Nursing Elites

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

• A. Overhydration causes the skin to tent.
• B. Dehydration causes the skin to appear edematous and spongy.
• C. Inelastic skin turgor is a normal part of aging.
• D. Normal skin turgor is moist and boggy.

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. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:

• A. Choose a proximal site.
• B. Choose a distal site.
• C. Have the patient hold their arm in a dependent position.
• D. Leave the tourniquet on for no longer than 2 minutes.

Correct answer: B

Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Opting for a distal site ensures that upper veins remain available for future cannulations. Instructing the patient to hold their arm in a dependent position can enhance blood flow, aiding in the procedure. It is crucial never to leave a tourniquet on for more than 2 minutes as prolonged restriction can lead to complications. Choice A is incorrect because a proximal site is not preferred for IV insertion. Choice C is incorrect as having the patient hold their arm over their head is not necessary and may impede proper blood flow. Choice D is incorrect as leaving the tourniquet on for at least 5 minutes is excessive and can be harmful.

3. The chief mechanism for maintaining fluid balance is to:

• A. adjust fluid intake so it equals fluid output.
• B. adjust fluid intake so it is slightly above fluid output.
• C. adjust fluid output so it equals fluid input.
• D. adjust fluid intake so it is slightly below fluid output.

Correct answer: C

Rationale: The correct answer is C: 'adjust fluid output so it equals fluid input.' Maintaining fluid balance involves ensuring that the amount of fluid lost through processes like urination, sweating, and respiration equals the amount of fluid taken in. This ensures that the body stays properly hydrated. Choices A, B, and D are incorrect because they do not focus on the balance between fluid input and output, which is crucial for maintaining proper fluid balance. By adjusting fluid output to equal fluid input, the body can regulate hydration levels effectively, preventing dehydration or overhydration.

4. Where is the largest volume of water in the body located?

• A. Plasma
• B. The fluid inside the cells
• C. Interstitial fluid
• D. Lymph

Correct answer: B

Rationale: The correct answer is B. The largest volume of water in the body is found inside the cells, known as intracellular fluid. This fluid makes up the majority of the body's total water content. Choices A, C, and D are incorrect because while plasma, interstitial fluid, and lymph are important components of the body's fluid compartments, they do not contain the largest volume of water in the body.

5. A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of which acid-base imbalance?

• A. Respiratory acidosis
• B. Respiratory alkalosis
• C. Increased PaCO2
• D. CNS disturbances

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation, which can be caused by extreme anxiety, is the most common cause of acute respiratory alkalosis. This leads to a decrease in PaCO2 levels. Respiratory acidosis, choice A, occurs in conditions like hypoventilation, leading to an increase in PaCO2 levels. Choice C, Increased PaCO2, is not the correct term for an acid-base imbalance related to hyperventilation. Choice D, CNS disturbances, is not directly related to the acid-base imbalance caused by hyperventilation.

Similar Questions