Nokea
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
- A. Ask family members to speak quietly to keep the client calm
- B. Assess the client's mental status daily
- C. Encourage the client to drink at least 1 liter of fluids each shift
- D. Dangle the client on the bedside before ambulating
Correct Answer: D
Rationale: An older adult with moderate dehydration may experience orthostatic hypotension. Dangling on the bedside before ambulating helps prevent falls and injuries due to sudden blood pressure drops.
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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.
After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?
- A. Toasted English muffin with butter and blueberry jam, and tea with sugar
- B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
- C. Sausage, whole-wheat toast, half cup of raisins, and a glass of milk
- D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee
Correct Answer: C
Rationale: Meat, dairy products, and dried fruit have high concentrations of potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of high-potassium items.
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.
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Bowel sounds
- B. Depth of respirations
- C. Grip strength
- D. Electrocardiography
Correct Answer: B
Rationale: A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse should assess the client's respiratory status first to ensure respirations are sufficient.
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.