Fluid, Electrolyte, and Acid-Base Balance

Question 1An elderly nursing home resident has refused toeat or drink for several days and is admitted tothe hospital. The nurse should assess for whichof the following?1. Increased blood pressure2. Weak, rapid pulse3. Moist mucous membranes4. Jugular vein distentionRationales 11. This option is indicative of fluidvolume excess.2. Correct. A client that has not eatenor drank anything for several dayswould be experiencing fluid volumedeficit.3. This option is indicative of fluidvolume excess.4. This option is indicative of fluidvolume excess.Question 2A man brings his elderly wife to theemergency department. He states that shehas been vomiting and has had diarrheafor the past 2 days. She appears lethargicand is complaining of leg cramps. Whatshould the nurse do first?1. Start an IV.2. Review the results of serum electrolytes.3. Offer the woman foods that are high in sodiumand potassium content.4. Administer an antiemetic.Rationales 21. While the nurse may perform thisintervention, assessment is neededinitially.2. Correct.: Further assessment isneeded to determine appropriateaction.3. While the nurse may this intervention,assessment is needed initially.4. While the nurse may this intervention,assessment is needed initially.Question 3Which of the following client statementsindicates a need for further teachingregarding treatment for hypokalemia?1. “I will use avocado in my salads.”2. “I will be sure to check my heart rate before Itake my digoxin.”3. “I will take my potassium in the morning aftereating breakfast.”4. “I will stop using my salt substitute.”Rationales 31. Avocado is higher in potassium than mostfoods.2. Hypokalemia can potentiate digoxintoxicity and checking the pulse will helpthe client to avoid this.3. It is important to take potassium with foodto avoid gastric upset.4. Correct. Salt substitutes containpotassium. The client can still use it withinreason.11