Question 1

During assessment of hydration status,the client tells the nurse that she usually drinks 3 quarts of liquids each day.Which question by the nurse is best?

Accepted Answer

It is just as important to determine the types of fluids ingested as the amount,because fluids vary widely in their osmolarity.In addition,some liquids,such as those that contain alcohol or caffeine,can contribute to fluid and electrolyte imbalances.

Question 2

The nurse assesses distended neck veins in a client sitting in a chair to eat.What intervention is the nurse's priority?

Accepted Answer

Neck veins in the normovolemic person are full in the supine position and flat in the sitting position.Full neck veins in the sitting position are an indicator of overhydration.Checking the pulse and blood pressure can help determine whether overhydration is present.Urine specific gravity is not as important a measure of volume status and deep tendon reflexes and does not give information on volume status at all.The nurse needs to document the finding,but interventions should not end there.

Question 3

Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion?

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 optimum.Increasing the IV flow rate would increase perfusion.However,depending on the degree of dehydration,rehydrating the person too rapidly with IV fluids can lead to cerebral edema.

Question 4

Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?

Accepted Answer

A change in ring size over a relatively short period of time may indicate a change in body fluid amount or distribution rather than a change in body fat.The other statements are not indicators of a fluid or electrolyte imbalance.

Question 5

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 6

A client has been taught to restrict dietary sodium.Which food selection by the client indicates to the nurse that teaching has been effective?

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 Chinese food likely would have soy sauce,the tomato soup is processed,and the crackers are a snack food-a category of foods often high in sodium.

Question 7

Which action does the nurse teach a client to reduce the risk for dehydration?

Accepted Answer

Although a fixed oral intake of 1500 mL daily is good,the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake.This is especially true in warm or dry environments,or when conditions result in greater than usual fluid loss through perspiration or ventilation.

Question 8

A client is being treated for dehydration.Which statement made by the client indicates understanding of this condition?

Accepted Answer

Because 1 L of water weighs 1 kg,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 9

Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated?

Accepted Answer

Orthostatic or postural hypotension can be caused by or worsened by dehydration.The other statements are not as indicative of the severe degree of dehydration as dizziness on standing.

Question 10

The client is taking a medication that inhibits aldosterone secretion and release.The nurse assesses for what potential complication?

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 and increased potassium reabsorption.The client would not be at risk for overhydration or sodium imbalance.

Question 11

A nurse is caring for several clients with dehydration.The nurse assesses the client with which finding as needing oxygen therapy?

Accepted Answer

Severe dehydration can decrease circulating volume and decrease cardiac output,placing vital organs at risk for hypoxia,anoxia,and ischemia.Whenever cardiac output is decreased with dehydration,oxygen therapy is indicated.

Question 12

Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte imbalances?

Accepted Answer

Restricting fluids without a medical reason can lead to dehydration.Many older clients believe that restricting fluids will prevent incontinence and reduce the number of times that they wake up during the night.The increased osmolarity of the urine in response to reducing fluid intake increases irritation of the bladder and sphincter,increasing the sensation of needing to urinate.The other statements do not indicate practices that could potentially lead to dehydration.

Question 13

What intervention is most important to teach the client about identifying the onset of dehydration?

Accepted Answer

Because 1 L of water weighs 1 kg,change in body weight is a good measure of excess fluid loss or fluid retention.Obtaining and charting accurate daily weights is the most sensitive and cost-effective way of monitoring fluid balance in the home.The other options would not be useful for early detection of dehydration.

Question 14

A client is on a potassium-restricted diet.Which protein choice by the client indicates a good understanding of the dietary regimen?

Accepted Answer

Eggs contain few cells and have one of the lowest potassium contents among high-protein foods.Meat and fish have cells that contain large amounts of potassium.Dairy products are also high in potassium.

Question 15

Which question does the nurse ask the client who has isotonic dehydration to determine a possible cause?

Accepted Answer

Misuse or overuse of diuretics is a common cause of isotonic dehydration.The other statements are not indicative of causes of isotonic dehydration.

Question 16

A nurse is caring for several clients at risk for overhydration.The nurse assesses the older client with which finding first?

Accepted Answer

Blood replacement therapy involves intravenous fluid administration,which inherently increases the risk for overhydration.The fact that the fluid consists of packed red blood cells greatly increases the risk,because this fluid increases the colloidal oncotic pressure of the blood,causing fluid to move from interstitial and intracellular spaces into the plasma volume.An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid.

Question 17

Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L?

Accepted Answer

The blood osmolarity is low.The client could be dehydrated (hypo-osmolar dehydration)or overhydrated with dilution of blood solute.The most sensitive noninvasive indicator of circulation adequacy is urine output.Measuring abdominal girth,comparing pulses,and monitoring fluid intake would not be accurate assessment techniques for this client.

Question 18

A client is being discharged with mild dehydration.Which statement by the client indicates an understanding of measures to prevent mild dehydration from becoming more severe?

Accepted Answer

Feeling lightheaded or dizzy is an indication of low blood pressure and poor perfusion.Mild dehydration can cause these problems,and increasing fluid intake at the first sign of dehydration may prevent it from becoming worse.The other options would not prevent mild dehydration from progressing.

Question 19

The nurse observes skin tenting on the back of the older adult client's hand.Which action by the nurse is most appropriate?

Accepted Answer

Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area.Areas that more accurately show skin turgor status on an older client include the skin of the forehead,chest,and abdomen.These should also be assessed,rather than merely examining dependent body areas.Further assessment is needed rather than only documenting,monitoring,and notifying the physician.

Question 20

A client has been diagnosed with overhydration and is confused.Which intervention does the nurse include in the client's plan of care to relieve the confusion?

Accepted Answer

Overhydration most frequently leads to poor neuronal function,causing confusion as a result of electrolyte imbalances (usually sodium dilution).Eliminating fluid excess is the best way to reduce confusion.The other interventions would not relieve the client's confusion.

Quiz 13: Assessment and Care of Patients With Fluid and Electrolyte Imbalances