Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances

Chapter 11: Assessment and Care of Patients with Fluid and Electrolyte Imbalances

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?
   1. A 36-year-old who is prescribed long-term steroid therapy
   2. A 55-year-old receiving hypertonic intravenous fluids
   3. A 76-year-old who is cognitively impaired
   4. 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.

DIF:     Understanding/Comprehension         REF: 156                    KEY: Hydration MSC:             Integrated Process: Nursing Process: Assessment                 NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort

2. A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
   1. Measure intake and output every 4 hours.
   2. Apply oxygen by mask or nasal cannula.
   3. Increase the IV flow rate to 250 mL/hr.
   4. 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 if 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.

DIF:     Applying/Application                         REF: 156                    KEY: Hydration MSC:             Integrated Process: Nursing Process: Implementation           NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

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?
   1. “I must drink a quart of water or other liquid each day.”
   2. “I will weigh myself each morning before I eat or drink.”
   3. “I will use a salt substitute when making and eating my meals.”
   4. “I will not drink liquids after 6 PM so I won’t have to get up at night.”

ANS:           B

One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.

DIF:            Analyzing/Analysis                            REF:    156                  KEY: Hydration MSC: Integrated Process: Teaching/Learning                                               NOT:              Client Needs Category: Health Promotion and Maintenance

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?
   1. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
   2. Daily weight increase from 55 kg to 57 kg
   3. Heart rate decrease from 100 beats/min to 82 beats/min
   4. 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.

DIF:            Applying/Application                         REF:    166                   KEY: Hydration| angiotensin-converting enzyme (ACE) inhibitor                       MSC: Integrated Process: Nursing Process: Evaluation                      NOT:                                                 Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

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?
   1. Client taking furosemide (Lasix)
   2. Anxious client who has tachypnea
   3. Client who is on fluid restrictions
   4. Client who is constipated with abdominal pain

ANS:           B

Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.

DIF:            Applying/Application                         REF:    153                  KEY: Hydration MSC:                     Integrated Process: Nursing Process: Assessment                 NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation