Question 1

A nurse teaches clients at a community center about risks for dehydration.Which client is at greatest risk for dehydration?

Accepted Answer

Older adults,because they have less total body water than younger adults,are at greater risk for development of dehydration.Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.

Question 2

A nurse is assessing a client with hypokalemia,and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago.Which action should the nurse take first?

Accepted Answer

In a client with hypokalemia,progressive skeletal muscle weakness is associated with increasing severity of hypokalemia.The most life-threatening complication of hypokalemia is respiratory insufficiency.It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy.Cardiac dysrhythmias are also associated with hypokalemia.The client's pulse and blood pressure should be assessed after assessing respiratory status.Next,the nurse would call the health care provider to obtain orders for potassium replacement.Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.

Question 3

A nurse is evaluating a client who is being treated for dehydration.Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?

Accepted Answer

The focus of management for clients with dehydration is to increase fluid volumes to normal.When fluid volumes return to normal,clients should perfuse the brain more effectively,therefore improving confusion and decreasing orthostatic light-headedness or dizziness.Increased respiratory rate,decreased skin turgor,and increased specific gravity are all manifestations of dehydration.

Question 4

A nurse is caring for a client who has a serum calcium level of 14 mg/dL.Which provider order should the nurse implement first?

Accepted Answer

This client has hypercalcemia.Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias.Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes.Encouraging oral fluids,assessing urine output,and administering calcitonin are treatments for hypercalcemia,but are not the highest priority.

Question 5

After teaching a client who is prescribed a restricted sodium diet,a nurse assesses the client's understanding.Which food choice for lunch indicates the client correctly understood the teaching?

Accepted Answer

Clients on restricted sodium diets generally should avoid processed,smoked,and pickled foods and those with sauces and other condiments.Foods lowest in sodium include fish,poultry,and fresh produce.The ham,tomato soup,salami,and crackers are often high in sodium.

Question 6

A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release.For which potential complications should the nurse assess? (Select all that apply.)

Accepted Answer

Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium.Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss (increased urine output),increased potassium reabsorption,decreased blood osmolality,and increased urine specific gravity.The client would not be at risk for sodium imbalance.

Question 7

A nurse is caring for a client who exhibits dehydration-induced confusion.Which intervention should the nurse implement first?

Accepted Answer

Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia,causing confusion.Applying oxygen can reduce confusion,even if perfusion is still less than optimal.Increasing the IV flow rate would increase perfusion.However,depending on the degree of dehydration,rehydrating the client too rapidly with IV fluids can lead to cerebral edema.Measuring intake and output and placing the client in a high-Fowler's position will not address the client's problem.

Question 8

A nurse assesses a client who is admitted for treatment of fluid overload.Which manifestations should the nurse expect to find? (Select all that apply.)

Accepted Answer

Manifestations of fluid overload include increased pulse rate,distended neck veins,increased blood pressure,pale and cool skin,and skeletal muscle weakness.

Question 9

After teaching a client to increase dietary potassium intake,a nurse assesses the client's understanding.Which dietary meal selection indicates the client correctly understands the teaching?

Accepted Answer

Meat,dairy products,and dried fruit have high concentrations of potassium.Eggs,breads,cereals,sugar,and some fruits (berries,peaches)are low in potassium.The menu selection of sausage,toast,raisins,and milk has the greatest number of items with higher potassium content.

Question 10

A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L,magnesium 1.8 mEq/L,calcium 8.5 mEq/L,sodium 144 mEq/L.Which assessment should the nurse complete first?

Accepted Answer

A client with a low serum potassium level may exhibit hypoactive bowel sounds,cardiac dysrhythmias,and muscle weakness resulting in shallow respirations and decreased handgrips.The nurse should assess the client's respiratory status first to ensure respirations are sufficient.The respiratory assessment should include rate and depth of respirations,respiratory effort,and oxygen saturation.The other assessments are important but are secondary to the client's respiratory status.

Question 11

A nurse is caring for an older adult client who is admitted with moderate dehydration.Which intervention should the nurse implement to prevent injury while in the hospital?

Accepted Answer

An older adult with moderate dehydration may experience orthostatic hypotension.The client should dangle on the bedside before ambulating.Although dehydration in an older adult may cause confusion,speaking quietly will not help the client remain calm or decrease confusion.Assessing the client's urine may assist with the diagnosis of dehydration but would not prevent injury.Clients are encouraged to drink fluids,but 1 liter of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload,especially if the client has heart failure or renal insufficiency.

Question 12

A nurse is assessing clients on a medical-surgical unit.Which client is at risk for hypokalemia?

Accepted Answer

A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia.The other clients are at risk for potassium excess or hyperkalemia.

Question 13

A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor).For which expected therapeutic effect should the nurse assess?

Accepted Answer

ACE inhibitors will disrupt the renin-angiotensin II pathway and prevent the kidneys from reabsorbing water and sodium.The kidneys will excrete more water and sodium,decreasing the client's blood pressure.

Question 14

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes.Which prescription should the nurse implement first?

Accepted Answer

A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level.Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps.Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia.Kayexalate may be ordered,but this therapy may take hours to reduce potassium levels.Dialysis may also be needed,but this treatment will take much longer to implement and is not the first prescription the nurse should implement.Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client's current potassium level.

Question 15

A client at risk for developing hyperkalemia states,"I love fruit and usually eat it every day,but now I can't because of my high potassium level." How should the nurse respond?

Accepted Answer

Not all fruit is potassium rich.Fruits that are relatively low in potassium and can be included in the diet include apples,apricots,berries,cherries,grapefruit,peaches,and pineapples.Fruits high in potassium include bananas,kiwi,cantaloupe,oranges,and dried fruit.Cooking fruit does not alter its potassium content.

Question 16

A nurse is assessing clients for fluid and electrolyte imbalances.Which client should the nurse assess first for potential hyponatremia?

Accepted Answer

Dextrose 5% in water (D₅W)contains no electrolytes.Because the client is not taking any food or fluids by mouth (NPO),normal sodium excretion can lead to hyponatremia.The sulfonamide antibiotic,ibuprofen,and digoxin will not put a client at risk for hyponatremia.

Question 17

A nurse is assessing clients on a medical-surgical unit.Which clients are at increased risk for hypophosphatemia? (Select all that apply.)

Accepted Answer

Clients at risk for hypophosphatemia include those who are malnourished,those with uncontrolled diabetes mellitus,and those who use aluminum hydroxide-based or magnesium-based antacids.Hyperparathyroidism and chronic renal failure are common causes of hyperphosphatemia.

Question 18

A nurse teaches a client who is at risk for mild hypernatremia.Which statement should the nurse include in this client's teaching?

Accepted Answer

Most prepackaged foods have a high sodium content.Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia.Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia,but they do not prevent it.The addition of substances during cooking,not the method of cooking,increases the sodium content of a meal.

Question 19

After teaching a client who is being treated for dehydration,a nurse assesses the client's understanding.Which statement indicates the client correctly understood the teaching?

Accepted Answer

One liter of water weighs 1 kg; therefore,a change in body weight is a good measure of excess fluid loss or fluid retention.Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss.The other statements are not indicative of practices that will prevent dehydration.

Question 20

A nurse is assessing clients on a medical-surgical unit.Which adult client should the nurse identify as being at greatest risk for insensible water loss?

Accepted Answer

Insensible water loss is water loss through the skin,lungs,and stool.Clients at risk for insensible water loss include those being mechanically ventilated,those with rapid respirations,and those undergoing continuous GI suctioning.Clients who have thyroid crisis,trauma,burns,states of extreme stress,and fever are also at increased risk.The client taking furosemide will have increased fluid loss,but not insensible water loss.The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.

Quiz 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances