Nokea
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?
- A. Client with fever and rapid respirations
- B. Client with diabetes mellitus
- C. Client receiving intravenous isotonic fluids
- D. Client with stable heart failure
Correct Answer: A
Rationale: Insensible water loss occurs through the skin, lungs, and stool. Clients with fever and rapid respirations lose more water through increased respiratory rate and perspiration, putting them at greatest risk for insensible water loss.
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A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?
- A. A 36-year-old who is prescribed long-term steroid therapy
- B. A 55-year-old receiving hypertonic intravenous fluids
- C. A 75-year-old who is cognitively impaired
- D. A 63-year-old with congestive heart failure
Correct Answer: C
Rationale: 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 fluid needs known is at high risk for dehydration.
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.)
- A. Increased pulse rate
- B. Distended neck veins
- C. Decreased blood pressure
- D. Pale and cool skin
- E. Skeletal muscle weakness
Correct Answer: A,B,E
Rationale: Manifestations of fluid overload include increased pulse rate, distended neck veins, increased blood pressure, pale and cool skin, and skeletal muscle weakness.
A nurse teaches a client who is at risk for mild hyponatremia. Which statement should the nurse include in this client's teaching?
- A. Weigh yourself every morning and every night
- B. A 3-year-old with a client who is prescribed a sulfonamide antibiotic
- C. Read food labels to determine sodium content
- D. Bake and grill to treat rather than frying it
Correct Answer: C
Rationale: Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate sodium content helps manage sodium intake to prevent hyponatremia. The method of cooking does not significantly alter sodium content unless high-sodium ingredients are added.
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.)
- A. Urine output of 250 mL in 8 hours
- B. Serum potassium level of 5.8 mEq/L
- C. Blood pressure of 88/54 mm Hg
- D. Decreased urine specific gravity
- E. Increased urine specific gravity
Correct Answer: B,E
Rationale: Aldosterone inhibition increases potassium retention and water excretion, leading to hyperkalemia (elevated serum potassium) and increased urine specific gravity due to concentrated urine.
A nurse develops a plan of care for a client who has a history of hypokalemia. Which interventions should be included in this client's care plan? (Select all that apply.)
- A. Encourage oral fluid intake of at least 2 L/day
- B. Use a draw sheet to reposition the client in bed
- C. Monitor serum potassium levels daily
- D. Provide nonslip footwear for the client to use when out of bed
- E. Rotate the client from side to side every 2 hours
Correct Answer: B,D
Rationale: Clients with long-standing hypokalemia have brittle bones that may fracture easily. Using a draw sheet to reposition and providing nonslip footwear enhance safety and prevent fractures and falls.