Nokea
A client was admitted to the unit with a diagnosis of hypovolemia. When it is time to complete discharge teaching, which of the following will the nurse teach the client and family? Select all that apply.
- A. Drink at least eight glasses of fluid each day.
- B. Drink caffeinated beverages to retain fluid.
- C. Drink alcoholic beverages to help balance fluid volume.
- D. Drink water as an inexpensive way to meet fluid needs.
- E. Respond to thirst
Correct Answer: A,D,E
Rationale: In addition, the nurse teaches clients who have a potential for hypovolemia and their families to respond to thirst because it is an early indication of reduced fluid volume; consume at least 8 to 10 (8 ounce) glasses of fluid each day and more during hot, humid weather; drink water as an inexpensive means to meet fluid requirements; and avoid beverages with alcohol and caffeine because they increase urination and contribute to fluid deficits.
You may also like to solve these questions
The nurse is caring for a client with laboratory values indicating dehydration. Which clinical symptom is consistent with the dehydration?
- A. Cool and pale skin
- B. Crackles in the lung fields
- C. Distended jugular veins
- D. Dark, concentrated urine
Correct Answer: D
Rationale: Dehydration indicates a fluid volume deficit. Dark, concentrated urine indicates a lack of fluid volume. Adding more fluid would dilute the urine. The other options indicate fluid excess.
The nurse is caring for a client with frequent dizziness. The nurse is evaluating the client for postural hypotension. Which of the following symptoms would indicate a potential diagnosis?
- A. A blood pressure elevation upon activity
- B. A drop in systolic blood pressure $(15 \mathrm{~mm} \mathrm{Hg}$ ) upon rising
- C. A pulsating headache
- D. A drop in diastolic blood pressure $(25 \mathrm{mmHg}$ ) upon rising
Correct Answer: B
Rationale: Postural hypotension occurs when the client rises from a supine or semi- Fowler's position to a standing position and the systolic blood pressure drops by $15 \mathrm{~mm} \mathrm{Hg}$. The client has symptoms of dizziness or a near syncopal episode.
The nursing instructor is talking with the nursing class about fluid and electrolyte balance. What would the instructor tell the students that the average daily fluid intake for an adult is?
- A. 2000 mL
- B. 2500 mL
- C. 3000 mL
- D. 3500 mL
Correct Answer: B
Rationale: In healthy adults, oral fluid intake averages about $2500 \mathrm{~mL} /$ day; however, it can range between 1800 and $3000 \mathrm{~mL} /$ day, with a similar volume of fluid loss. $2000 \mathrm{~mL}, 3000 \mathrm{~mL}$, and $3500 \mathrm{~mL}$ are not the average amounts of fluid a healthy adult takes in daily.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction. Which acid-base imbalance is most likely to occur?
- A. Respiratory alkalosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Metabolic acidosis
Correct Answer: B
Rationale: Metabolic alkalosis results in increased plasma $\mathrm{pH}$ because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate- containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more $\mathrm{CO}_2$ than necessary.
An adult client is brought into the clinic feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy. The nurse reconciles the client's medication list and notes that salt tablets had been prescribed. What would the nurse do next?
- A. Continue to monitor client with another appointment.
- B. Be prepared to administer a lactated Ringer's IV.
- C. Be prepared to administer a sodium chloride IV.
- D. Consider sodium restriction with discontinuation of salt tablets.
Correct Answer: D
Rationale: The client's symptoms of feeling thirsty with dry, sticky mucous membranes; decreased urine output; fever; a rough tongue; and lethargy suggest hypernatremia. The client needs to be evaluated with serum blood tests soon; a later appointment will delay treatment. It is necessary to restrict sodium intake. Salt tablets and a sodium chloride IV will only worsen this condition. A Lactated Ringer's IV is a hypertonic IV and is not used with hypernatremia. A hypotonic solution IV may be a part of the treatment, but not along with the salt tablets.