Fluid and Electrolytes NCLEX Questions, Fluid and Electrolytes NCLEX Questions, Chapter 13: Fluid and Electrolytes NCLEX

*The nurse is discussing safety when administering bumetanide with a nursing student. The nurse recognizes that the student understands side effects of this medication when the student makes which statement? A. "The client's PT and INR may be prolonged while taking this medication." B. "The client may develop hypoglycemia during treatment." C. "Inverted T waves and a U wave may appear on the ECG." D. "I need to tell the client to avoid salt substitutes."

C. "Inverted T waves and a U wave may appear on the ECG." RATIONALE: The nursing student understands the side effects of Bumex when commenting that inverted T waves and a U wave may appear on the EKG. Hypokalemia may cause depressed ST segments, flat or inverted T waves or the presence of a U wave on the ECG as well as dysrhythmias. High-ceiling (loop) diuretics, such as furosemide (Lasix, furosemide), promote loss of water, sodium, and potassium.PT and INR are typically prolonged with therapy with warfarin (Coumadin) or individuals with liver disease. Hypoglycemia may occur with oral hypoglycemic medications or insulin. Salt substitutes are typically avoided when the client has hyperkalemia or is taking an ACE inhibitor because many substitutes contain potassium chloride.

The nurse at a long-term care facility is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. Which of these should be included in the education session? A. "Be careful not to overload them with too many oral fluids." B. "Offer fluids that they prefer frequently and on a regular schedule." C. "Restrict their fluids if they are incontinent." D. "Wake them every 2 hours during the night with a drink."

B. "Offer fluids that they prefer frequently and on a regular schedule." RATIONALE: The long-term care nurse teaches the UAPs to frequently offer older adults fluids that they prefer and on a regular basis. Because of the decreased thirst mechanism, older adults can become dehydrated and must be offered oral fluids every 2 hours. The likelihood of their accepting the fluid increases if it is one they prefer.Risk of overhydration, especially with oral fluids, is minimal. Fluids would never be restricted even if the client is incontinent. Restricting fluids to incontinent clients is a common mistake made by UAP in long-term care environments. It is not necessary to disturb older adults during their sleep to offer fluids. However, they should be offered a drink during waking hours at frequent intervals (e.g., every 2 hours).

A client with mild hypokalemia caused by diuretic use is discharged home. The home health nurse delegates which of these interventions to the home health aide? A. Assessment of muscle tone and strength B. Education about potassium-rich foods C. Instruction on the proper use of drugs D. Measurement of the client's weight

D. Measurement of the client's weight RATIONALE: The intervention that can be delegated to the home health aide is to measure the client's weight. Measuring the client's intake and output and reporting it to the RN helps determines if the plan of care has been effective.Assessment, education, and instruction are higher-level nursing actions within the scope of practice of the professional nurse.

C (A common cause of hypocalcemia is hypothyroidism. The calcium value is low, correlating with this condition. The sodium level is only slightly high, and hypothyroidism is not related to sodium imbalances. The potassium level is normal. The magnesium level is low, but hypothyroidism can cause hypermagnesemia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Laboratory Values) MSC: Integrated Process: Nursing Process (Analysis))

A client has a history of hypothyroidism. Which laboratory value is the nurse most concerned about? a. Na+ 146 mEq/L b. K+ 3.6 mEq/L c. Ca2+ 8.2 mg/dL d. Mg2+ 1.1 mEq/L

C (Overhydration most frequently leads to poor neuronal function, causing confusion as a result of electrolyte imbalances (usually sodium dilution). Eliminating fluid excess is the best way to reduce confusion. The other interventions would not relieve the client's confusion. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapy—Expected Actions/Outcomes) MSC: Integrated Process: Nursing Process (Implementation))

A client has been diagnosed with overhydration and is confused. Which intervention does the nurse include in the client's plan of care to relieve the confusion? a. Measuring intake and output every shift b. Slowing the IV flow rate to 50 mL/hr c. Administering diuretic agents as prescribed d. Placing the client in Trendelenburg position

C (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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation))

A client has been taught to increase potassium in the diet. What dietary meal selection indicates to the nurse that teaching has been effective? a. Toasted English muffin with butter and blueberry jam, and tea with sugar b. Two scrambled eggs, a slice of white toast, and a cup of strawberries c. Sausage, one slice of whole wheat toast, cup of raisins, and a glass of milk d. Bowl of oatmeal with brown sugar, cup of sliced peaches, and coffee

D (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 Chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food—a category of foods often high in sodium. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation))

A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? a. Chinese take-out, including steamed rice b. A grilled cheese sandwich with tomato soup c. Slices of ham and cheese on whole grain crackers d. A chicken leg, one slice of bread with butter, and steamed carrots

A (Hypokalemia depresses all excitable tissues, including gastrointestinal smooth muscle. Clients who have hypokalemia have reduced or absent bowel sounds and are constipated. The other answer options are not applicable to hypokalemia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Evaluation))

A client has been treated for hypokalemia. Which clinical manifestation or condition indicates that treatment has been effective? a. Having a bowel movement daily b. Gaining 2 lb during the past week c. Electrocardiogram (ECG) showing inverted T-waves d. Fasting blood glucose level of 106 mg/dL

B (Misuse and overuse of diuretics, especially high-ceiling (loop) and thiazide diuretics, and laxatives are common causes of hypokalemia in older adults and in clients with eating disorders. Sugar substitutes and bowel habits are not related to hypokalemia. The client with kidney disease would be more likely to have hyperkalemia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Assessment))

A client has hypokalemia. Which question by the nurse obtains the most information on a possible cause? a. "Do you use sugar substitutes?" b. "Do you use diuretics or laxatives?" c. "Do you have any kidney disease?" d. "Have your bowel habits changed recently?"

D (The client's calcium is low. Treatment for hypocalcemia includes calcium replacement, administering drugs that increase calcium absorption, and giving medications to control bothersome neuromuscular effects. Aluminum hydroxide helps the body absorb calcium. The client's potassium is normal, so giving potassium is not warranted. Asking the laboratory to rerun the tests will not help the client's problem, although if this seems contradictory to the client's condition, it might be an option. Documenting findings and performing ongoing assessments will not help the client's problem. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation))

A client has the following laboratory values: Ca2+ 8.7 mg/dL; K+ 4.2 mEq/L; Na+ 142 mEq/L. Which intervention by the nurse is most appropriate? a. Prepare to administer IV potassium chloride. b. Ask the lab to redraw and rerun the tests. c. Document findings and continue to assess. d. Prepare to administer aluminum hydroxide.

C (Hyperaldosteronism results in increased reabsorption of sodium and water while enhancing excretion of potassium. Therefore, any client with this condition is at high risk for the development of hypokalemia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment))

A client in the emergency department has potassium of 2.9 mEq/L. For which disease process or condition does the nurse assess the client? a. Diabetes mellitus b. Addison's disease c. Hyperaldosteronism d. Diabetes insipidus

A (Clinical manifestations of hyponatremia are most evident in excitable tissues and include lethargy, decreased blood pressure, increased gastric motility, and diminished deep tendon reflexes. Bowel sounds that are more hyperactive than on a previous assessment indicate that the condition is worsening. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment))

A client is admitted with hyponatremia. Four hours after the initial assessment, the nurse notes that the client has new hyperactive bowel sounds in all four quadrants. What analysis about the client's condition is correct? a. The hyponatremia is worse. b. The hyponatremia is the same. c. The hyponatremia is better. d. The client now has hypernatremia.

A (Chronic alcoholism leads to malnutrition. Malnutrition is a major contributing factor to the development of hypophosphatemia. None of the other conditions contribute to hypophosphatemia. DIF: Cognitive Level: Knowledge/Remembering REF: Table 13-11, p. 192 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment))

A client is admitted with multiple fractures from a motor vehicle crash (MVC). Which of the client's previous or concurrent health problems is most likely to increase the client's risk for hypophosphatemia? a. Chronic alcoholic pancreatitis b. 50-pack-year smoking history c. Prostate cancer history d. Heart surgery 8 years ago

B (As potassium levels rise, dysrhythmias can develop. By being vigilant for changes in pulse rate, rhythm, and quality, the client can seek medical attention before hyperkalemia becomes severe. Taking a daily weight will help determine fluid retention, but this is not an accurate indicator of potassium increase or decrease. Fluid intake should be based on body weight. Sodium restriction may not be necessary. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning)

A client is being discharged and needs to self-monitor for the development of hyperkalemia. Which intervention is most important for the nurse to teach the client? a. Weighing self daily at the same time of day b. Assessing radial pulse for a full minute twice a day c. Ensuring an oral intake of a least 3 L of fluids per day d. Restricting sodium as well as potassium intake

B (Feeling lightheaded or dizzy is an indication of low blood pressure and poor perfusion. Mild dehydration can cause these problems, and increasing fluid intake at the first sign of dehydration may prevent it from becoming worse. The other options would not prevent mild dehydration from progressing. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation))

A client is being discharged with mild dehydration. Which statement by the client indicates an understanding of measures to prevent mild dehydration from becoming more severe? a. "I will weigh myself at the same time daily wearing the same clothes." b. "When I feel lightheaded, I will drink a full glass of water." c. "I will decrease my fluid intake if my urine output increases." d. "If I forget to take my diuretic, I will take twice the dose next time."

B (Because 1 L of water weighs 1 kg, 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation))

A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition? 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."

C (Chronic hypophosphatemia can be managed with nutrition therapy. The client needs to increase his or her ingestion of phosphorus and to decrease ingestion of calcium because phosphorus and calcium exist in the blood in a balanced inverse relationship. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Maintenance and Promotion (Self-Care) MSC: Integrated Process: Nursing Process (Implementation))

A client with hypophosphatemia is being discharged. Which activity demonstrated by the client indicates that discharge teaching has been effective? a. Assessing radial pulse rate and rhythm b. Interspersing daily activities with periods of rest c. Selecting foods high in phosphorus and low in calcium d. Weighing himself or herself correctly at the same time each day

C (Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Diagnostic Tests/Treatments/Procedures) MSC: Integrated Process: Nursing Process (Assessment))

A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? a. Has had diabetes mellitus for 12 years b. Uses sodium-containing antacids frequently c. Just received 3 units of packed red blood cells d. Had abdominal surgery and has a nasogastric tube

D (Severe dehydration can decrease circulating volume and decrease cardiac output, placing vital organs at risk for hypoxia, anoxia, and ischemia. Whenever cardiac output is decreased with dehydration, oxygen therapy is indicated. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Assessment))

A nurse is caring for several clients with dehydration. The nurse assesses the client with which finding as needing oxygen therapy? a. Tenting of skin on the back of the hand b. Increased urine osmolarity c. Weight loss of 10 pounds d. Pulse rate of 115 beats/min

An older adult is admitted to the medical surgical unit with dehydration. The nurse performs which of these assessments to determine whether the client is safe for independent ambulation? A. Assesses for dry oral mucous membranes B. Checks for orthostatic blood pressure changes C. Notes pulse rate is 72 beats/min and bounding D. Evaluates that the serum potassium level is 4.0 mEq/L (4.0 mmol/L)

B. Checks for orthostatic blood pressure changes RATIONALE: When caring an older adult admitted for dehydration, the nurse determines if the client is safe for independent ambulation by assessing for orthostatic blood pressure. Blood pressure measured with the client lying, then sitting, and finally standing is done to detect orthostatic or postural changes. During low blood volume states, especially when standing, insufficient blood flow to the brain may cause hypotension and tachycardia upon arising. This may cause light-headedness and dizziness, which increases the risk for falls, especially in older adults.Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does ensure safety for ambulation nor assess for fall risk.

The nurse is infusing 3% saline for a client with syndrome of inappropriate secretion (SIADH). Which of these complications does the nurse report to the primary care provider? A. Peripheral edema B. Crackles ½ way up the lung fields C. Serum osmolarity of 294 mOsm/kg D. Urine output of 1300 mL over 24 hours

B. Crackles ½ way up the lung fields RATIONALE: The nurse needs to report to the PCP crackles heard ½ way up the lung fields when assessed on a client with SIADH receiving an infusion of 3% saline. When a hyperosmotic IV solution such as 3% saline is infused, the interstitial fluid is pulled into the circulation in an attempt to dilute the blood. As a result, the plasma volume expands. The nurse needs to evaluate the client for fluid volume excess and symptoms of heart failure including crackles.Peripheral edema may occur with SIADH. A serum osmolarity of 294 mOsm/kg (294 mmol/kg) is normal. A urine output of 1300 mL over 24 hours is considered normal.

A client develops fluid overload while in the intensive care unit. Which nursing intervention does the nurse perform first? A. Draws blood for laboratory tests B. Elevates the head of the bed C. Places the extremities in a dependent position D. Puts the client in a side-lying position

B. Elevates the head of the bed The nurse first needs to elevate the client's head of bed when caring for a client with fluid overload. Remember to follow the ABC's and perform interventions that promote lung expansion and oxygenation to relieve symptoms of fluid overload.Drawing blood for laboratory tests may be indicated, but would not be performed first. Placing the extremities in a dependent position increases peripheral edema, and positioning the client in a side-

A client with hypokalemia has a prescription for parenteral potassium chloride (KCl). Which of these interventions does the nurse use to safely administer KCl? SELECT ALL THAT APPLY. A. Use a potassium infusion prepared by a registered pharmacist. B. Assess for burning or redness during infusion. C. Infuse at a rate of no more than 10 mEq per hour. D. Administer only through a central venous catheter. E. Administer by IV push only during cardiac arrest.

A, B, C RATIONALE: Interventions to safely administer KCl to a client with hypokalemia include: using a pharmacy prepared potassium infusion, checking the client for any burning or redness during infusion, and infusing the IV at not more than 10 mEq per hour. The Joint Commission's National Client Safety Goals mandates that concentrated potassium be diluted and added to IV solutions only in the pharmacy by a registered pharmacist and that vials of concentrated potassium not be available in client care areas. IV potassium solutions irritate veins and cause phlebitis. Assess the IV site hourly, and ask the client whether he or she feels burning or pain at the site. The presence of pain or burning at the insertion site may require a new intravenous to be started. A dose of KCl 5-10 mEq/hour, no more than 20 mEq/hr is recommended.Potassium may be administered by peripheral or central vein. There is no circumstance where potassium is given by IV push.

The nurse is caring for a client who is receiving a loop diuretic for treatment of heart failure. Which of these actions will be included in the plan of care? SELECT ALL THAT APPLY. A. Assess daily weights. B. Encourage consumption of citrus fruits. C. Weigh the client weekly. D. Monitor serum potassium. E. Discourage intake of spinach. F. Monitor for bradycardia.

A, B, D RATIONALE: Actions for the nurse to include when caring for a client taking a loop diuretic for heart failure include: assessing daily weights, encouraging consumption of citrus fruits, and monitoring the client's serum potassium. High-ceiling (loop) diuretics remove excess fluid and are potassium-depleting drugs. Consuming citrus fruit, green leafy vegetables, cantaloupe, tomato, and other food with potassium is indicated while receiving this type of diuretic to compensate for urinary loss of potassium.The client must be weighed at the same time each day, using the same scale and wearing approximately the same amount of clothes. Green leafy vegetables such as spinach contain potassium and are encouraged. The diuretic itself has no effect on the heart rate, however potassium depletion caused by the diuretic may cause cardiac irritability with a weak and thready pulse.

A client with diarrhea for 3 days and inability to eat or drink well is brought to the emergency department (ED) by her family. She states she has been taking her diuretics for congestive heart failure (CHF). What nursing actions are indicated at this time? SELECT ALL THAT APPLY. A. Place the client on bed rest. B. Evaluate the electrolyte levels. C. Administer the ordered diuretic. D. Assess for orthostatic hypotension E. Initiate cardiac monitoring.

A, B, D, E RATIONALE: Nursing actions indicated at this time include: placing the client on bedrest and assisting the client out of bed, evaluating electrolyte levels, assessing for orthostatic hypotension, and applying a cardiac monitor. Safety is required to prevent falls due to weakness from a likely fluid volume deficit and electrolyte imbalance. The nurse should review the laboratory and diagnostic results to detect likely loss of sodium, potassium, and magnesium secondary to diarrhea and diuretic us. Fluid volume deficit is likely with diarrhea and diuretic use and leads to fluid and electrolyte imbalances, especially hypokalemia. Assessing for orthostatic changes will confirm presence of volume deficit. Monitoring for inverted T wave or presence of U wave on the ECG as well as dysrhythmias is indicated when hypokalemia is anticipated.Diuretics increase loss of fluids and electrolytes. The nurse would question this order in the presence of assessment data indicating fluid loss from the diuretics and diarrhea.

A client is admitted to the hospital with dehydration secondary to influenza and vomiting. The provider orders an intravenous (IV) potassium replacement for potassium level of 2.7 mEq/L (2.7 mmol/L). Which of these best practice techniques does the nurse include when administering this medication? SELECT ALL THAT APPLY. A. Ensuring that the concentration is no greater than 1?9?mEq/10?9?mL of solution B. Use a vein in the hand for better flow C. Use an IV pump to deliver the medication D. Check IV access for blood return after the infusion E. Push the medication over 5 minutes

A, C RATIONALE: Best practice technique for administering IV potassium replacement is to ensure that the concentration is no greater than 1 mEq/10 mL of solution. A pump or controller device must be used to deliver the medication to prevent rapid infusion and complications of hyperkalemia, including cardiac arrest.Potassium must be infused via a large vein with a high volume of flow, avoiding the hand. The maximum recommended infusion rate of potassium is 5 to 10 mEq/hr. This rate is never to exceed 20 mEq/hr. Potassium would never be administered via IV push. Assess the IV access for placement and an adequate blood return before administering potassium-containing solutions.

The RN is assessing a 70-year-old client admitted to the unit with severe dehydration. Which finding requires immediate intervention by the nurse? A. Client behavior that changes from anxious to lethargic B. Deep furrows on the surface of the tongue C. Poor skin turgor with tenting remaining for 2 minutes after the skin is pinched D. Urine output of 950 mL for the past 24 hours

A. Client behavior that changes from anxious to lethargic RATIONALE: Immediate intervention by the nurse is required when a client's behavior changes from anxious to lethargic. This change in mental status suggests poor cerebral blood flow and fluid shifts within the brain cells. Immediate intervention is needed to prevent further cerebral dysfunction.Deep furrows on the surface of the tongue, poor skin turgor, and low urine output are all caused by the fluid volume deficit, but do not indicate complications of dehydration that are immediately life-threatening.

The nurse is caring for a client who takes furosemide (Lasix) and digoxin (Lanoxin). The client's potassium (K+) level is 2.5 mEq/L (2.5 mmol/L). Which additional assessment will the nurse make? A. Heart rate B. Blood pressure (BP) C. Increases in edema D. Sodium level

A. Heart rate RATIONALE: The nurse must assess the heart rate for bradycardia related to digoxin and irritability or irregularity related to hypokalemia. Hypokalemia increases the sensitivity of cardiac muscle to digoxin and may result in digoxin toxicity, even when the digoxin level is within the therapeutic range. The nurse also assesses for GI symptoms such as diarrhea, and other symptoms of toxicity to digoxin.The BP may decrease with low potassium level but monitoring the pulse is essential. The diuretic would reduce edema, therefore assessing the heart rate is the priority. High serum sodium levels would not be expected in this scenario unless fluid volume deficit is present.

A nurse is planning care for a client with hypokalemia. Which interventions should be included in the plan of care? Select all that apply. A. Ensure adequate fluid intake. B. Implement safety measures to prevent falls C. Encourage low fiber foods to prevent diarrhea. D. Instruct the client about foods that contain potassium. E. Encourage the client to obtain assistance to ambulate.

Answer: A,B, D, and E Rationale: Clients with hypokalemia will need instruction on potassium-rich foods, and all clients should maintain adequate hydration, Safety is also a priority because hypokalemia may cause muscle weakness, resulting in falls and injury. Hypokalemia is associated with constipation, not diarrhea, owing to decreased peristalsis.

*A nurse is assisting in the care of a group of clients on the nursing unit. When considering effects of each medical diagnosis, the nurse determines that which client has the least risk for developing third-spacing of fluid? A. Client with a major burn B. Client with an ischemic stroke C. Client with Laennec's cirrhosis D. Client with chronic kidney disease.

Answer: B Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third-spacing include the pleural and peritoneal cavities and pericardial sac. Risk factors include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal (GI) malabsorption, and malnutrition. The client who has suffered a stroke is not at risk for third-spacing.

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment data would indicate to the nurse that the dehydration remains unresolved? A. An oral temperature of 98.8 F B. A urine specific gravity of 1.043 C. A urine output that is pale yellow D. A blood pressure of 120/80 mmHg

Answer: B Rationale: The client who is dehydrated will have a urine specific gravity greater than 1.030. Normal values for urine specific gravity are 1.010 to 1.030. A temperature of 98.8° F is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as would the urine specific gravity. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range.

A client's kidneys are retaining increased amounts of sodium. The nurse plans care, anticipating that the kidneys also are retaining greater amounts of which substances? A. Calcium and Chloride B. Chloride and bicarbonate C. Potassium and Phosphates D. Aluminum and magnesium

Answer: B. Rationale: Sodium is a cation. With increased retention of sodium, the kidneys also increase reabsorption of chloride and bicarbonate, which are anions. Options 1 and 3 are incorrect because calcium and potassium are cations. The same is true for option 4.

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation? A. Sustained tissue damage B. Requires Nasogastric suction C. Has a history of Addison's disease D. Is taking a potassium-retaining diuretic

Answer: B. Rationale: The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium-rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium-retaining diuretic are at risk for hyperkalemia.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? A. Bradycardia B. Elevated blood pressure C. Changes in mental status D. Bilateral crackles in the lung

Answer: C Rationale: A client with dehydration is likely to be lethargic or complaining of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and an unrelated finding of dehydration.

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? A. Weight Loss B. Flat neck and Hand veins C. An increase in blood pressure D. Decreased central venous pressure (CVP)

Answer: C Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? A. Muscle twitches B. Decreased Urinary output C. Hyperactive bowel sounds D. Increased specific gravity of the urine

Answer: C Rationale: Hyponatremia is evidenced by a serum sodium level lower than 135 mEq/L. Hyperactive bowel sounds indicate hyponatremia. The remaining options are signs of hypernatremia. In hyponatremia, muscle weakness, increased urinary output, and decreased specific gravity of the urine would be noted.

A nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? A. Tetany B. Tremors C. Areflexia D. Muscular excitability

Answer: C Rationale: Signs of hypermagnesemia include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes (areflexia), respiratory paralysis, and loss of consciousness. Tetany, muscular excitability, and tremors are seen with hypomagnesemia.

A nurse is caring for a client whose magnesium level is 3.5 mg/dL. Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? A. Tetany B. Twitches C. Positive Trousseau's sign D. Loss of deep tendon reflexes

Answer: D Rationale: The normal magnesium level is 1.6 to 2.6 mg/dL. A client with a magnesium level of 3.5 mg/dL is experiencing hypermagnesemia. Assessment findings include neurological depression, drowsiness and lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, and hypotension. Tetany, twitches, and a positive Trousseau's sign are seen in a client with hypomagnesemia.

A registered nurse (RN) has instructed an unlicensed assistive personnel (UAP) to administer soap solution enemas until clear to a client. The UAP reports that three enemas have been administered and that the client is still passing brown liquid stool. What should the RN instruct the UAP to do? A. Administer a Fleet Enema B. Administer an oil retention enema C. Wait 30 minutes and then administer another enema D. Stop administering the enemas until the health care provider is notified

Answer: D Rationale: Up to three enemas may be given when there is a prescription for enemas until clear. If more than three are necessary, the nurse should call the HCP (or act according to agency policy). Excessive enemas could cause fluid and electrolyte depletion. Options 1 and 3 are incorrect for these reasons. An oil retention enema is an enema that is used to soften dry, hard stool and would have no use in this situation.

The nurse is teaching a client who is taking a potassium-sparing diuretic about precautions while taking this medication. Which of these does the nurse teach the client to avoid or use cautiously? SELECT ALL THAT APPLY. A. Apples B. Bananas C. ACE inhibitors D. Grapes E. Salt substitute

B, C, E RATIONALE: While taking a potassium-sparing diuretic, the nurse teaches the client to avoid bananas, ACE inhibitors, and salt substitutes. Other foods high in potassium include cantaloupe, kiwi, oranges, avocados, broccoli, dried beans, lima beans, mushrooms, potatoes, seaweed, soybeans, and spinach. Salt substitutes contain potassium and may predispose the client to hyperkalemia.Apples and grapes are considered lower potassium-containing foods.

C (Clients with long-standing hypocalcemia have brittle bones that may fracture easily. Safety needs are a priority. Having the client wear nonslip footwear to get out of bed can help prevent falls. The other interventions would not provide safety for this client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection Control—Accident/Injury Prevention) MSC: Integrated Process: Nursing Process (Assessment))

A client has a history of hypocalcemia. What intervention is most important for the nurse to add to this client's care plan? a. Push fluids to 2 L/day. b. Strain all urine output. c. Use nonslip footwear to get out of bed. d. Position the client supine twice a day.

A (Many salt substitutes are composed of potassium chloride. Heavy use can contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potassium. NSAIDs promote the retention of sodium but not potassium. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment))

A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia? a. Client with heart failure using a salt substitute b. Client taking a thiazide diuretic for hypertension c. Client taking nonsteroidal anti-inflammatory drugs daily d. Client with type 2 diabetes taking an oral antidiabetic agent

A nurse is caring for a client with a nasogastric tube (NGT) who has a prescription for NGT irrigation once every 8 hours. To maintain homeostasis, which solution should the nurse use to irrigate the NGT? A. Tap water B. Sterile Water C. 0.9% Sodium Chloride D. 0.45% Sodium Chloride

Answer: C Rationale: Homeostasis is maintained by irrigating with an isotonic solution, such as 0.9% sodium chloride. Tap water, sterile water, and sodium chloride are hypotonic solutions.

The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which client is most appropriate to assign to the LPN/LVN? A. A 44-year-old with congestive heart failure (CHF) who has gained 3 pounds (1.4 kg) since the previous day B. A 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L (6.0 mmol/L) C. A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) D. An 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest

C. A 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/kg (300 mmol/kg) RATIONALE: The most appropriate client for the nurse to assign to the LPV/LVN is the 76-year-old adult with poor skin turgor and a serum osmolarity of 300 mOsm/kg (300 mmol/kg). Although the 76-year-old client has poor skin turgor, the serum osmolarity indicates normal fluid balance. This client is the most stable of the four clients described.The 44-year-old with CHF who has gained 3 pounds (1.4 kg) since the previous day requires additional assessments and interventions which should be performed by an RN. The data about the 58-year-old client with CRF and a serum potassium level of 6 mEq/L (6.0 mmol/L) has a risk for dysrhythmia and instability. Assessments and interventions performed by an RN are also needed on this client. The data about the 80-year-old client with edema and congested lungs indicate that the client is not stable, requiring ongoing assessments and interventions by an RN.

After receiving change-of-shift report, which client does the RN assess first? A. A client with nausea and vomiting who complains of abdominal cramps B. A client with a nasogastric (NG) tube who has dry oral mucosa and is complaining of thirst C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg D. A client with normal saline infusing at 150 mL/hr whose hourly urine output has been averaging 75 mL

C. A client receiving intravenous (IV) diuretics whose blood pressure is 88/52 mm Hg RATIONALE: The nurse must first assess the client receiving IV diuretics whose blood pressure is 88/52 mm Hg. This client with hypotension may have developed hypoperfusion caused by hypovolemia. Immediate interventions are needed.The client with nausea and vomiting, the client with an NG tube complaining of thirst, and the client receiving normal saline with an hourly urine output of 75 mL/hr have problems which are not urgent at this time.

The nurse is assessing a client with a sodium level of 118 mEq/L (118 mmol/L). Which activity takes priority? A. Monitoring urine output B. Encouraging sodium rich fluids and foods throughout the day C. Instructing the client not to ambulate without assistance D. Assessing deep tendon reflexes

C. Instructing the client not to ambulate without assistance RATIONALE: Safety is the priority in this instance. Instructing the client not to ambulate without assistance is the priority for a client with a sodium level of 118 mEq/L (118 mmol/L). This sodium level denotes severe hyponatremia which makes depolarization slower and cell membranes less excitable. This is manifested as general muscle weakness which is worse in the legs and arms. Additionally, this client may have developed confusion from cerebral edema.Monitoring urine output needs to be done but is not the priority action in this situation. Generally, fluid is restricted, rather than sodium rich foods offered, to minimize the hyponatremia. While the nurse may assess muscle strength and deep tendon reflex responses, safety is the priority.

The step down unit receives a new admission who has uncontrolled diabetes, polyuria, and a blood pressure of 86/46 mm Hg. Which staff member is assigned to care for her? A. LPN/LVN who has floated from the hospital's long-term care unit B. LPN/LVN who frequently administers medications to multiple clients C. RN who has floated from the intensive care unit D. RN who usually works as a diabetes educator

C. RN who has floated from the intensive care unit RATIONALE: The RN who has floated from the intensive care unit needs to care for this clinically unstable woman with uncontrolled diabetes. The clinical manifestations suggest that the client is experiencing hypovolemia and possible hypovolemic shock from osmotic diuresis. The RN from the intensive care unit will have extensive experience caring for clients with hypovolemia, hyperglycemia, and fluid volume deficit/shock.The LPN/LVN who has floated from the long-term care unit or who frequently administers medications to multiple clients will not be as familiar with care for critically ill clients, or qualified to care for this clinically unstable client. Although the resource on diabetes is helpful, the RN who works as a diabetes educator will not be as familiar with care for acutely or critically ill clients.

The nurse is caring for a group of clients with electrolytes and blood chemistry abnormalities. Which client will the nurse see first? A. The client with a random glucose reading of 123 mg/dL (6.8 mmol/L) B. The client who has a magnesium level of 2.1 mEq/L (1.0 mmol/L) C. The client whose potassium is 6.2 mEq/L (6.2 mmol/L) D. The client with a sodium level of 143 mEq/L (143 mmol/L)

C. The client whose potassium is 6.2 mEq/L (6.2 mmol/L) RATIONALE: The first client the nurse sees with electrolyte and blood chemistry abnormalities is the client whose potassium is 6.2 mEq/L (6.2 mmol/L). A potassium value of 6.2 mEq/L (6.2 mmol/L) is elevated and the client has potential for cardiac dysrhythmias.A random or casual glucose, taken at any time of day, is elevated if ≥200mg/dL(>11.1mmol/L); a random value of 123 mg/dL (6.9 mmol/L) does not require intervention. The other clients with a magnesium value of 2.1 mEq/L (1.0 mmol/L) and a sodium value of 143 mEq/L (143 mmol/L) demonstrate normal laboratory values and do not require intervention.

The nurse is preparing a client a diagnosis of congestive heart failure (CHF) for discharge. Which statement by the client indicates a correct understanding of self-management of CHF? A. "I can gain 2 pounds (1 kg) of water a day without risk." B. "I should call my provider if I gain more than 1 pound (0.5 kg) a week." C. "Weighing myself daily can determine if my caloric intake is adequate." D. "Weighing myself daily can reveal increased fluid retention."

D. "Weighing myself daily can reveal increased fluid retention." RATIONALE: The client with CHF should weigh himself daily to observe for increasing fluid retention, which may not be visible. Rapid weight gain is the best indicator of fluid retention and overload. Each pound (0.5 kg) of weight gained (after the first half-pound [0.2 kg]) equates to 500 mL of retained water. The client must be weighed at the same time every day (before breakfast), and on the same scale.The client would call the primary care provider if more than 1 or 2 pounds (0.5 or 1 kg) are gained in a 24-hour period or if more than 3 pounds (1.4 kg) are gained in 1 week. Daily weights are not an indication of effective dieting for purposes of weight loss or gain. They will show fluid retention after an especially high sodium intake (in a client with fluid retention problems), but caloric intake is related to food intake rather than fluid retention problems.

C (Neck veins in the normovolemic person are full in the supine position and flat in the sitting position. Full neck veins in the sitting position are an indicator of overhydration. Checking the pulse and blood pressure can help determine whether overhydration is present. Urine specific gravity is not as important a measure of volume status and deep tendon reflexes and does not give information on volume status at all. The nurse needs to document the finding, but interventions should not end there. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment))

The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority? a. Document the observation in the chart. b. Measure urine specific gravity and volume. c. Assess the pulse and blood pressure. d. Assess the client's deep tendon reflexes.

C (Most prepackaged foods have high sodium content. Teaching the client how to read labels and calculate the sodium content of food can help him or her adhere to the prescribed sodium restriction and can prevent hypernatremia. Daily self-weighing and checking the pulse are methods of identifying manifestations of hypernatremia, but they do not prevent it. The addition of substances during cooking increases the sodium content of a meal, not the method of cooking. DIF: Cognitive Level: Comprehension/Understanding REF: p. 183 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning))

The nurse is providing discharge teaching for a client who is at risk for mild hypernatremia. What action is most important for the nurse to teach the client? 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."

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. Next, the nurse would call the health care provider to obtain orders for potassium replacement. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation))

The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority? 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.

B (Decreased handgrip strength indicates worsening of hypophosphatemia and general muscle weakness. Muscle weakness can impair respiratory effort and reduce gas exchange to the point that the client becomes hypoxemic. IV phosphorus is given slowly to avoid rebound hyperphosphatemia. Phosphorus and calcium exist in an inverse relationship, and the nurse might want to know the calcium level, but this is less important than ensuring that the client has adequate respiratory function. Simply documenting the finding without intervening would not help the client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Evaluation))

The nurse observes that the handgrip of the client with hypophosphatemia has diminished in strength since the last assessment 2 hours ago. What is the nurse's primary intervention? a. Document the finding and continue to assess. b. Assess respiratory status immediately. c. Request an order for a serum calcium level. d. Administer a rapid bolus of intravenous phosphorus.

C (Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Obtaining and charting accurate daily weights is the most sensitive and cost-effective way of monitoring fluid balance in the home. The other options would not be useful for early detection of dehydration. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Implementation))

What intervention is most important to teach the client about identifying the onset of dehydration? a. Measuring abdominal girth b. Converting ounces to milliliters c. Obtaining and charting daily weight d. Selecting food items with high water content

C (Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation. DIF: Cognitive Level: Comprehension/Understanding REF: p. 174 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning)

Which action does the nurse teach a client to reduce the risk for dehydration? a. Restricting sodium intake to no greater than 4 g/day b. Maintaining an oral intake of at least 1500 mL/day c. Maintaining a daily oral intake approximately equal to daily fluid loss d. Avoiding the use of glycerin suppositories to manage constipation

B (This client has hypercalcemia. Both forcing fluids and providing cardiac monitoring are appropriate, but because calcium has significant cardiac effects, placing the client on a cardiac monitor takes priority. Assessing for Chvostek's sign and administering calcium would be appropriate for the client with hypocalcemia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of Care—Establishing Priorities) MSC: Integrated Process: Nursing Process (Implementation))

A client has a calcium level of 14 mg/dL. Which intervention is the priority? a. Forcing fluids to 2 L/day b. Placing the client on a cardiac monitor c. Assessing for Chvostek's sign every 2 hours d. Administering IV calcium chloride

A (D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Parenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Assessment))

A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia? a. Client who is NPO receiving intravenous D5W b. Client taking a sulfonamide antibiotic c. Client taking ibuprofen (Motrin) d. Client taking digoxin (Lanoxin)

*The nurse aspirates 40 mL of undigested formula from the client's nasogastric (NG) tube. Before administering an intermittent tube feeding, what should the nurse do with the 40 mL of gastric aspirate? A. Pour into the NG tube through a syringe with the plunger removed B. Dilute with water and inject into the NG tube by putting pressure on the plunger C. Discard properly and record as output on the client's intake and output record. D. Mix with the formula and pour into the NG tube through a syringe with the plunger removed.

Answer: A Rationale: After checking residual feeding contents, the gastric contents should be reinstilled to maintain the client's electrolyte balance. The gastric contents should be poured into the NG tube through a syringe without a plunger and not injected by pushing on the plunger. Gastric contents are not mixed with formula or diluted with water, and should not be discarded.

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? A. Hypotension B. Increased heart rate C. Bounding peripheral pulses D. Shortened QT interval on electrocardiography (ECG)

Answer: A Rationale: Cardiovascular manifestations that occur with hypocalcemia include decreased heart rate, diminished peripheral pulses, and hypotension. On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.

C (It is just as important to determine the types of fluids ingested as the amount, because fluids vary widely in their osmolarity. In addition, some liquids, such as those that contain alcohol or caffeine, can contribute to fluid and electrolyte imbalances. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment))

During assessment of hydration status, the client tells the nurse that she usually drinks 3 quarts of liquids each day. Which question by the nurse is best? a. "Do you usually drink liquids that are hot or cold?" b. "How much salt do you add to your food?" c. "What kinds of liquids do you usually drink?" d. "Do you drink fluids with meals or between meals?

A (Misuse or overuse of diuretics is a common cause of isotonic dehydration. The other statements are not indicative of causes of isotonic dehydration. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Assessment))

Which question does the nurse ask the client who has isotonic dehydration to determine a possible cause? a. "Do you take diuretics, or 'water pills'?" b. "What do you normally eat over a day's time?" c. "How many bowel movements do you have daily?" d. "Have you been diagnosed with diabetes mellitus?"

The nurse is assessing fluid balance in the client with heart failure. Which of these strategies will the nurse employ? A. Ask the client how much fluid was consumed yesterday. B. Place an indwelling catheter to measure urine output. C. Auscultate the lungs for adventitious sounds. D. Weigh the client daily, at the same time.

D. Weigh the client daily, at the same time. When assessing fluid balance on a client with heart failure the nurse must weigh the client at the same time every day. Changes in daily weights are the best indicators of fluid losses or gains. A weight change of 1 pound (0.5 kg) corresponds to a fluid volume change of about 500 mL therefore the weight must be compared to intake and output.The nurse must weigh the client rather than rely on client estimate or memory. An indwelling catheter poses a risk for catheter associated urinary tract infection, and is reserved for specific reasons. Auscultating for adventitious lung sounds or crackles will demonstrate fluid overload, but may not immediately show up.

D (The parathyroid glands secrete parathyroid hormone. The actions of parathyroid hormone include increasing intestinal absorption of calcium, decreasing renal excretion of calcium, and increasing calcium resorption from the bones. All these actions increase the serum calcium level. DIF: Cognitive Level: Comprehension/Understanding REF: Table 13-10, p. 190 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications From Surgical Procedures and Health Alterations) MSC: Integrated Process: Nursing Process (Assessment))

Which client is at greatest risk for developing hypercalcemia? a. Client taking furosemide (Lasix) for heart failure b. Client with long-standing osteoarthritis c. Woman who is pregnant with twins d. Client with hyperparathyroidism

A (The blood osmolarity is low. The client could be dehydrated (hypo-osmolar dehydration) or overhydrated with dilution of blood solute. The most sensitive noninvasive indicator of circulation adequacy is urine output. Measuring abdominal girth, comparing pulses, and monitoring fluid intake would not be accurate assessment techniques for this client. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment))

Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L? a. Measuring urine output b. Measuring abdominal girth c. Monitoring fluid intake d. Comparing radial versus apical pulses

D (A change in ring size over a relatively short period of time may indicate a change in body fluid amount or distribution rather than a change in body fat. The other statements are not indicators of a fluid or electrolyte imbalance. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment))

Which assessment finding obtained while taking the history of an older adult client alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance? a. "I am often cold and need to wear a sweater." b. "I seem to urinate more when I drink coffee." c. "In the summer, I feel thirsty more often." d. "My rings seem to be tighter this week."

D (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. DIF: Cognitive Level: Comprehension/Understanding REF: p. 174 TOP: Client Needs Category: Physiological Integrity (Basic Care and Comfort—Nutrition and Oral Hydration) MSC: Integrated Process: Nursing Process (Assessment))

Which client is at greatest risk for dehydration? a. Younger adult client on bedrest b. Older adult client receiving hypotonic IV fluid c. Younger adult client receiving hypertonic IV fluid d. Older adult client with cognitive impairment

C (Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms, and tetany. Flexion contractions that occur during blood pressure measurement are indicative of hypocalcemia and are referred to as a positive Trousseau's sign. Client safety is a priority, and the nurse must ensure that the client has a working intravenous line. Seizure precautions and decreasing environmental stimuli are also important. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation))

When taking the blood pressure of a very ill client, the nurse observes that the client's hand undergoes flexion contractions. Which intervention is most appropriate? a. Administer isotonic intravenous fluids. b. Remove the blood pressure cuff and give oxygen. c. Ensure the client has a patent intravenous line. d. Document the finding in the client's chart.

A (Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Analysis))

A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition? a. 2.9 mEq/L b. 3.8 mEq/L c. 5.0 mEq/L d. 6.0 mEq/L

The rapid response team (RRT) is called to the bedside of a client with heart rate of 38 beats per minute and a potassium level of 7.0 mEq/L (7.0 mmol/L). For which medication will the nurse anticipate a prescription? A. Insulin B. atropine C. Sodium polystyrene sulfonate (Kayexalate) D. potassium phosphate

A. Insulin RATIONALE: The rapid response nurse expects to administer a combination of 20 units of regular insulin in 100 mL of 20% dextrose in water. This may be prescribed to promote movement of potassium from the blood into the intracellular fluid.While atropine will treat bradycardia, it does not address the underlying cause of bradycardia which is likely hyperkalemia. Sodium polystyrene sulfonate (Kayexalate)may be used for hyperkalemia, but it will not act quickly enough in an emergency. Additional potassium such as contained in potassium phosphate will make the client's condition more critical.

The nurse is reading a health care provider's (HCP) progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800 mL daily." The nurse interprets that this type of fluid loss can occur through which route? A. The Skin B. Urinary Output C. Wound Drainage D. The gastrointestinal tract

Answer: A Rationale: Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs. Sensible losses are those of which the person is aware, such as through urination, wound drainage, and gastrointestinal tract losses.

The nurse caring for a client with heart failure is notified by the hospital laboratory that the client's serum magnesium level is 1.3 mg/dL. Which would be the most appropriate nursing action for this client? A. Monitor the client for dysrhythmias B. Encourage increased intake of phosphate antacids C. Discontinue any magnesium-contain medications. D. Encourage intake of foods such as ground beef, eggs, or chicken breast.

Answer: A Rationale: The normal serum magnesium level is 1.6 to 2.6 mg/dL. Cardiac monitoring is indicated because this client is at risk for ventricular dysrhythmias. Phosphate use should be limited in the presence of hypomagnesemia because it worsens the condition. It is not necessary to discontinue magnesium products. Ground beef, eggs, and chicken breast are low in magnesium.

*Which client is least likely to be at risk for the development of third spacing? A. The client with cirrhosis B. The client with liver failure C. The client with diabetes mellitus D. The client with chronic kidney disease

Answer: C Rationale: Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. Common sites for third spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors for third spacing include clients with liver or kidney disease, major trauma, burns, sepsis, wound healing or major surgery, malignancy, gastrointestinal malabsorption, malnutrition, and alcoholic or older adult clients.

Which client is most appropriate for the nurse manager of the medical-surgical unit to assign to the LPN/LVN? A. A client admitted with dehydration who has a heart rate of 126 beats/min B. A client just admitted with hyperkalemia who takes a potassium-sparing diuretic at home C. A client admitted yesterday with heart failure with dependent pedal edema D. A client who has just been admitted with severe nausea, vomiting, and diarrhea

C. A client admitted yesterday with heart failure with dependent pedal edema The most appropriate client to assign to the LPN/LVN is the 64-year-old client admitted yesterday with heart failure and dependent pedal edema. This client is the most stable of all the four clients.Dehydration, tachycardia, potassium overload, and GI signs and symptoms in a client indicate that he or she is unstable. Care must be given by the RN who can carry out assessments, prescriptions, and participate interdisciplinary collaboration as needed.

Furosemide (Lasix) has been ordered for a client with heart failure, shortness of breath, and 3+ pitting edema of the lower extremities. Which assessment finding indicates to the nurse that the medication has been effective? A. The client's potassium level is 5.1 mEq/L (5.1 mmol/L). B. The client's heart rate is 101 beats per minute. C. The client is free from adventitious breath sounds. D. The client has experienced a weight gain of 1 pound (0.5 kg).

C. The client is free from adventitious breath sounds. RATIONALE: The nurse recognizes that Furosemide is effective when the client is free from adventitious breath sounds such as crackles. Other positive outcomes to the diuretic include normal heart rate, weight loss with resolution of edema, and increased urine output.A potassium value of 5.1 mEq/L or (5.1 mmol/L) is normal. Changes in potassium levels such as hypokalemia are side effects of furosemide, not therapeutic effects. Although a fall in the client's BP may occur with the decrease in body fluid, this is not the priority. Tachycardia may occur during episodes of fluid volume excess or deficit and does not directly indicate the medication has been effective. Weight loss, rather than weight gain, is often the effect of Furosemide, caused by the diuresis.

The nurse is caring for an older adult with hypernatremia. Which of these interventions does the nurse perform first? A. Restrict the client's intake of sodium B. Administer a diuretic C. Monitor the serum osmolarity D. Encourage fluid intake

D. Encourage fluid intake RATIONALE: When caring for an older adult with hypernatremia, the nurse first encourages the client to take more fluid. Encouraging fluids in the older adult is important to prevent dehydration with resulting concentrated sodium levels.Hypernatremia and fluid loss typically occur in tandem in the older adult. Restricting sodium does not replace fluids needed by many elderly clients. A diuretic will worsen the fluid volume deficit the client is experiencing. Monitoring the osmolarity will detect an abnormality, but not resolve the problem.

The nurse is caring for a group of clients on a medical surgical unit. Which newly written prescription will the nurse administer first? A. Intravenous normal saline to a client with a serum sodium of 132 mEq/L (132 mmol/L) B. Oral calcium supplements to a client with severe osteoporosis C. Oral phosphorus supplements to a client with acute hypophosphatemia D. Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L)

D. Oral potassium chloride to a client whose serum potassium is 3 mEq/L (3 mmol/L) RATIONALE: The nurse must first administer oral potassium supplements to the client with hypokalemia. Even minor changes in serum potassium levels can cause life-threatening dysrhythmias.The electrolyte disturbances (sodium level of 132 and low phosphorus level) and the need for calcium in the other clients are not immediately life-threatening.

D (Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Parenteral/Intravenous Therapies) MSC: Integrated Process: Nursing Process (Implementation))

The client is receiving an intravenous infusion of 60 mEq of potassium chloride in a 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first? a. Notify the physician. b. Assess for a blood return. c. Document the finding. d. Stop the IV infusion.

C (Skin turgor cannot be accurately assessed on an older adult client's hands because of age-related loss of tissue elasticity in this area. Areas that more accurately show skin turgor status on an older client include the skin of the forehead, chest, and abdomen. These should also be assessed, rather than merely examining dependent body areas. Further assessment is needed rather than only documenting, monitoring, and notifying the physician. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) MSC: Integrated Process: Nursing Process (Assessment))

The nurse observes skin tenting on the back of the older adult client's hand. Which action by the nurse is most appropriate? a. Notify the physician. b. Examine dependent body areas. c. Assess turgor on the client's forehead. d. Document the finding and continue to monitor.

The RN is caring for a client who is severely dehydrated. Which nursing action can be delegated to the unlicensed assistive personnel (UAP)? A. Consulting with a health care provider about a client's laboratory results B. Infusing 500 mL of normal saline over 60 minutes C. Monitoring IV fluid to maintain the drip rate at 75 mL/hr D. Providing oral care every 1 to 2 hours

D. Providing oral care every 1 to 2 hours RATIONALE: Appropriate intervention by an UAP to a client who is severely dehydrated is to provide oral care every 1 to 2 hours. Frequent oral care is important for a client with fluid volume deficit.Consulting with a primary care provider about a client's laboratory results, infusing 500 mL of normal saline, and monitoring IV fluids are complex actions and would be performed by licensed personnel.

B (The intestinal tract is relatively sensitive to decreasing potassium levels. Common manifestations of hypokalemia are decreased peristalsis and constipation. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Nursing Process (Evaluation))

Which client statement indicates the need for more teaching regarding identification of the early manifestations of hypokalemia? a. "I have been weighing myself every day." b. "When I am constipated, I drink more fluids." c. "When my muscles feel weak, I eat a banana." d. "I check my pulse each morning and each night."

B, C, E (Lactose intolerance can lead to hypocalcemia because people avoid milk and dairy products to control their symptoms. Although anyone can have lactose intolerance, the incidence is between 75% and 90% among Asians, blacks, and American Indians. DIF: Cognitive Level: Comprehension/Understanding REF: Cultural Awareness Box, p. 188 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment))

Which ethnic groups should the nurse screen specifically for hypocalcemia? (Select all that apply.) a. Whites b. Blacks c. Asians d. Hispanics e. American Indians

C (Orthostatic or postural hypotension can be caused by or worsened by dehydration. The other statements are not as indicative of the severe degree of dehydration as dizziness on standing. DIF: Cognitive Level: Comprehension/Understanding REF: p. 175 TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology) MSC: Integrated Process: Nursing Process (Assessment))

Which item of assessment data obtained by the home care nurse suggests that an older adult client may be dehydrated? a. The client has dry, scaly skin on bilateral upper and lower extremities. b. The client states that he gets up three or more times during the night to urinate. c. The client states that he feels lightheaded when he gets out of bed or stands up. d. The nurse observes tenting on the back of the hand when testing skin turgor.

C (Restricting fluids without a medical reason can lead to dehydration. Many older clients believe that restricting fluids will prevent incontinence and reduce the number of times that they wake up during the night. The increased osmolarity of the urine in response to reducing fluid intake increases irritation of the bladder and sphincter, increasing the sensation of needing to urinate. The other statements do not indicate practices that could potentially lead to dehydration. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Alterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment))

Which statement made by the older adult client alerts the nurse to assess specifically for fluid and electrolyte imbalances? a. "My skin is always so dry, especially here in the Southwest." b. "I often use a glycerin suppository for constipation." c. "I don't drink liquids after 5 PM so I don't have to get up at night." d. "In addition to coffee, I drink at least one glass of water with each meal."

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? Select all that apply. A. Dehydration B. HTN C. Physiological stress D. Decreased blood volume E. Decreased plasma osmolarity

Answer: A, C, and D Rationale: Antidiuretic hormone, or vasopressin, is produced in the brain and stored in the posterior pituitary gland. Its release from the posterior pituitary gland is controlled by the hypothalamus in response to changes in blood osmolarity. Stimuli for ADH release are increased plasma osmolality, decreased blood volume, hypotension, pain, dehydration from nausea, vomiting, or diarrhea, and stress.

The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A. Assessing oral mucosa for dryness B. Choosing appropriate oral fluids C. Monitoring skin turgor for tenting D. Offering fluids to drink every hour

D. Offering fluids to drink every hour RATIONALE: Offering oral fluids every hour is within the scope of practice for a UAP.Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor would be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.

The nurse manager of a medical-surgical unit is completing assignments for the day shift staff. The client with which electrolyte laboratory value is assigned to the LPN/LVN? A. Calcium level of 9.5 mg/dL (2.4 mmol/L) B. Magnesium level of 4.1 mEq/L (2.1 mmol/L) C. Potassium level of 6.0 mEq/L (6.0 mmol/L) D. Sodium level of 120 mEq/L (120 mmol/L)

A. Calcium level of 9.5 mg/dL (2.4 mmol/L) RATIONALE: The client with a calcium level of 9.5 mg/dL (2.4 mmol/L), a normal value, would be assigned to the LPN/LVN.A magnesium level of 4.1 mEq/L (2.1 mmol/L) (normal is 1.8-2.6 mEq/L [0.74-1.07 mmol/L]) and potassium level of 6.0 mEq/L (6.0 mmol/L) pose risk for dysrhythmia, and a sodium level of 120 mEq/L (120 mmol/L) may cause serious cerebral dysfunction requiring assessments and/or interventions by the RN.

The primary care provider writes prescriptions for a client who is admitted with a serum potassium level of 6.9 mEq/L (6.9 mmol/L). What does the nurse implement first? A. Administer sodium polystyrene sulfonate (Kayexalate) orally. B. Ensure that a potassium-restricted diet is ordered. C. Place the client on a cardiac monitor. D. Teach the client about foods that are high in potassium.

C. Place the client on a cardiac monitor. RATIONALE: The nurse must first place this client on a monitor. Because hyperkalemia can lead to life-threatening bradycardia, placing the client on a cardiac monitor permits early intervention in the event of dysrhythmias.Administering a potassium-reducing medication, recommending a potassium-restricted diet, and teaching the client about diet are appropriate but will not immediately decrease the serum potassium level and do not need to be implemented as quickly as monitoring cardiac rhythm.

A client with hypermagnesemia is seen in the emergency department (ED). Which of these interventions is most appropriate? A. Monitor for hyperactive reflexes B. prepare for endotracheal intubation C. Institute teaching on avoiding magnesium rich foods D. Place the client on a cardiac monitor

D. Place the client on a cardiac monitor RATIONALE: Hypermagnesemia causes changes in cardiac rhythm and may result in cardiac arrest, therefore instituting cardiac monitoring is most appropriate.Reflexes are typically reduced in the presence of hypermagnesemia. There is no indication that the client has signs and symptoms of respiratory distress at this time, however the nurse would monitor the client for respiratory weakness and respiratory failure. The nurse will institute teaching after the emergency passes and the cause of the magnesium excess is determined.

B (Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the client's risk for excessive water loss and increased potassium reabsorption. The client would not be at risk for overhydration or sodium imbalance. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral Therapies—Adverse Effects/Contraindications/Side Effects/Interactions) MSC: Integrated Process: Nursing Process (Assessment))

The client is taking a medication that inhibits aldosterone secretion and release. The nurse assesses for what potential complication? a. Fluid retention b. Hyperkalemia c. Hyponatremia d. Hypervolemia

C (Eggs contain few cells and have one of the lowest potassium contents among high-protein foods. Meat and fish have cells that contain large amounts of potassium. Dairy products are also high in potassium. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning)

A client is on a potassium-restricted diet. Which protein choice by the client indicates a good understanding of the dietary regimen? a. 1% or 2% milk b. Grilled salmon c. Poached eggs d. Baked chicken

C (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. DIF: Cognitive Level: Comprehension/Understanding REF: Chart 13-8, p. 188 TOP: Client Needs Category: Health Promotion and Maintenance (Self-Care) MSC: Integrated Process: Teaching/Learning)

A client at risk for continuing hyperkalemia states that she is upset because she cannot eat fruit every day. Which response by the nurse is best? a. "You are correct. Fruit is usually very high in potassium." b. "If you cook the fruit first, that lowers the potassium." c. "Berries, cherries, apples, and peaches are low in potassium." d. "Fresh fruit is higher in potassium than dried fruit."

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? A. Dehydration B. Hypokalemia C. Fluid Overload D. Hypernatremia

Answer: A Rationale: When a client is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the client stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist, are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

A client is brought to the emergency department for increasing weakness and muscle twitching. The laboratory results include a potassium level of 7.0 mEq/L (7.0 mmol/L). Which assessments does the nurse make? SELECT ALL THAT APPLY. A. History of liver disease B. Use of salt substitute C. Use of an ACE inhibitor D. Potassium-sparing diuretics E. Prescription for insulin

B, C, D, RATIONALE: When caring for an ED client with an elevated potassium level, the nurse needs to assess the client for any use of salt substitutes, any use of ACE inhibitors or potassium-sparing diuretics, as well as kidney disease.History of liver disease does not increase the client's potassium level. Insulin, which moves potassium into the cell, can be used as a treatment for hyperkalemia, in addition to diabetes. Taking insulin would lower the potassium level.

The nurse is caring for a client receiving lactated Ringer's solution IV for rehydration. Which assessments will the nurse monitor during intravenous therapy? SELECT ALL THAT APPLY A. Blood serum glucose B. Blood pressure C. Pulse rate and quality D. Urinary output E. Urine specific gravity

B, C, D, E RATIONALE: The two most important areas to monitor during rehydration are pulse rate and quality and urine output. In addition, decreasing specific gravity of urine is also an indication of rehydration. Blood pressure is another important vital sign to monitor during rehydration.Blood glucose changes do not have a direct relation to a client's hydration status; lactated ringers are free from glucose.

The nurse is caring for a client who is receiving intravenous (IV) magnesium sulfate. Which assessment parameter is critical? A. Monitoring 24-hour urine output B. Asking the client about feeling depressed C. Assessing the blood pressure hourly D. Monitoring the serum calcium levels

C. Assessing the blood pressure hourly RATIONALE: Assessing hourly blood pressures is critical when caring for a client receiving IV magnesium sulfate. Hypotension is a sign/symptom of hypermagnesemia during magnesium infusion.Most clients who have fluid and electrolyte problems will be monitored for intake and output, and will not immediately indicate problems with magnesium overdose. Low magnesium levels can cause psychological depression, but assessing this parameter as the levels are restored would not safely assess a safe dose or an overdose. Although administration of magnesium sulfate can cause a drop in calcium levels, this occurs over a period of time and would not be the best way to assess magnesium toxicity.

B (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 optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological Adaptation—Illness Management) MSC: Integrated Process: Nursing Process (Implementation))

Which intervention in a client with dehydration-induced confusion is most likely to relieve the confusion? a. Measuring intake and output every four hours b. Applying oxygen by mask or nasal cannula c. Increasing the IV flow rate to 250 mL/hr d. Placing the client in a high Fowler's position