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Nurs 1220 Exam 3 Questions With Correct
Answers
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 36 year old who is prescribed long-term steroid therapy.
A 55 year old who recently received intravenous fluids.
A 76 year old who is cognitively impaired.
An 83 year old with congestive heart failure. - answer✔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.
The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent
IV fluid administration do not increase the risk of dehydration.
2. A nurse is caring for an older client who exhibits dehydration-induced confusion. Which
intervention by the nurse is best?
a. Measure intake and output every 4 hours.
b. Assess client further for fall risk.
c. Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler position. - answer✔ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing
confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic
hypotension, dysrhythmia, and/or muscle weakness. The nurse's best response is to do a more
thorough evaluation of the client's risk for falls. Measuring intake and output may need to occur
more frequently than every 4 hours, but does not address a critical need. The nurse would not
adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid
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an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or
may not be comfortable but still does not address the most important issue which is safety.
After teaching a client who is being treated for dehydration, a nurse assesses the client's
understanding. Which statement indicates that the client correctly UNDERSTOOD the teaching?
a. "I must drink a quart (liter) 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 p.m. so I won't have to get up at night. - answer✔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 (0.2 kg) daily is indicative of
excessive fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to
dehydration. Clients may want to limit fluids after dinner so they won't have to get up, but this
does not address dehydration if the patient drinks the recommended amount of fluid during the
earlier parts of the day.
A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify
as being at greatest risk for insensible water loss?
a. Client taking furosemide.
b. Anxious client who has tachypnea.
c. Client who is on fluid restrictions.
d. Client who is constipated with abdominal pain. - answer✔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 insensible fluid loss.
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?
a. Increased respiratory rate from 12 to 22 breaths/min
b. Decreased skin turgor on the client's posterior hand and forehead
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c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic changes when standing - answer✔ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal.
When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This
assessment finding shows a therapeutic response to treatment. Increased respirations, decreased
skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.
6. After teaching a client who is prescribed a RESTRICTED SODIUM DIET, a nurse assesses
the client's understanding. Which food choice for lunch indicates that the client correctly
UNDERSTOOD the teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese sandwich
c. Salami and cheese on whole-wheat crackers
d. Grilled chicken breast with glazed carrots - answer✔ANS: D
Clients on restricted sodium diets generally avoid processed, smoked, and pickled foods and
those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh
produce. The ham, tomato soup, salami, and crackers are usually high in sodium.
7. A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse
assess first for potential hyponatremia?
a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic.
c. A 67 year old who is experiencing pain and is prescribed ibuprofen.
d. A 73 year old with tachycardia who is receiving digoxin. - answer✔ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when
infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions
can lead to hyponatremia. Because the client is not taking any food or fluids by mouth (NPO),
normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen,
and digoxin will not put a client at risk for hyponatremia.
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include
in this client's teaching?
a. "Have you spouse watch you for irritability and anxiety."
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b. "Notify the clinic if you notice muscle twitching."
c. "Call your primary health care provider for diarrhea."
d. "Bake or grill your meat rather than frying it." - answer✔ANS: C
One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be
taught to call the primary health care provider if this is noticed. Irritability and anxiety are
common neurologic signs of hypokalemia. Muscle twitching is related to hypernatremia.
Cooking methods are not a cause of hyponatremia
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 8.5 mEq/L (2.13 mmol/L), and sodium
144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography - answer✔ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac
dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips.
The nurse would assess the client's respiratory status first to ensure that respirations are
sufficient. The respiratory assessment would include rate and depth of respirations, respiratory
effort, and oxygen saturation. The other assessments are important but are secondary to the
client's respiratory status.
A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is
exhibiting cardiovascular changes. Which intervention will the nurse implement first?
a. Prepare to administer patiromer by mouth.
b. Provide a heart-healthy, low-potassium diet.
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
d. Prepare the client for hemodialysis treatment. - answer✔ANS: C
A client with a critically high serum potassium level and cardiac changes would be treated
immediately to reduce the extracellular potassium level. Potassium movement into the cells is
enhanced by insulin by increasing the activity of sodium-potassium pumps. Insulin will decrease
both serum potassium and glucose levels and therefore would be administered with dextrose to
prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce
