N4 test Fluid Imbalances

Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 4th Edition Chapter 12: Interventions for Clients with Fluid Imbalances

1. Which client is at greatest risk for the development of hypotonic overhydration?
A. Older adult with chronic congestive heart failure
B. Older adult with poorly controlled diabetes mellitus
C. Younger adult with continuous fever of 39º C for 8 hours
D. Younger adult during the first 24 hours after a burn injury

2. The client has had diarrhea for two days and has lost 11 pounds. Laboratory tests show the client’s serum osmolarity to be 285 mOsm/L and serum potassium of 4.8 mmol/L (mEq/L). What is your interpretation of these data?
A. Relative dehydration
B. Isotonic dehydration
C. Hypertonic dehydration
D. Hypotonic dehydration

3. During a physical assessment, you observe the client with dehydration to have deep furrows on the tongue and a thick white substance on the oral mucous membranes. What is your best action?
A. Obtain an oral specimen for culture and sensitivity.
B. Document the findings as the only action.
C. Do not give the client dairy products.
D. Offer oral hygiene.

4. What is the priority nursing diagnosis for the client with dehydration?
A. Risk for injury related to poor skin turgor
B. Decreased cardiac output related to decreased plasma volume
C. Impaired oral mucous membranes related to inadequate oral secretions
D. Knowledge deficiency related to medication regimen and preventive measures

5. Which statement made by the client indicates a need for clarification regarding the prevention of dehydration?
A. “If I urinate 6 to 10 times a day and the urine is light yellow, I’m probably drinking enough.”
B. “I have made a chart to keep track of whether my weight changes each day.”
C. “If I forget to take my diuretic on one day, I will take two the next day.”
D. “When summer comes, I will drink more fluids.”

6. Which assessment finding for the client being treated for overhydration indicates a need for revision of the treatment plan?
A. Urine specific gravity of 1.020
B. One kilogram weight gain in 24 hours
C. Pulse pressure of 30 mm Hg
D. Serum potassium level of 3.8 mEq/L (mmol/L)