Fundamentals of Nursing: Fluid and Electrolyte Imbalance| 50 Questions And Answers|100% Correct

An older adult client is admitted with dehydration. Which nursing assessment data identify that the client is at risk for falling? A. Dry oral mucous membranes B. Orthostatic blood pressure changes C. Pulse rate of 72 beats/min and bounding D. Serum potassium level of 4.0 mEq/L -️️ B Blood pressure decreases when changing positions. The client may not have sufficient blood flow to the brain, causing sensations of light-headedness and dizziness. This problem increases the risk for falling, especially in older adults. Assessment of oral mucous membranes and the pulse rate can detect symptoms of dehydration, but these are not the best ways to assess for a fall risk. Checking serum potassium does not assess for fall risk. A client has a low serum potassium level and is ordered a dose of parenteral potassium chloride (KCl). How does a nurse safely administer KCl to the client? A. Administers 5 mEq intramuscularly B. Dilutes 200 mEq in 1 liter of normal saline and infuses at 100 mL/hr C. Infuses 10 mEq over a 1-hour period D. Pushes 5 mEq through a central access line -️️ C A dose of KCl 10 mEq given over 1 hour is appropriate for this client. A dose of KCl 200 mEq in 1 liter of normal saline infused at 100 mL/hr is too concentrated and can cause injury. Potassium is a severe tissue irritant and is never given by the intramuscular or subcutaneous route. Because rapid infusion of potassium can cause cardiac arrest, potassium is not administered through central lines. A client is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond? A. "Fast thinking! She really needs to rest after the night she had." B. "Get the information now, or I'll report you for not doing your job." C. "Never mind—I will do it myself." D. "Weigh her now. We need her weight daily, at the same time." -️️ D The nurse should educate the nursing assistant as to why obtaining the client's weight at the same time each day is important. Although the nursing assistant may be hesitant to wake the client, assessing the client's fluid balance is more important. The responses that the client needed the rest, telling the nursing assistant to get the information now or she'll be reported, or that the nurse will get the information herself do not demonstrate good leadership. The assistant needs to understand the rationale for waking and weighing the client. She should not be dismissed and belittled by the nurse.