, ensuring the patient's safety by checking for allergies comes first. Removing excessive hair at the selected site (choice D) is not necessary and can lead to skin irritation.

3. The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining of having trouble breathing with abdominal pain. An ABG reveals the following results: pH 7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?

Correct answer: D

Rationale:

4. When does dehydration begin to occur?

Correct answer: C

Rationale: Dehydration leads to a decrease in the body's fluid levels, causing the salivary glands to produce less saliva, resulting in a dry mouth. Therefore, when dehydration begins to occur, salivary secretions decrease. Choice A is incorrect because the body does not reduce fluid output to zero during dehydration; it tries to conserve fluids. Choice B is incorrect as dehydration does not directly increase the release of ANH (Atrial Natriuretic Hormone). Choice D is incorrect because salivary secretions do not increase but decrease during dehydration.

5. A client at risk for developing hyperkalemia states, 'I love fruit and usually eat it every day, but now I can't because of my high potassium level.' How should the nurse respond?

Correct answer: C

Rationale: The correct answer is C. Berries, cherries, apples, and peaches are indeed low in potassium, making them suitable choices for someone at risk for hyperkalemia. Choice A is incorrect because potatoes and avocados are high in potassium and should be avoided in this situation. Choice B is incorrect because cooking fruit does not significantly lower its potassium content. Choice D is incorrect as it provides incorrect information, as not all fruits are very high in potassium.

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