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. After teaching a client who was malnourished and is being discharged, a nurse assesses the clients understanding. Which statement indicates the client correctly understood teaching to decrease risk for the development of metabolic acidosis?

A. I will drink at least three glasses of milk each day.
B. . I will eat three well-balanced meals and a snack daily.
C. . I will not take pain medication and antihistamines together.
D. I will avoid salting my food when cooking or during meals.

Correct answer: A

Rationale:

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.

5. What is the fluid that surrounds the cells called?

A. plasma
B. interstitial fluid
C. intracellular fluid
D. edema

Correct answer: B

Rationale: The correct answer is interstitial fluid. Interstitial fluid is the fluid that surrounds and fills the spaces between cells, facilitating nutrient and waste exchange. Plasma, referred to in choice A, is the liquid part of blood. Choice C, intracellular fluid, is the fluid inside cells. Choice D, edema, is an abnormal accumulation of fluid in interstitial spaces, causing swelling.