Chapter 11: ... Fluid and Electrolyte Imbalances
(Practice Questions)
The nurse observes skin tenting on the back of the older adult client's hand.
Which action by the nurse is most appropriate?
a. Notify the physician.
b. Examine dependent body areas.
c. Assess turgor on the client's forehead.
d. Document the finding and continue to monitor. - CORRECT ANSWER-c.
Assess turgor on the client's forehead.
Rational:Skin turgor cannot be accurately assessed on an older adult client's
hands because of age-related loss of tissue elasticity in this area. Areas that
more accurately show skin turgor status on an older client include the skin of
the forehead, chest, and abdomen. These should also be assessed, rather than
merely examining dependent body areas. Further assessment is needed rather
than only documenting, monitoring, and notifying the physician.
The client is taking a medication that inhibits aldosterone secretion and
release. The nurse assesses for what potential complication?
a. Fluid retention
b. Hyperkalemia
c. Hyponatremia
d. Hypervolemia - CORRECT ANSWER-b. Hyperkalemia
Rational: Aldosterone is a naturally occurring hormone of the mineralocorticoid
type that increases the reabsorption of water and sodium in the kidney at the
same time that it promotes excretion of potassium. Any drug or condition that
,disrupts aldosterone secretion or release increases the client's risk for
excessive water loss and increased potassium reabsorption. The client would
not be at risk for overhydration or sodium imbalance.
Which assessment does the nurse use to determine the adequacy of circulation
in a client whose blood osmolarity is 250 mOsm/L?
a. Measuring urine output
b. Measuring abdominal girth
c. Monitoring fluid intake
d. Comparing radial versus apical pulses - CORRECT ANSWER-a. Measuring
urine output
Rational: The blood osmolarity is low. The client could be dehydrated (hypo-
osmolar dehydration) or overhydrated with dilution of blood solute. The most
sensitive noninvasive indicator of circulation adequacy is urine output.
Measuring abdominal girth, comparing pulses, and monitoring fluid intake
would not be accurate assessment techniques for this client.
Which statement made by the older adult client alerts the nurse to assess
specifically for fluid and electrolyte imbalances?
a. "My skin is always so dry, especially here in the Southwest."
b. "I often use a glycerin suppository for constipation."
c. "I don't drink liquids after 5 PM so I don't have to get up at night."
d. "In addition to coffee, I drink at least one glass of water with each meal." -
CORRECT ANSWER-c. "I don't drink liquids after 5 PM so I don't have to get up
at night."
Rational: Restricting fluids without a medical reason can lead to dehydration.
Many older clients believe that restricting fluids will prevent incontinence and
reduce the number of times that they wake up during the night. The increased
, osmolarity of the urine in response to reducing fluid intake increases irritation
of the bladder and sphincter, increasing the sensation of needing to urinate.
The other statements do not indicate practices that could potentially lead to
dehydration.
A client has been taught to restrict dietary sodium. Which food selection by the
client indicates to the nurse that teaching has been effective?
a. Chinese take-out, including steamed rice
b. A grilled cheese sandwich with tomato soup
c. Slices of ham and cheese on whole grain crackers
d. A chicken leg, one slice of bread with butter, and steamed carrots - CORRECT
ANSWER-d. A chicken leg, one slice of bread with butter, and steamed carrots
Rational: Clients on restricted sodium diets generally should avoid processed,
smoked, and pickled foods and those with sauces and other condiments. Foods
lowest in sodium include fish, poultry, and fresh produce. The Chinese food
likely would have soy sauce, the tomato soup is processed, and the crackers are
a snack food—a category of foods often high in sodium.
A client is on a potassium-restricted diet. Which protein choice by the client
indicates a good understanding of the dietary regimen?
a. 1% or 2% milk
b. Grilled salmon
c. Poached eggs
d. Baked chicken - CORRECT ANSWER-c. Poached eggs
Rational: Eggs contain few cells and have one of the lowest potassium contents
among high-protein foods. Meat and fish have cells that contain large amounts
of potassium. Dairy products are also high in potassium.
(Practice Questions)
The nurse observes skin tenting on the back of the older adult client's hand.
Which action by the nurse is most appropriate?
a. Notify the physician.
b. Examine dependent body areas.
c. Assess turgor on the client's forehead.
d. Document the finding and continue to monitor. - CORRECT ANSWER-c.
Assess turgor on the client's forehead.
Rational:Skin turgor cannot be accurately assessed on an older adult client's
hands because of age-related loss of tissue elasticity in this area. Areas that
more accurately show skin turgor status on an older client include the skin of
the forehead, chest, and abdomen. These should also be assessed, rather than
merely examining dependent body areas. Further assessment is needed rather
than only documenting, monitoring, and notifying the physician.
The client is taking a medication that inhibits aldosterone secretion and
release. The nurse assesses for what potential complication?
a. Fluid retention
b. Hyperkalemia
c. Hyponatremia
d. Hypervolemia - CORRECT ANSWER-b. Hyperkalemia
Rational: Aldosterone is a naturally occurring hormone of the mineralocorticoid
type that increases the reabsorption of water and sodium in the kidney at the
same time that it promotes excretion of potassium. Any drug or condition that
,disrupts aldosterone secretion or release increases the client's risk for
excessive water loss and increased potassium reabsorption. The client would
not be at risk for overhydration or sodium imbalance.
Which assessment does the nurse use to determine the adequacy of circulation
in a client whose blood osmolarity is 250 mOsm/L?
a. Measuring urine output
b. Measuring abdominal girth
c. Monitoring fluid intake
d. Comparing radial versus apical pulses - CORRECT ANSWER-a. Measuring
urine output
Rational: The blood osmolarity is low. The client could be dehydrated (hypo-
osmolar dehydration) or overhydrated with dilution of blood solute. The most
sensitive noninvasive indicator of circulation adequacy is urine output.
Measuring abdominal girth, comparing pulses, and monitoring fluid intake
would not be accurate assessment techniques for this client.
Which statement made by the older adult client alerts the nurse to assess
specifically for fluid and electrolyte imbalances?
a. "My skin is always so dry, especially here in the Southwest."
b. "I often use a glycerin suppository for constipation."
c. "I don't drink liquids after 5 PM so I don't have to get up at night."
d. "In addition to coffee, I drink at least one glass of water with each meal." -
CORRECT ANSWER-c. "I don't drink liquids after 5 PM so I don't have to get up
at night."
Rational: Restricting fluids without a medical reason can lead to dehydration.
Many older clients believe that restricting fluids will prevent incontinence and
reduce the number of times that they wake up during the night. The increased
, osmolarity of the urine in response to reducing fluid intake increases irritation
of the bladder and sphincter, increasing the sensation of needing to urinate.
The other statements do not indicate practices that could potentially lead to
dehydration.
A client has been taught to restrict dietary sodium. Which food selection by the
client indicates to the nurse that teaching has been effective?
a. Chinese take-out, including steamed rice
b. A grilled cheese sandwich with tomato soup
c. Slices of ham and cheese on whole grain crackers
d. A chicken leg, one slice of bread with butter, and steamed carrots - CORRECT
ANSWER-d. A chicken leg, one slice of bread with butter, and steamed carrots
Rational: Clients on restricted sodium diets generally should avoid processed,
smoked, and pickled foods and those with sauces and other condiments. Foods
lowest in sodium include fish, poultry, and fresh produce. The Chinese food
likely would have soy sauce, the tomato soup is processed, and the crackers are
a snack food—a category of foods often high in sodium.
A client is on a potassium-restricted diet. Which protein choice by the client
indicates a good understanding of the dietary regimen?
a. 1% or 2% milk
b. Grilled salmon
c. Poached eggs
d. Baked chicken - CORRECT ANSWER-c. Poached eggs
Rational: Eggs contain few cells and have one of the lowest potassium contents
among high-protein foods. Meat and fish have cells that contain large amounts
of potassium. Dairy products are also high in potassium.
