while assessing a clients peripheral iv site the nurse observes a streak of red along the vein path and palpates a 4 cm venous cord how should the nur

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?

A. Grade 3 phlebitis at IV site
B. infection at IV site
C. Thrombosed area at IV site
D. infiltration at IV site

Correct answer: A

Rationale:

2. 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.

3. A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take?

A. Monitor daily hemoglobin and hematocrit values.
B. Administer furosemide (Lasix) intravenously.
C. Encourage the client to take deep breaths.
D. Teach the client fall prevention measures.

Correct answer: D

Rationale:

4. What is the most abundant positive ion in blood plasma?

A. Potassium.
B. Calcium.
C. Sodium.
D. Both potassium and sodium are in equal concentrations.

Correct answer: C

Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.