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NURS 1220 Exam 3 Questions And 100% Correct Answers (A+ Graded)
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NURS 1220 Exam 3 Questions And 100%Correct Answers (A+ Graded)
A nurse assesses clients in a family practice clinic who are susceptible to dehydration.
Which of the following clients is most susceptible to dehydration?
A 36-year-old who has received the prescription for long-term steroid therapy
A 55-year-old who has been receiving intravenous fluids recently
A 76-year-old who is cognitively impaired
An 83-year-old with congestive heart failure ANS: C
Because older adults have less total body water than younger adults, they are at a
higher risk for the development of dehydration. Any client who is cognitively impaired
and unable to obtain fluids independently, or who cannot make his or her need for fluids
known, is considered to be at high risk for dehydration. The client with heart failure
does have 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 a geriatric client who demonstrates confusion due to
dehydration. Which intervention should the nurse perform?
a. Document client's intake and output every 4 hr.
b. Continue to evaluate the client for risk for injury related to falling.
c. Increase the flow rate of IV fluid to 250 mL/hr
d. Place the client in high-Fowler position. ANS: B
Dehydration most commonly leads to inadequate cerebral perfusion and to cerebral
hypoxia, which is manifested as confusion. This confusion, orthostatic hypotension,
dysrhythmia, and/or muscle weakness puts the client with dehydration at risk for falls.
The nurse's best response is one that provides more detail about the client's risk for
falls. Although the intake and output may need to be measured more frequently than
every 4 hours, it does not meet a priority 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 providing teaching to a client receiving treatment for dehydration, the nurse
assesses the client's understanding. Which statement by the client BEST reflects that
the client UNDERSTOOD the teaching? a. "I must drink one quart (liter) of water or other
fluid daily." b. "I will weigh myself every morning before I take in any food or fluids." c. "I
will add a salt substitute to food when preparing it and when I eat my meals.
d. "I won't drink liquids after 6 p.m. so I won't have to get up at night. - ANS: B
One litre 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 litre of fluid a day is not sufficient. A salt substitute
has nothing to do with dehydration. Patients may want to avoid fluids after dinner so
they won't need to get up, but this does not help their dehydration if the patient drinks
the recommended amount of fluid during the earlier parts of the day.
A nurse is planning assessments for clients on a medical-surgical unit. Which adult
client should the nurse identify as being at greatest risk for insensible water loss?
a. Client receiving furosemide.
b. Anxious client who is experiencing tachypnea.
c. Client who is receiving fluid restrictions.
d. Constipated client with abdominal pain. - Answer ANS: B
Insensible water loss is the loss of water through the skin, lungs, and stool. The
mechanically ventilated client, the client with rapid respirations, and the client receiving
continuous GI suctioning are all clients that are at risk for insensible water loss. Clients
who also have thyroid crisis, trauma, burns, states of extreme stress, and fever are at
risk. The client receiving furosemide will be losing more fluids, but will not have
insensible water loss. The two other clients with fluid restriction and constipation are
not at risk for insensible fluid loss.
A nurse is evaluating a client who is receiving care for dehydration. Which assessment
finding does the nurse correlate with a therapeutic response to the treatment plan?
a. An increased respiratory rate from 12 to 22 breaths/min
b. Decreased skin turgor in the client's posterior hand and forehead
c. An increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic changes when standing - Answer ANS: D
,The goal of management for dehydrated clients is to restore fluid volumes to within a
normal range. The client whose blood volume has returned to normal will not exhibit
orthostatic blood pressure and pulse changes. This assessment finding reflects a
therapeutic response to treatment. Tachypnea, poor skin turgor, and elevated urine
specific gravity are all signs suggesting the client remains dehydrated.
6. A nurse teaches a client who is taking a RESTRICTED SODIUM DIET and then
evaluates the client's understanding. Which of the following lunch food choices by the
client demonstrates that the client appropriately 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 with restricted sodium intake usually avoid foods that are commercially
prepared, smoked, or pickled, or those with sauces and other condiments. The foods
that are naturally lowest in sodium include fish, poultry, and fresh vegetables and fruits.
The ham, tomato soup, the salami, and crackers would generally have high levels of
sodium.
7. A nurse is assessing clients for fluid and electrolyte imbalances. For which client will
the nurse initially assess the risk for hyponatremia?
a. A 34-year-old client who is NPO and receiving rapid intravenous D5W infusions.
b. A 50-year-old client with an infection who is receiving a sulfonamide antibiotic.
c. A 67-year-old client who has pain and is receiving ibuprofen.
d. A 73-year-old client with tachycardia who is receiving digoxin. - Answer ANS: A
D5W does not contain any electrolytes. The dextrose is quickly metabolized when
infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic
solutions can result in hyponatremia. Because the client is NPO, normal excretion of
sodium can also cause hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin
will not place 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."
d. "Bake or grill your meat rather than frying it." ANS: C
One symptom of hyponatremia is diarrhea from increased intestinal motility. The client
would be instructed to notify the primary health care provider if this is observed.
Neurologic manifestations common to hypokalemia are irritability and anxiety. Muscle
twitching is associated with hypernatremia. Cooking methods are not a cause of
hyponatremia.
A nurse is caring for a client whose laboratory studies reveal the following: 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), sodium 144 mEq/L (144 mmol/L). What is the nurse's first assessment?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography ANS: A
A client who is experiencing a low serum potassium level is at risk for hypoactive bowel
sounds, cardiac dysrhythmias, and muscle weakness that creates shallow respirations
and weak handgrips. The nurse would initiate this client's care by monitoring the client's
respiratory status to ensure that respirations are adequate. Respiratory assessment
includes rate and depth of respirations, work of breathing, and oxygen saturation. The
remaining assessments are all important, but they are secondary to the client's
respiratory status.
A nurse is caring for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and
who is demonstrating cardiovascular changes. What is the first intervention the nurse
will perform?
a. Prepare to administer patiromer orally.
b. Offer a cardiovascular, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d. Prepare the client for hemodialysis treatment. - Answer ANS: C
A patient with a critically high serum potassium level with associated cardiac changes
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