when dehydration begins to occur

ATI RN

ATI Fluid and Electrolytes

1. When does dehydration begin to occur?

A. the body reduces fluid output to zero.
B. the body increases the release of ANH.
C. the salivary secretions decrease.
D. the salivary secretions increase.

Correct answer: C

Rationale: Dehydration leads to a decrease in the body's fluid levels, causing the salivary glands to produce less saliva, resulting in a dry mouth. Therefore, when dehydration begins to occur, salivary secretions decrease. Choice A is incorrect because the body does not reduce fluid output to zero during dehydration; it tries to conserve fluids. Choice B is incorrect as dehydration does not directly increase the release of ANH (Atrial Natriuretic Hormone). Choice D is incorrect because salivary secretions do not increase but decrease during dehydration.

2. A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:

A. She will need to have her medications adjusted and be readmitted to the hospital for a complete workup.
B. Limiting fluids can create imbalances in the body that can result in confusion; maybe we need to adjust the timing of your fluids.
C. It is normal to be a little confused following surgery and it is safe not to urinate at night.
D. Confusion following surgery is common in the elderly due to loss of sleep.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.

3. Place a washcloth between the skin and tourniquet

A. Provide a bed bath instead of letting the client take a shower
B. Use sterile technique when changing the dressing.
C. Disconnect the intravenous fluid tubing prior to the clients bath.
D. Use a plastic bag to cover the extremity with the device

Correct answer: D

Rationale:

4. 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?

A. Ask family members to speak quietly to keep the client calm.
B. Assess urine color, amount, and specific gravity each day.
C. Encourage the client to drink at least 1 liter of fluids each shift.
D. Dangle the client on the bedside before ambulating.

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.