the nurse assessing skin turgor in an elderly patient should remember that
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Nursing Elites

ATI RN

Fluid and Electrolytes ATI

1. The nurse assessing skin turgor in an elderly patient should remember that:

Correct answer: C

Rationale: Inelastic skin turgor is a normal part of aging. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Normal skin turgor is dry and firm. Choice A is incorrect because overhydration does not cause the skin to tent; it is dehydration that leads to tenting. Choice B is incorrect because dehydration, not overhydration, causes the skin to appear edematous and spongy. Choice D is incorrect because normal skin turgor is dry and firm, not moist and boggy.

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?

Correct answer: D

Rationale:

3. 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?

Correct answer: D

Rationale:

4. What is the fluid inside the cell called?

Correct answer: B

Rationale: The correct answer is 'Intracellular fluid.' Intracellular fluid refers to the fluid contained within the cells, constituting a significant portion of the body's total water content. Choices A, C, and D are incorrect. Plasma is the liquid component of blood outside the cells, interstitial fluid is the fluid surrounding cells in tissues, and the combination of plasma and intracellular fluid is not the specific term for the fluid inside the cell.

5. A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to call the physician, report the symptoms, and request to draw a blood sample to determine the patient's potassium level. Furosemide is a potassium-wasting diuretic, and low potassium levels can lead to weakness and palpitations. Resting more often won't address the underlying issue of hypokalemia caused by furosemide. While digoxin can have side effects, it is not causing the symptoms described by the patient. Avoiding caffeine may be beneficial, but addressing the potassium level is more critical in this situation.

Similar Questions

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Which of the following statements is correct?
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