Chapter 11: ... Fluid and Electrolyte
Imbalances (Practice Questions)
Questions and Correct Detailed Answers (Verified
Answers)
QUIZ: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.
✓✓~ 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.
QUIZ: 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
✓✓~ 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.
QUIZ: 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
,✓✓~ 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.
QUIZ: 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."
, ✓✓~ 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.
QUIZ: 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
Imbalances (Practice Questions)
Questions and Correct Detailed Answers (Verified
Answers)
QUIZ: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.
✓✓~ 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.
QUIZ: 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
✓✓~ 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.
QUIZ: 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
,✓✓~ 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.
QUIZ: 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."
, ✓✓~ 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.
QUIZ: 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
