A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. which client is at greatest risk for dehydration
A 76 year old who is cognitively impaired
A nurse is caring for an older client who exhibits dehydration induced confusion which intervention by the nurse is best
Assess client further for fall risk
After teaching a client who is being treated for dehydration a nurse assesses the clients understanding which statement indicates that the client correctly understood the teaching
I will weigh myself each morning before I eat or drink
A nurse is assessing clients on the medical- surgical unit which adult client does the nurse identify as being at greatest risk for insensible water loss
Anxious client who has tachypnea
A nurse is evaluating a client who is being treated for dehydration which assessment result does the nurse correlate with a therapeutic response to the treatment plan
Decreased orthostatic changes when standing
After teaching a client who is prescribed a restricted sodium diet a nurse assesses the clients understanding which food choice foe lunch indicates that the client correctly understood the teaching
Grilled chicken breast with glazed carrots
A nurse is assessing clients for fluid and electrolyte imbalances which client will the nurse assess first for potential hyponatremia
A 34 year old who is NPO and receiving rapid intravenous D5W infusions
A nurse teaches a client who is at risk for hyponatremia which statement does the nurse include in this clients teaching
Call your primary healthcare provider for diarrhea
A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L(2.4 mmol/L) magnesium 1.8 mEq/L(0.74 mmol/L) calcium 8.5mEq/L(2.13 mmol/L)and sodium 144mEq/L(144 mmol/L)which assessment does the nurse complete first
Depth of respirations
A nurse cares for a client who has a serum potassium 6.5 mEq/L(6.5 mmol/L) and is exhibiting cardiovascular changes which intervention will the nurse implement first
Prepare to administer dextrose 20% and 10 units of regular insulin IV push
The nurse is caring for a client who has fluid overload what actions by the nurse takes priority
Assess the clients lung sounds every 2 hours
A nurse is assessing a client with hypokalemia and notes that the clients handgrip strength has diminished since the previous assessment 1 hour ago what action does the nurse take first
Assess the clients respiratory rate rhythm and depth
A new nurse is preparing to administer IV potassium to a client with hypokalemia what action indicates the nurse needs to review this procedure
Sets the IV pump to deliver 30 mEq of potassium an hour
A nurse is caring for a client with hypocalcemia which action by the nurse shows poor understanding of this condition
Administer bisphosphonates as prescribed
A nurse is caring for a client who has a serum calcium level of 14 mg/dL(3.5 mmol/L) which primary health care provider does the nurse implement first
Connect the client to a cardiac monitor
A nurse is caring for an older adult client is admitted with moderate dehydration which intervention will the nurse implement to prevent injury while in the hospital
Dangle the client on the bedside before ambulating
A nurse assesses a client who is admitted for treatment of fluid overload which signs and symptoms does the nurse expect to find (SATA)
Increased pulse rate
DIstended neck veins
Skeletal muscle weakness
visual disturbances
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release for which potential complications will the nurse assess(SATA)
Serum potassium level of 5.4 mEq/L
Blood osmolality of 250 m0sm/kg
A nurse is assessing a client who has an electrolyte imbalance related to renal failure for which potential complications of this electrolyte imbalance related to renal failure for which potential complications of this electrolyte imbalance does the nurse assess(SATA)
Reports of palpitations
Skeletal muscle weakness
Tall peaked T waves on ECG
A nurse is caring for a client with electrolyte imbalances on medical surgical unit which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance(SATA)
Hypokalemia - muscle weakness with respiratory depression
Hypermagnesium - bradycardia and hypotension
Hyponatremia- decreased level of consciousness
Hypomagnesium- hyperactive deep tendon reflexes
Hypernatremia- weak peripheral pulses
After administering potassium chloride a nurse evaluates the clients response which signs and symptoms indicate that treatment is improving the clients hypokalemia (SATA)
Strong productive cough
Active bowel sounds
A nurse develops a plan of care for an older client who as a fluid overload what interventions will the nurse include in the clients care plan
Calculate pulse pressure with each blood pressure reading
Assess for pitting edema in dependent body areas
Monitor trends in clients daily weight
Assist the client to change positions frequently
Teach client and family how to read food labels for sodium
A nurse is caring for clients with electrolyte imbalances on a medical surgical unit which common causes are correctly paired with corresponding electrolyte imbalance(SATA)
Hyperkalemia - salt substitutes
Hyponatremia- heart failure
Hypernatremia- hyperaldosteronism
Hypocalcemia- diarrhea
Hypokalemia- loop diuretics
A nurse is caring for several clients at risk for fluid imbalances which laboratory results are paired with the correct potential imbalance(SATA)
Potassium 5.4mEq/L dehydration
Osmolarity 250 : overhydration
Hematocrit 68% dehydration
Magnesium 0.8 dehydration