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NRS 381 Chapters 11 & 32 with rationale
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NRS 381 Chapters 11 & 32 with rationale
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Chapters 11 &32.
1. 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 therapy.
C. A 76-year-old who is cognitively impaired.
D. An 83-year-old with congestive heart failure.
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.
2. 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/hour.
D. Place the client in a high-Fowler’s position.
ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing
confusion. Applying oxygen can reduce confusion, even in 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.
3. 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 6PM so I won’t have to get up at night.”
ANS: B
One L 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.
4. 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 mmHg to 144/50 mmHg.
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.
ANS: A
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.
5. 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 restriction.
D. 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.
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