Fluids and Electrolytes

A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best?

• Measure intake and output every 4 hours.

• Assess client further for fall risk.

• Increase the IV flow rate to 250 mL/hr.

• Place the client in a high-Fowler position.

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?

• Increased respiratory rate from 12 to 22 breaths/min

• Decreased skin turgor on the client’s posterior hand and forehead

• Increased urine specific gravity from 1.012 to 1.030 g/mL

• Decreased orthostatic changes when standing

A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client’s teaching?

• “Have you spouse watch you for irritability and anxiety.”

• “Notify the clinic if you notice muscle twitching.”

• “Call your primary health care provider for diarrhea.”

• “Bake or grill your meat rather than frying it.”

The nurse is caring for a client who has fluid overload. What action by the nurse takes priority?

• Administer high-ceiling (loop) diuretics.

• Assess the client’s lung sounds every 2 hours.

• Place a pressure-relieving overlay on the mattress.

• Weigh the client daily at the same time on the same scale.

A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?

• Notifies the pharmacy of the IV potassium order.

• Assesses the client’s IV site every hour during infusion.

• Sets the IV pump to deliver 30 mEq of potassium an hour.

• Double-checks the IV bag against the order with the precepting nurse.

A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms would the nurse NOT expect to find?

• Increased pulse rate

• Decreased blood pressure

• Distended neck veins

• Bilateral peripheral edema