1a nurse prepares to insert a peripheral venous catheter in an older adult client which action should the nurse take to protect the clients skin durin

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. 1.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?

A. Lower the extremity below the level of the heart.
B. Apply warm compresses to the extremity.
C. Tap the skin lightly and avoid slapping.
D. Place a washcloth between the skin and tourniquet

Correct answer: D

Rationale:

2. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?

A. Place the patient in low Fowler's position and notify the physician.
B. Increase the patient's IV fluid and auscultate the lungs.
C. Place the patient in semi-Fowler's position and prepare to give the PRN diuretic as ordered.
D. Discontinue the patient's IV.

Correct answer: C

Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.

3. A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:

A. She will need to have her medications adjusted and be readmitted to the hospital for a complete workup.
B. Limiting fluids can create imbalances in the body that can result in confusion; maybe we need to adjust the timing of your fluids.
C. It is normal to be a little confused following surgery and it is safe not to urinate at night.
D. Confusion following surgery is common in the elderly due to loss of sleep.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.

4. When considering overhydration:

A. occurs less often than dehydration.
B. can strain the kidneys.
C. can be caused by giving intravenous fluids too rapidly.
D. less common than dehydration.

Correct answer: C

Rationale: The correct answer is C. Overhydration can occur when intravenous fluids are administered too quickly, overwhelming the body's ability to excrete the excess fluid. Choices A, B, and D are incorrect. Choice A is incorrect because overhydration is less common than dehydration. Choice B is incorrect because while overhydration can strain the kidneys, it is not due to the burden being too heavy. Choice D is incorrect because dehydration is more common than overhydration.