Nokea
You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?
- A. Overhydration is common among healthy older adults.
- B. Dehydration causes the skin to appear spongy.
- C. Inelastic skin turgor is a normal part of aging.
- D. Skin turgor cannot be assessed in patients over 70.
Correct Answer: C
Rationale: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.
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You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your colleague dismisses. What can this increase in creatinine indicate in older adults?
- A. Substantially reduced renal function
- B. Acute kidney injury
- C. Decreased cardiac output
- D. Alterations in ratio of body fluids to muscle mass
Correct Answer: A
Rationale: Normal physiologic changes of aging, including reduced cardiac, renal, and respiratory function, and reserve and alterations in the ratio of body fluids to muscle mass, may alter the responses of elderly people to fluid and electrolyte changes and acidbase disturbances. Renal function declines with age, as do muscle mass and daily exogenous creatinine production, excretion. Therefore, a high-normal or minimally elevated blood serum creatinine value, may be used to substantially reduce renal function in older adults. An acute indication of injury would likely cause a more significant increase of serum creatinine.
One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acute-care nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over 15 minutes. This intervention will achieve which of the following?
- A. Help distinguish hyponatremia from hypernatremia
- B. Help evaluate pituitary gland function
- C. Help distinguish reduced renal blood flow from decreased renal function
- D. Help provide an effective treatment for hypertension-induced oliguria
Correct Answer: C
Rationale: If a patient is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid volume deficit (FVD or prerenal azotemia), or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a patient with FVD but with normal renal function is increased urine output and an increase in blood pressure. Laboratory examinations are needed to distinguish hyponatremia from hypernatremia. A fluid challenge is not used to evaluate pituitary gland function. A fluid challenge may provide information regarding hypertension-induced oliguria, but it is not an effective treatment.
A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be encouraged to deal with excess hair at the intended site?
- A. Leave the hair intact.
- B. Shave the area.
- C. Clip the hair in the area.
- D. Remove the hair with a depilatory.
Correct Answer: C
Rationale: Hair can be a source of infection and should be removed by clipping; it should not be left at the site. Shaving the area can cause skin abrasions, and depilatories can irritate the skin.
You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?
- A. Hypertension
- B. Kussmaul respirations
- C. Increased DTRs
- D. Shallow respirations
Correct Answer: D
Rationale: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs.
Diagnostic testing has been ordered to differentiate between normal anion gap acidosis and high anion gap acidosis in an acutely ill patient. What health problem typically precedes normal anion gap acidosis?
- A. Metastases
- B. Excessive potassium intake
- C. Water intoxication
- D. Excessive administration of chloride
Correct Answer: D
Rationale: Normal anion gap acidosis results from the direct loss of sodium bicarbonate, as in diarrhea, loss from lower intestinal fistulas, ureterostomies, and use of diuretics; early renal insufficiency; excessive administration of chloride; and the administration of parenteral nutrition without bicarbonate or bicarbonate-producing solutes (e.g., lactate). Based on these facts, the other listed options are incorrect.