Nokea
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.
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A nurse is assessing a client on a medical-surgical unit. Which client is at risk for hypokalemia?
- A. Client with pancreatitis who has continuous nasogastric suctioning
- B. Client with a prescription for an angiotensin-converting enzyme (ACE) inhibitor
- C. Client in a motor vehicle crash who is receiving 2 units of packed red blood cells
- D. Client with uncontrolled diabetes and a serum pH level of 7.33
Correct Answer: A
Rationale: A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia due to the removal of potassium-rich gastric fluids.
Which meal choice is most appropriate for a client on a low-sodium diet?
- A. Ham sandwich with mustard
- B. Tomato soup with crackers
- C. Spaghetti with meat sauce
- D. Grilled chicken breast with glazed carrots
Correct Answer: D
Rationale: Clients on restricted sodium diets should avoid processed, smoked, and pickled foods and those with sauces and condiments. Foods lowest in sodium include fish, poultry, and fresh produce. Grilled chicken breast with glazed carrots is the lowest in sodium.
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.
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.
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.