a nurse is caring for an older adult client who is admitted with moderate dehydration which intervention should the nurse implement to prevent injury
Logo

Nursing Elites

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

Correct answer: D

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.

2. . A nurse assesses a client who had an intraosseous catheter placed in the left leg. Which assessment finding is of greatest concern?

Correct answer: D

Rationale:

3. The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?

Correct answer: D

Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. Monitoring for an elevated thyroid-stimulating hormone (choice A) is not relevant in assessing for hypocalcemia. Observing for swelling of the neck, tracheal deviation, and severe pain (choice B) are more related to airway compromise. Evaluating the quality of the patient's voice postoperatively (choice C) is important but not a primary sign of hypocalcemia.

4. A nurse sees a variety of patients in the community health clinic. Which of the following patients would be at the greatest risk of dehydration?

Correct answer: B

Rationale: The correct answer is B. Infants are particularly vulnerable to dehydration due to diarrhea because they have a higher fluid turnover and less reserve. Option A, the 18-year-old basketball player with a stress fracture, is less likely to be at the greatest risk of dehydration compared to an infant with diarrhea. Option C, the 45-year-old with stomach flu, may experience dehydration but is not at the same level of risk as an infant with diarrhea. Option D, the elderly patient living alone, could be at risk of dehydration, but infants with diarrhea are at the greatest risk due to their unique physiological characteristics.

5. What is the most abundant positive ion in blood plasma?

Correct answer: C

Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.

Similar Questions

What happens first in dehydration?
A nurse is assessing clients for fluid and electrolyte imbalances. Which client should the nurse assess first for potential hyponatremia?
You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would the nurse interpret the results?
While assessing clients on a medical-surgical unit, which client is at risk for hypokalemia?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses