Question 1

The nurse is concerned that a client diagnosed with a fluid imbalance is at risk for an alteration in perfusion. Which assessment data should indicate to the nurse that the client is not currently experiencing an alteration in perfusion? Select all that apply.

Accepted Answer

A)To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds or less, and orientation to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status.
B)To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds or less, and orientation to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status.
C)To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds or less, and orientation to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status.
D)To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds or less, and orientation to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status.
E)To determine whether the client's perfusion status is being affected, the nurse should assess pulses, nail beds, and orientation. Full and present peripheral pulses, capillary refill of 3 seconds or less, and orientation to person, place, and time indicate that the client's perfusion status is being maintained. Skin turgor and bowel sounds would be used to determine whether the fluid imbalance is affecting the client's elimination status. Skin turgor that takes 20 seconds to return to normal and sluggish bowel sounds indicate that the fluid imbalance is affecting the client's elimination status.

Question 2

During an assessment, the nurse learns that a client who is seeking emergency treatment for a headache and nausea works in a mill without air conditioning. The current air temperature outside is 88 degrees, and the client reports drinking water several times throughout the day because of heavy sweating. Based on this data, which instruction is most appropriate for the nurse to give the client?

Accepted Answer

A)Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. Thus, the client should be instructed to eat something salty when drinking water to help replace the lost sodium. Eating something sweet will not help replace sodium, nor will consuming juices and carbonated sodas. Doubling the amount of water being ingested could lead to hyponatremia and further manifestations.
B)Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. Thus, the client should be instructed to eat something salty when drinking water to help replace the lost sodium. Eating something sweet will not help replace sodium, nor will consuming juices and carbonated sodas. Doubling the amount of water being ingested could lead to hyponatremia and further manifestations.
C)Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. Thus, the client should be instructed to eat something salty when drinking water to help replace the lost sodium. Eating something sweet will not help replace sodium, nor will consuming juices and carbonated sodas. Doubling the amount of water being ingested could lead to hyponatremia and further manifestations.
D)Both salt and water are lost through sweating. When only water is replaced, the individual is at risk for salt depletion. Symptoms include fatigue, weakness, headache, and gastrointestinal symptoms such as loss of appetite and nausea. Thus, the client should be instructed to eat something salty when drinking water to help replace the lost sodium. Eating something sweet will not help replace sodium, nor will consuming juices and carbonated sodas. Doubling the amount of water being ingested could lead to hyponatremia and further manifestations.

Question 3

The nurse is reviewing laboratory values for a female client suspected of having a fluid imbalance. Which laboratory value should indicate a diagnosis of dehydration to the nurse?

Accepted Answer

A)The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. A client's hematocrit increases with dehydration and decreases with overhydration. A normal hematocrit value for a female is 37% to 47%. Serum osmolality is a measure of the solute concentration of the blood and is used to evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit, whereas a decrease reflects fluid volume excess. Serum potassium is not an electrolyte used to determine alterations in fluid balance. Serum sodium values would be more appropriate for that purpose.
B)The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. A client's hematocrit increases with dehydration and decreases with overhydration. A normal hematocrit value for a female is 37% to 47%. Serum osmolality is a measure of the solute concentration of the blood and is used to evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit, whereas a decrease reflects fluid volume excess. Serum potassium is not an electrolyte used to determine alterations in fluid balance. Serum sodium values would be more appropriate for that purpose.
C)The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. A client's hematocrit increases with dehydration and decreases with overhydration. A normal hematocrit value for a female is 37% to 47%. Serum osmolality is a measure of the solute concentration of the blood and is used to evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit, whereas a decrease reflects fluid volume excess. Serum potassium is not an electrolyte used to determine alterations in fluid balance. Serum sodium values would be more appropriate for that purpose.
D)The hematocrit measures the volume of whole blood that is composed of RBCs. Because the hematocrit is a measure of the volume of cells in relation to plasma, it is affected by changes in plasma volume. A client's hematocrit increases with dehydration and decreases with overhydration. A normal hematocrit value for a female is 37% to 47%. Serum osmolality is a measure of the solute concentration of the blood and is used to evaluate fluid balance. Normal values are 280-300 mOsm/kg. An increase in serum osmolality indicates a fluid volume deficit, whereas a decrease reflects fluid volume excess. Serum potassium is not an electrolyte used to determine alterations in fluid balance. Serum sodium values would be more appropriate for that purpose.

Question 4

The nurse reviewing lab results on one of her adult clients notices the client's serum sodium level is 150 mg/dL. Based on this data, which interventions should the nurse plan for this client? Select all that apply.

Accepted Answer

A)For an elevated sodium level, intake of this electrolyte will need to be restricted by adherence to a low-sodium diet. Diuretics may also be prescribed, as certain diuretics block sodium absorption. Diuretics will also remove any excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate if the client had a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. The client's fluid volume status is not known at this time, and raising the head of the bed would not be a routine intervention for a client with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance, so more information would be needed before a potassium supplement was prescribed.
B)For an elevated sodium level, intake of this electrolyte will need to be restricted by adherence to a low-sodium diet. Diuretics may also be prescribed, as certain diuretics block sodium absorption. Diuretics will also remove any excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate if the client had a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. The client's fluid volume status is not known at this time, and raising the head of the bed would not be a routine intervention for a client with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance, so more information would be needed before a potassium supplement was prescribed.
C)For an elevated sodium level, intake of this electrolyte will need to be restricted by adherence to a low-sodium diet. Diuretics may also be prescribed, as certain diuretics block sodium absorption. Diuretics will also remove any excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate if the client had a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. The client's fluid volume status is not known at this time, and raising the head of the bed would not be a routine intervention for a client with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance, so more information would be needed before a potassium supplement was prescribed.
D)For an elevated sodium level, intake of this electrolyte will need to be restricted by adherence to a low-sodium diet. Diuretics may also be prescribed, as certain diuretics block sodium absorption. Diuretics will also remove any excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate if the client had a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. The client's fluid volume status is not known at this time, and raising the head of the bed would not be a routine intervention for a client with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance, so more information would be needed before a potassium supplement was prescribed.
E)For an elevated sodium level, intake of this electrolyte will need to be restricted by adherence to a low-sodium diet. Diuretics may also be prescribed, as certain diuretics block sodium absorption. Diuretics will also remove any excess fluid being held in the body because of the extra sodium. Monitoring of heart rate and rhythm would be more appropriate if the client had a potassium imbalance. Elevating the head of the bed would be appropriate if the client were demonstrating signs of fluid volume overload. The client's fluid volume status is not known at this time, and raising the head of the bed would not be a routine intervention for a client with an elevated sodium level. A potassium imbalance is not associated with a sodium imbalance, so more information would be needed before a potassium supplement was prescribed.

Question 5

The nurse is caring for a client who is 3 days postoperative following an emergency appendectomy. The nurse is reviewing the client's lab values and notes that the client's calcium levels have increased since before the surgery. Which intervention should the nurse implement to decrease the client's possibility of developing hypercalcemia?

Accepted Answer

A)Hypercalcemia can occur from immobility. Ambulation helps prevent leaching of calcium from the bones into the serum. None of the other options listed here is related to the development of hypercalcemia.
B)Hypercalcemia can occur from immobility. Ambulation helps prevent leaching of calcium from the bones into the serum. None of the other options listed here is related to the development of hypercalcemia.
C)Hypercalcemia can occur from immobility. Ambulation helps prevent leaching of calcium from the bones into the serum. None of the other options listed here is related to the development of hypercalcemia.
D)Hypercalcemia can occur from immobility. Ambulation helps prevent leaching of calcium from the bones into the serum. None of the other options listed here is related to the development of hypercalcemia.

Question 6

A pediatric nurse is assigned phone triage for the shift. The nurse takes a call from the mother of a 3-month-old infant. The mother tells the nurse that the child has been vomiting and experiencing diarrhea for several days. Based on this information, which response by the nurse is most appropriate?

Accepted Answer

A)Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.
B)Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.
C)Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.
D)Parents and caregivers need to be taught the seriousness of vomiting or diarrhea in infants due to rapid fluid loss that can occur in this age group. They should also be taught the importance of bringing an infant in this situation to healthcare providers for evaluation. Encouraging fluids for an infant who is actively vomiting will not improve fluid balance status, and juice and glucose water are not the best choices of fluid. Simply monitoring the loss over the next 24 hours would increase the potential for the infant to become dehydrated.

Question 7

Which of the following total serum calcium levels would be considered normal in an adult client?

Accepted Answer

A)Normal total serum calcium levels, which represent both bound and unbound calcium, range from 9 to 11 mg/dL.
B)Normal total serum calcium levels, which represent both bound and unbound calcium, range from 9 to 11 mg/dL.
C)Normal total serum calcium levels, which represent both bound and unbound calcium, range from 9 to 11 mg/dL.
D)Normal total serum calcium levels, which represent both bound and unbound calcium, range from 9 to 11 mg/dL.

Question 8

The nurse is caring for an older adult client who is receiving intravenous fluids at 150 mL/hr. Upon assessment, the nurse notes crackles, shortness of breath, and jugular vein distention. Based on this data, which complication of IV fluid therapy does the nurse anticipate?

Accepted Answer

A)Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly. The findings given in this scenario do not support the other options.
B)Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly. The findings given in this scenario do not support the other options.
C)Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly. The findings given in this scenario do not support the other options.
D)Fluid volume excess may occur if clients, especially the very young or old, receive IV fluid rapidly. The findings given in this scenario do not support the other options.

Question 9

The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit. In the assessment, the nurse documents that the client is experiencing tachycardia, decreased urine output, and pale, cool skin. Based on this information, which should the nurse anticipate as the cause of the client's current symptoms?

Accepted Answer

A)Vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally to protect the brain and heart. A diuretic would cause further fluid loss and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. Also, the manifestations reported are not indicative of cardiac failure in this client.
B)Vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally to protect the brain and heart. A diuretic would cause further fluid loss and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. Also, the manifestations reported are not indicative of cardiac failure in this client.
C)Vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally to protect the brain and heart. A diuretic would cause further fluid loss and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. Also, the manifestations reported are not indicative of cardiac failure in this client.
D)Vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally to protect the brain and heart. A diuretic would cause further fluid loss and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. Also, the manifestations reported are not indicative of cardiac failure in this client.

Question 10

A client is admitted to the emergency department for vomiting and diarrhea that has lasted 4 days. The client's current weight is 154 pounds. The healthcare provider has diagnosed the client with a viral infection. The nurse has been monitoring intravenous fluids and urine output. Which urinary output would indicate that efforts to rehydrate this client have been successful?

Accepted Answer

A)Normal urine output for an adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. Thus, the only option that indicates adequate urine output is 40 mL per hour.
B)Normal urine output for an adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. Thus, the only option that indicates adequate urine output is 40 mL per hour.
C)Normal urine output for an adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. Thus, the only option that indicates adequate urine output is 40 mL per hour.
D)Normal urine output for an adult client is at least 0.5 mL/kg per hour. This client weighs 70 kg, so adequate urine output would be at least 35 mL per hour. Thus, the only option that indicates adequate urine output is 40 mL per hour.

Question 11

Which of the following lab values is indicative of hypokalemia?

Accepted Answer

A)Hypokalemia is a deficit in potassium. Normal serum potassium levels range from 3.5 to 5.3 mEq/L, so of the choices listed, only a serum potassium of 3.25 mEq/L would be considered indicative of hypokalemia.
B)Hypokalemia is a deficit in potassium. Normal serum potassium levels range from 3.5 to 5.3 mEq/L, so of the choices listed, only a serum potassium of 3.25 mEq/L would be considered indicative of hypokalemia.
C)Hypokalemia is a deficit in potassium. Normal serum potassium levels range from 3.5 to 5.3 mEq/L, so of the choices listed, only a serum potassium of 3.25 mEq/L would be considered indicative of hypokalemia.
D)Hypokalemia is a deficit in potassium. Normal serum potassium levels range from 3.5 to 5.3 mEq/L, so of the choices listed, only a serum potassium of 3.25 mEq/L would be considered indicative of hypokalemia.

Question 12

The nurse is reviewing the lab values for a client being cared for on the unit. The client's phosphorus level is currently 2.0 mg/dL. Based on this data, which nursing intervention is most appropriate for the nurse to implement?

Accepted Answer

A)A phosphorus level of 2.0 is low, so the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. There is no indication of the need to place this client on contact precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
B)A phosphorus level of 2.0 is low, so the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. There is no indication of the need to place this client on contact precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
C)A phosphorus level of 2.0 is low, so the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. There is no indication of the need to place this client on contact precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.
D)A phosphorus level of 2.0 is low, so the client will need additional dietary phosphorus. Providing phosphorus-rich foods such as milk and yogurt is a good way to provide that additional phosphorus. There is no indication of the need to place this client on contact precautions, to increase the client's carbohydrate calorie intake, or to strain all urine.

Question 13

An older adult client is admitted to the hospital after a fall. The client is intermittently confused. Based on age and current data, which of the following conditions is the client most at risk for developing?

Accepted Answer

A)As an adult ages, the thirst mechanism declines. Also, an altered level of consciousness can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues.
B)As an adult ages, the thirst mechanism declines. Also, an altered level of consciousness can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues.
C)As an adult ages, the thirst mechanism declines. Also, an altered level of consciousness can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues.
D)As an adult ages, the thirst mechanism declines. Also, an altered level of consciousness can increase the risk of dehydration and high serum osmolality. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues.

Question 14

The nurse is analyzing the intake and output record for a client being treated for dehydration. The client weighs 176 lb and had a 24-hour intake of 2000 mL and urine output of 1200 mL. Based on this data, which conclusion by the nurse is the most appropriate?

Accepted Answer

A)Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1500-2000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, this client is dehydrated, so the extra fluid intake is being used to improve body fluid balance. The client's output is 50 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance.
B)Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1500-2000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, this client is dehydrated, so the extra fluid intake is being used to improve body fluid balance. The client's output is 50 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance.
C)Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1500-2000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, this client is dehydrated, so the extra fluid intake is being used to improve body fluid balance. The client's output is 50 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance.
D)Urinary output is normally equivalent to the amount of fluids ingested; the usual range is 1500-2000 mL in 24 hours, or 40-80 mL in 1 hour (0.5 mL/kg per hour). Clients whose intake substantially exceeds output are at risk for fluid volume excess; however, this client is dehydrated, so the extra fluid intake is being used to improve body fluid balance. The client's output is 50 mL/hr, which is within the normal range. A diuretic is not needed because the client is being treated for dehydration. Treatment has been effective; however, it should continue until the intake and output are more balanced. Ending treatment now could further jeopardize this client's fluid balance.

Question 15

During an assessment, the nurse becomes concerned that an older adult client is at risk for dehydration. Which of the following assessment findings would cause the nurse to come to this conclusion?

Accepted Answer

A)Poor intake of water (in this case, only two glasses per day)could indicate a loss of the thirst response, which is a normal age-related change that increases the risk for dehydration. Skin turgor is a poor indicator of fluid balance in older adult clients, as the skin's elasticity naturally decreases with age. The client's blood pressure is elevated, but this could indicate either fluid volume overload or sodium sensitivity. The client's body mass index is within normal limits and thus would not contribute to dehydration. Note, however, that a body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water.
B)Poor intake of water (in this case, only 2 glasses per day)could indicate a loss of the thirst response, which is a normal age-related change that increases the risk for dehydration. Skin turgor is a poor indicator of fluid balance in older adult clients, as the skin's elasticity naturally decreases with age. The client's blood pressure is elevated, but this could indicate either fluid volume overload or sodium sensitivity. The client's body mass index is within normal limits and thus would not contribute to dehydration. Note, however, that a body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water.
C)Poor intake of water (in this case, only 2 glasses per day)could indicate a loss of the thirst response, which is a normal age-related change that increases the risk for dehydration. Skin turgor is a poor indicator of fluid balance in older adult clients, as the skin's elasticity naturally decreases with age. The client's blood pressure is elevated, but this could indicate either fluid volume overload or sodium sensitivity. The client's body mass index is within normal limits and thus would not contribute to dehydration. Note, however, that a body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water.
D)Poor intake of water (in this case, only 2 glasses per day)could indicate a loss of the thirst response, which is a normal age-related change that increases the risk for dehydration. Skin turgor is a poor indicator of fluid balance in older adult clients, as the skin's elasticity naturally decreases with age. The client's blood pressure is elevated, but this could indicate either fluid volume overload or sodium sensitivity. The client's body mass index is within normal limits and thus would not contribute to dehydration. Note, however, that a body mass index associated with overweight or obesity could be associated with dehydration, as fat cells contain little or no water.

Question 16

The nurse is providing care to a client who is exhibiting clinical manifestations of a severe fluid and electrolyte imbalance. Based on this data, which of the following orders should the nurse anticipate from the healthcare provider? Select all that apply.

Accepted Answer

A)If the client is experiencing a fluid volume deficit, intravenous fluids may be ordered if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, or subcutaneous administration of fluid, may also be employed as a delivery method, especially among older adults. Conversely, if the client is experiencing a fluid volume excess, diuretics may be ordered. Antibiotics are not used for fluid and electrolyte imbalance. Blood transfusion is implemented for blood loss, not for a fluid and electrolyte imbalance.
B)If the client is experiencing a fluid volume deficit, intravenous fluids may be ordered if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, or subcutaneous administration of fluid, may also be employed as a delivery method, especially among older adults. Conversely, if the client is experiencing a fluid volume excess, diuretics may be ordered. Antibiotics are not used for fluid and electrolyte imbalance. Blood transfusion is implemented for blood loss, not for a fluid and electrolyte imbalance.
C)If the client is experiencing a fluid volume deficit, intravenous fluids may be ordered if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, or subcutaneous administration of fluid, may also be employed as a delivery method, especially among older adults. Conversely, if the client is experiencing a fluid volume excess, diuretics may be ordered. Antibiotics are not used for fluid and electrolyte imbalance. Blood transfusion is implemented for blood loss, not for a fluid and electrolyte imbalance.
D)If the client is experiencing a fluid volume deficit, intravenous fluids may be ordered if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, or subcutaneous administration of fluid, may also be employed as a delivery method, especially among older adults. Conversely, if the client is experiencing a fluid volume excess, diuretics may be ordered. Antibiotics are not used for fluid and electrolyte imbalance. Blood transfusion is implemented for blood loss, not for a fluid and electrolyte imbalance.
E)If the client is experiencing a fluid volume deficit, intravenous fluids may be ordered if replacement oral fluids cannot be taken in sufficient quantity. Hypodermoclysis, or subcutaneous administration of fluid, may also be employed as a delivery method, especially among older adults. Conversely, if the client is experiencing a fluid volume excess, diuretics may be ordered. Antibiotics are not used for fluid and electrolyte imbalance. Blood transfusion is implemented for blood loss, not for a fluid and electrolyte imbalance.

Question 17

Which statement is true?

Accepted Answer

A)Tonicity represents the balance between the amounts of water on either side of a membrane. Different states of balance can exist relative to the sides of the membrane. A patient may be in a hypotonic condition if there is a lower concentration of solutes to water. The opposite exists in hypertonic states when there is a higher concentration of solutes in relation to water. Dehydrated clients are hypertonic because there is a reduced percentage of water in their bodies and thus a higher concentration of solutes to water.
B)Tonicity represents the balance between the amounts of water on either side of a membrane. Different states of balance can exist relative to the sides of the membrane. A patient may be in a hypotonic condition if there is a lower concentration of solutes to water. The opposite exists in hypertonic states when there is a higher concentration of solutes in relation to water. Dehydrated clients are hypertonic because there is a reduced percentage of water in their bodies and thus a higher concentration of solutes to water.
C)Tonicity represents the balance between the amounts of water on either side of a membrane. Different states of balance can exist relative to the sides of the membrane. A patient may be in a hypotonic condition if there is a lower concentration of solutes to water. The opposite exists in hypertonic states when there is a higher concentration of solutes in relation to water. Dehydrated clients are hypertonic because there is a reduced percentage of water in their bodies and thus a higher concentration of solutes to water.
D)Tonicity represents the balance between the amounts of water on either side of a membrane. Different states of balance can exist relative to the sides of the membrane. A patient may be in a hypotonic condition if there is a lower concentration of solutes to water. The opposite exists in hypertonic states when there is a higher concentration of solutes in relation to water. Dehydrated clients are hypertonic because there is a reduced percentage of water in their bodies and thus a higher concentration of solutes to water.

Question 18

A home health nurse is providing care for a client diagnosed with heart failure. The client is taking furosemide (Lasix). The nurse reviews the client's most recent serum potassium, which was 3.4 mEq/L. Based on this data, which food should the nurse encourage the client to consume?

Accepted Answer

A)A potassium level of 3.4 mEq/L is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, banana is the highest in potassium.
B)A potassium level of 3.4 mEq/L is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, banana is the highest in potassium.
C)A potassium level of 3.4 mEq/L is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, banana is the highest in potassium.
D)A potassium level of 3.4 mEq/L is low, so the client should be encouraged to consume potassium-rich foods. Of the foods listed, banana is the highest in potassium.

Question 19

Which of the following electrolytes would be classified as a cation?

Accepted Answer

A)Electrolytes are ions, or charged particles, that are capable of conducting electricity when dispersed in water. Electrolytes may be positively or negatively charged. Positively charged electrolytes are called cations and include sodium, potassium, calcium, and magnesium. Negatively charged electrolytes are called anions and include chloride, bicarbonate, phosphate, and sulfate.
B)Electrolytes are ions, or charged particles, that are capable of conducting electricity when dispersed in water. Electrolytes may be positively or negatively charged. Positively charged electrolytes are called cations and include sodium, potassium, calcium, and magnesium. Negatively charged electrolytes are called anions and include chloride, bicarbonate, phosphate, and sulfate.
C)Electrolytes are ions, or charged particles, that are capable of conducting electricity when dispersed in water. Electrolytes may be positively or negatively charged. Positively charged electrolytes are called cations and include sodium, potassium, calcium, and magnesium. Negatively charged electrolytes are called anions and include chloride, bicarbonate, phosphate, and sulfate.
D)Electrolytes are ions, or charged particles, that are capable of conducting electricity when dispersed in water. Electrolytes may be positively or negatively charged. Positively charged electrolytes are called cations and include sodium, potassium, calcium, and magnesium. Negatively charged electrolytes are called anions and include chloride, bicarbonate, phosphate, and sulfate.

Question 20

The nurse is preparing to administer 20 mEq of potassium chloride to a client who has been vomiting. Which information about the purpose of this medication should the nurse explain to the client?

Accepted Answer

A)Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Calcium is vital in regulating muscle contraction and relaxation. Sodium controls and regulates water balance in the body. Magnesium is used in the cells to synthesize protein and DNA.
B)Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Calcium is vital in regulating muscle contraction and relaxation. Sodium controls and regulates water balance in the body Magnesium is used in the cells to synthesize protein and DNA.
C)Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Calcium is vital in regulating muscle contraction and relaxation. Sodium controls and regulates water balance in the body. Magnesium is used in the cells to synthesize protein and DNA.
D)Potassium is the major cation in intracellular fluids, with only a small amount found in plasma and interstitial fluid. Potassium is a vital electrolyte for skeletal, cardiac, and smooth muscle activity. Calcium is vital in regulating muscle contraction and relaxation. Sodium controls and regulates water balance in the body. Magnesium is used in the cells to synthesize protein and DNA.

Quiz 6: Fluids and Electrolytes