Chapter 11: ... Fluid and Electrolyte Imbalances (Practice Questions)

Chapter 11: ... Fluid and Electrolyte Imbalances (Practice

Questions) 4.7 (13 reviews) Students also studied Terms in this set (44) Guilford Technical Community College NUR 111 Save Fluid and Electrolytes NCLEX Quest...33 terms Alex_Hassiepen Preview Fluid & Electrolyte NCLEX Practice ...145 terms ngreen14Preview

Exam 1: Electrolyte Imbalance Ques...

39 terms tessa_sisleyPreview Med Su 61 terms Raf The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate?

• Notify the physician.
• Examine dependent body areas.
• Assess turgor on the client's forehead.
• Document the finding and continue to monitor.
• Assess turgor on the client's forehead.

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

• Fluid retention
• Hyperkalemia
• Hyponatremia
• Hypervolemia
• Hyperkalemia

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

• Measuring urine output
• Measuring abdominal girth
• Monitoring fluid intake
• Comparing radial versus apical pulses
• Measuring urine output

Rational: 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.

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

• "My skin is always so dry, especially here in the

Southwest."

• "I often use a glycerin suppository for constipation."
• "I don't drink liquids after 5 PM so I don't have to get up

at night."

• "In addition to coffee, I drink at least one glass of water

with each meal."

• "I don't drink liquids after 5 PM so I don't have to get up at night."

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

• Chinese take-out, including steamed rice
• A grilled cheese sandwich with tomato soup
• Slices of ham and cheese on whole grain crackers
• A chicken leg, one slice of bread with butter, and

steamed carrots

• A chicken leg, one slice of bread with butter, and steamed carrots

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

• 1% or 2% milk
• Grilled salmon
• Poached eggs
• Baked chicken
• Poached eggs

Rational: 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.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?

• "I am often cold and need to wear a sweater."
• "I seem to urinate more when I drink coffee."
• "In the summer, I feel thirsty more often."
• "My rings seem to be tighter this week."
• "My rings seem to be tighter this week."

Rational: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.Which client is at greatest risk for dehydration?

• Younger adult client on bedrest
• Older adult client receiving hypotonic IV fluid
• Younger adult client receiving hypertonic IV fluid
• Older adult client with cognitive impairment
• Older adult client with cognitive impairment

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

• "Do you take diuretics, or 'water pills'?"
• "What do you normally eat over a day's time?"
• "How many bowel movements do you have daily?"
• "Have you been diagnosed with diabetes mellitus?"
• "Do you take diuretics, or 'water pills'?"

Rational: Misuse or overuse of diuretics is a common cause of isotonic

dehydration. The other statements are not indicative of causes of isotonic dehydration.

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

• Measuring intake and output every four hours
• Applying oxygen by mask or nasal cannula
• Increasing the IV flow rate to 250 mL/hr
• Placing the client in a high Fowler's position
• Applying oxygen by mask or nasal cannula

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

• "I must drink a quart of water or other liquid each day."
• "I will weigh myself each morning before I eat or drink."
• "I will use a salt substitute when making and eating my

meals."

• "I will not drink liquids after 6 PM so I won't have to get

up at night."

• "I will weigh myself each morning before I eat or drink."

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

• Measuring abdominal girth
• Converting ounces to milliliters
• Obtaining and charting daily weight
• Selecting food items with high water content
• Obtaining and charting daily weight

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

• Tenting of skin on the back of the hand
• Increased urine osmolarity
• Weight loss of 10 pounds
• Pulse rate of 115 beats/min
• Pulse rate of 115 beats/min

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

• Restricting sodium intake to no greater than 4 g/day
• Maintaining an oral intake of at least 1500 mL/day
• Maintaining a daily oral intake approximately equal to

daily fluid loss

• Avoiding the use of glycerin suppositories to manage

constipation

• Maintaining a daily oral intake approximately equal to daily fluid loss

Rational: 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.

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

• The client has dry, scaly skin on bilateral upper and

lower extremities.

• The client states that he gets up three or more times

during the night to urinate.

• The client states that he feels lightheaded when he

gets out of bed or stands up.

• The nurse observes tenting on the back of the hand

when testing skin turgor.

• The client states that he feels lightheaded when he gets out of bed or stands

up.

Rational: 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.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?

• "I will weigh myself at the same time daily wearing the

same clothes."

• "When I feel lightheaded, I will drink a full glass of

water."

• "I will decrease my fluid intake if my urine output

increases."

• "If I forget to take my diuretic, I will take twice the dose

next time."

• "When I feel lightheaded, I will drink a full glass of water."

Rational: 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.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?

• "Do you usually drink liquids that are hot or cold?"
• "How much salt do you add to your food?"
• "What kinds of liquids do you usually drink?"
• "Do you drink fluids with meals or between meals?"
• "What kinds of liquids do you usually drink?"

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

• Has had diabetes mellitus for 12 years
• Uses sodium-containing antacids frequently
• Just received 3 units of packed red blood cells
• Had abdominal surgery and has a nasogastric tube
• Just received 3 units of packed red blood cells

Rational: 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.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?

• Measuring intake and output every shift
• Slowing the IV flow rate to 50 mL/hr
• Administering diuretic agents as prescribed
• Placing the client in Trendelenburg position
• Administering diuretic agents as prescribed

Rational: 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.