Ch. 11 Flashcards
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 76-year-old who is cognitively impaired
d.
An 83-year-old with congestive heart failure
c.
A 76-year-old who is cognitively impaired
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.
reference 156
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
a.
Measure intake and output every 4 hours.
b.
Apply oxygen by mask or nasal cannula.
c.
Increase the IV flow rate to 250 mL/hr.
d.
Place the client in a high-Fowler’s position.
b.
Apply oxygen by mask or nasal cannula.
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 optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowler’s position will not address the client’s problem.
reference 156
After teaching a client who is being treated for dehydration, a nurse assesses the client’s understanding. Which statement indicates the client correctly understood the teaching?
a.
“I must drink a quart of water or other liquid each day.”
b.
“I will weigh myself each morning before I eat or drink.”
c.
“I will use a salt substitute when making and eating my meals.”
d.
“I will not drink liquids after 6 PM so I won’t have to get up at night.”
b.
“I will weigh myself each morning before I eat or drink.”
One liter of water weighs 1 kg; therefore, a 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.
reference 156
A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess?
a.
Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
b.
Daily weight increase from 55 kg to 57 kg
c.
Heart rate decrease from 100 beats/min to 82 beats/min
d.
Respiratory rate increase from 12 breaths/min to 15 breaths/min
a.
Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
ACE inhibitors will disrupt the renin–angiotensin II pathway and prevent the kidneys from reabsorbing water and sodium. The kidneys will excrete more water and sodium, decreasing the client’s blood pressure.
ref. 166
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 taking furosemide (Lasix)
b.
Anxious client who has tachypnea
c.
Client who is on fluid restrictions
d.
Client who is constipated with abdominal pain
b.
Anxious client who has tachypnea
Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.
ref. 153
A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan?
a.
Increased respiratory rate from 12 breaths/min to 22 breaths/min
b.
Decreased skin turgor on the client’s posterior hand and forehead
c.
Increased urine specific gravity from 1.012 to 1.030 g/mL
d.
Decreased orthostatic light-headedness and dizziness
d.
Decreased orthostatic light-headedness and dizziness
The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.
ref. 156
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates the client correctly understood the teaching?
a.
Slices of smoked ham with potato salad
b.
Bowl of tomato soup with a grilled cheese sandwich
c.
Salami and cheese on whole wheat crackers
d.
Grilled chicken breast with glazed carrots
d.
Grilled chicken breast with glazed carrots
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 ham, tomato soup, salami, and crackers are often high in sodium.
ref. 157
A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
a.
A 34-year-old on NPO status who is receiving intravenous D5W
b.
A 50-year-old with an infection who is prescribed a sulfonamide antibiotic
c.
A 67-year-old who is experiencing pain and is prescribed ibuprofen (Motrin)
d.
A 73-year-old with tachycardia who is receiving digoxin (Lanoxin)
a.
A 34-year-old on NPO status who is receiving intravenous D5W
Dextrose 5% in water (D5W) contains no electrolytes. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.
ref. 161
A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client’s teaching?
a.
“Weigh yourself every morning and every night.”
b.
“Check your radial pulse twice a day.”
c.
“Read food labels to determine sodium content.”
d.
“Bake or grill the meat rather than frying it.”
c.
“Read food labels to determine sodium content.”
Most prepackaged foods have a high sodium content. Teaching clients how to read labels and calculate the sodium content of food can help them adhere to prescribed sodium restrictions and can prevent hypernatremia. Daily self-weighing and pulse checking are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking, not the method of cooking, increases the sodium content of a meal.
ref. 160
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.
Depth of respirations
b.
Bowel sounds
c.
Grip strength
d.
Electrocardiography
a.
Depth of respirations
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. The respiratory assessment should include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client’s respiratory status.
ref. 164
A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first?
a.
Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
b.
Provide a heart healthy, low-potassium diet.
c.
Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d.
Prepare the client for hemodialysis treatment.
c.
Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
A client with a high serum potassium level and cardiac changes should be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease both serum potassium and glucose levels and therefore should be administered with dextrose to prevent hypoglycemia. Kayexalate may be ordered, but this therapy may take hours to reduce potassium levels. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first prescription the nurse should implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client’s current potassium level.
ref. 166
A nurse is assessing clients on a medical-surgical unit. Which client is at risk for hypokalemia?
a.
Client with pancreatitis who has continuous nasogastric suctioning
b.
Client who is prescribed an angiotensin-converting enzyme (ACE) inhibitor
c.
Client in a motor vehicle crash who is receiving 6 units of packed red blood cells
d.
Client with uncontrolled diabetes and a serum pH level of 7.33
a.
Client with pancreatitis who has continuous nasogastric suctioning
A client with continuous nasogastric suctioning would be at risk for actual potassium loss leading to hypokalemia. The other clients are at risk for potassium excess or hyperkalemia.
ref 164
A nurse is assessing a client with hypokalemia, and notes that the client’s handgrip strength has diminished since the previous assessment 1 hour ago. Which action should the nurse take first?
a.
Assess the client’s respiratory rate, rhythm, and depth.
b.
Measure the client’s pulse and blood pressure.
c.
Document findings and monitor the client.
d.
Call the health care provider.
a.
Assess the client’s respiratory rate, rhythm, and depth.
In a client with hypokalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also associated with hypokalemia. The client’s pulse and blood pressure should be assessed after assessing respiratory status. Next, the nurse would call the health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client should occur during and after potassium replacement therapy.
ref 163
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, one slice of 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
c.
Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
Meat, dairy products, and dried fruit have high concentrations of potassium. Eggs, breads, cereals, sugar, and some fruits (berries, peaches) are low in potassium. The menu selection of sausage, toast, raisins, and milk has the greatest number of items with higher potassium content.
ref 163
A client at risk for developing hyperkalemia states, “I love fruit and usually eat it every day, but now I can’t because of my high potassium level.” How should the nurse respond?
a.
“Potatoes and avocados can be substituted for fruit.”
b.
“If you cook the fruit, the amount of potassium will be lower.”
c.
“Berries, cherries, apples, and peaches are low in potassium.”
d.
“You are correct. Fruit is very high in potassium.”
c.
“Berries, cherries, apples, and peaches are low in potassium.”
Not all fruit is potassium rich. Fruits that are relatively low in potassium and can be included in the diet include apples, apricots, berries, cherries, grapefruit, peaches, and pineapples. Fruits high in potassium include bananas, kiwi, cantaloupe, oranges, and dried fruit. Cooking fruit does not alter its potassium content.
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