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

ATI RN

Fluid and Electrolytes ATI

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. A nurse teaches a client who is being discharged home with a peripherally inserted central catheter (PICC). Which statement should the nurse include in this clients teaching?

A. avoid carrying your grandchild with the arm that has the central catheter.
B. Be sure to place the arm with the central catheter in a sling during the day
C. Flush the peripherally inserted central catheter line with normal saline daily.
D. You can use the arm with the central catheter for most activities of daily living.

Correct answer: A

Rationale:

3. Which positive ion is most prevalent in intracellular fluid?

A. Calcium
B. Potassium
C. Sodium
D. Magnesium

Correct answer: B

Rationale: The correct answer is Potassium (K+). Potassium is the predominant cation found within cells, making it the most prevalent positive ion in intracellular fluid. Calcium, sodium, and magnesium are also essential ions in the body, but they are not as abundant in intracellular fluid. Calcium is vital for bone health and muscle function, sodium helps in maintaining fluid balance and nerve function, and magnesium is involved in numerous biochemical reactions.

4. The patient asks the nurse if he will die if air bubbles get into the IV tubing. What is the nurse's best response?

A. The system is closed, and that scenario is highly unlikely.
B. Only relatively large volumes of air administered rapidly are dangerous.
C. There is a risk of complications associated with IV administration.
D. You have been influenced by movies too much.

Correct answer: B

Rationale: The correct answer is B because air emboli are more commonly associated with central vein access. Usually, only relatively large volumes of air administered rapidly are dangerous. It is a significant concern when air enters a central venous access line. Choice A is incorrect as it downplays the risk and is not entirely accurate. Choice C is too general and does not specifically address the patient's concern. Choice D is dismissive and does not provide any relevant information regarding the risk of air bubbles in IV tubing.

5. What is the fluid inside the cell called?

A. Plasma
B. Intracellular fluid
C. Interstitial fluid
D. Plasma and intracellular fluid

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.