Chapter 13: Assessment and Care of Patients with Fluid and Electrolyte Imbalances Complete Questions and Answers A+

Chapter 13: Assessment and Care of Patients with Fluid and Electrolyte Imbalances Complete Questions and Answers A+ 3. Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L? a.1. 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. - ANS ANSWER: C 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. DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Techniques of Physical Assessment) Integrated Process: Nursing Process (Assessment) 2. 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 - ANS ANSWER: B 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.