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Nurs 1220 Exam 3 Guide With Complete Solution
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Nurs 1220 Exam 3 Guide WithComplete Solution
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. - ANSWER ANS: C
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. The client with heart failure has a risk for both
fluid imbalances. Long-term steroids and recent IV fluid administration do not
increase the risk of dehydration.
2. A nurse is caring for an older client who exhibits dehydration-induced confusion.
Which intervention by the nurse is best?
a. Measure intake and output every 4 hours.
b. Assess client further for fall risk.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler position. - ANSWER 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?
a. "I must drink a quart (liter) 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 p.m. so I won't have to get up at night. - ANSWER
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?
a. Client taking furosemide.
b. Anxious client who has tachypnea.
,c. Client who is on fluid restrictions.
d. Client who is constipated with abdominal pain. - ANSWER 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?
a. Increased respiratory rate from 12 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 changes when standing - ANSWER 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.
6. 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?
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 - ANSWER 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.
7. A nurse is assessing clients for fluid and electrolyte imbalances. Which client will
the nurse assess first for potential hyponatremia?
a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
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.
d. A 73 year old with tachycardia who is receiving digoxin. - ANSWER 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?
a. "Have you spouse watch you for irritability and anxiety."
b. "Notify the clinic if you notice muscle twitching."
c. "Call your primary health care provider for diarrhea."
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