10th- CH 13 Flashcards
. A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?
A 36 year old who is prescribed long-term steroid therapy.
A 55 year old who recently received intravenous fluids.
A 76 year old who is cognitively impaired.
An 83 year old with congestive heart failure.
c
A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?
Measure intake and output every 4 hours.
Assess client further for fall risk.
Increase the IV flow rate to 250 mL/hr.
Place the client in a high-Fowler position.
ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension, dysrhythmia, and/or muscle weakness. The nurse’s best response is to do a more thorough evaluation of the client’s risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address a critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety.
After teaching a client who is being treated for dehydration, a nurse assesses the client’s understanding. Which statement indicates that the client correctly understood the teaching?
“I must drink a quart (liter) of water or other liquid each day.”
“I will weigh myself each morning before I eat or drink.”
“I will use a salt substitute when making and eating my meals.”
“I will not drink liquids after 6 p.m. so I won’t have to get up at night.”
ANS: B
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 (0.2 kg) daily is indicative of excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won’t have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier parts of the day.
A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?
Client taking furosemide.
Anxious client who has tachypnea.
Client who is on fluid restrictions.
Client who is constipated with abdominal pain.
ANS: B
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 insensible fluid loss.
A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?
Increased respiratory rate from 12 to 22 breaths/min
Decreased skin turgor on the client’s posterior hand and forehead
Increased urine specific gravity from 1.012 to 1.030 g/mL
Decreased orthostatic changes when standing
ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates that the client correctly understood the teaching?
Slices of smoked ham with potato salad
Bowl of tomato soup with a grilled cheese sandwich
Salami and cheese on whole-wheat crackers
Grilled chicken breast with glazed carrots
ANS: D
Clients on restricted sodium diets generally 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 usually high in sodium.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia?
A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
A 50 year old with an infection who is prescribed a sulfonamide antibiotic.
A 67 year old who is experiencing pain and is prescribed ibuprofen
A 73 year old with tachycardia who is receiving digoxin.
ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO), normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client’s teaching?
“Have you spouse watch you for irritability and anxiety.”
“Notify the clinic if you notice muscle twitching.”
“Call your primary health care provider for diarrhea.”
“Bake or grill your meat rather than frying it.”
ANS: C
One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia. Cooking methods are not a cause of hyponatremia.
A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?
Depth of respirations
Bowel sounds
Grip strength
Electrocardiography
ANS: A
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 would assess the client’s respiratory status first to ensure that respirations are sufficient. The respiratory assessment would 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.
A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first?
Prepare to administer patiromer by mouth.
Provide a heart-healthy, low-potassium diet.
Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
Prepare the client for hemodialysis treatment.
ANS: C
A client with a critically high serum potassium level and cardiac changes would 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 would be administered with dextrose to prevent hypoglycemia. Patiromer 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 intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client’s current potassium level.
The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?
Administer high-ceiling (loop) diuretics.
Assess the client’s lung sounds every 2 hours.
Place a pressure-relieving overlay on the mattress.
Weigh the client daily at the same time on the same scale.
ANS: B
All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client’s respiratory status.
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. What action does the nurse take first?
Assess the client’s respiratory rate, rhythm, and depth.
Measure the client’s pulse and blood pressure.
Document findings and monitor the client.
Call the health care primary health care provider.
ANS: A
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 would be assessed after assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy.
A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?
Notifies the pharmacy of the IV potassium order.
Assesses the client’s IV site every hour during infusion.
Sets the IV pump to deliver 30 mEq of potassium an hour.
Double-checks the IV bag against the order with the precepting nurse.
ANS: C
IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug.
A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition?
Assesses the client’s Chvostek and Trousseau sign.
Keeps the client’s room quiet and dimly lit.
Moves the client carefully to avoid fracturing bones.
Administers bisphosphonates as prescribed.
ANS: D
Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured.
A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first?
Encourage oral fluid intake.
Connect the client to a cardiac monitor.
Assess urinary output.
Administer oral calcitonin.
ANS: B
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering calcitonin are treatments for hypercalcemia, but are not the highest priority.
