How would the nurse assess the patient’s respiratory status?
a. Depth of respirations b. Bowel sounds d. Electrocardiography resulting in shallow respirations and decreased handgrips. The nurse would assess the client’s respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation.
How much fluid should a nurse give an older patient?
Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency. A nurse assesses a client who is admitted for treatment of fluid overload.
Should I assess the client’s urine for dehydration?
Assessing the client’s urine may assist with the diagnosis of dehydration but would not prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.
Can an infusion cause fluid overload in an older adult?
For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler position may or may not be comfortable but still does not address the most important issue which is safety. 3. After teaching a client who is being treated for dehydration, a nurse assesses the client’s understanding.
What does a nurse do after teaching a client who is prescribed a restricted sodium diet?
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the clients understanding. Which food choice for lunch indicates the client correctly understood the teaching?
What is the focus of management for clients with dehydration?
ANS: D - The focus of management for clients with dehydration is to increase fluid volumes to normal. When fluid volumes return to normal, clients should perfuse the brain more effectively, therefore improving confusion and decreasing orthostatic light-headedness or dizziness. Increased respiratory rate, decreased skin turgor, and increased specific gravity are all manifestations of dehydration.
What is insensible water loss?
ANS: B - Insensible water loss is water loss through the skin, lungs, and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma, burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid restriction and with constipation are not at risk for fluid loss.
What is the blood pressure of a person who has a low blood pressure of 180/72?
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
Why are older adults at greater risk for dehydration?
ANS: C - Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.
Is a change in body weight a good measure of fluid retention?
ANS: B - One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration.
Does oxygen help with confusion?
ANS: B - Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowlers position will not address the clients problem.
How much fluid should a client drink per shift?
Encourage the client to drink at least 1 liter of fluids each shift.
What is the result of increased oxygen demand in renal and gastrointestinal blood vessels?
Vasodilation results from increased oxygen demand of renal and gastrointestinal blood vessels.
What are the electrolytes associated with renal failure?
Electrolyte imbalances associated with acute renal failure include hyperkalemia and hyperphosphatemia. The nurse should assess for electrocardiogram changes, paralytic ileus caused by decrease bowel mobility, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia.
What is a nurse in electrolyte?
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that apply.)
What prevented superficial freezing and loss of heat?
Increased blood flow to the outer shell prevented superficial freezing and loss of heat.
Why is the thickness of the outer shell modifiable?
C, The thickness of the outer shell is modifiable in response to the environmental temperature and can be increased through decreased blood flow. Subcutaneous tissue provides protection due to its low, not high, conductivity. Blood flow decreases to the outer shell in low temperatures, and the lowering of the shell temperature does not necessarily minimize heat loss.
Which type of stimulation mediates hypothalamic control of cardiovascular activity?
Sympathetic and parasympathetic stimulation associated with muscle metabolism mediate hypothalamic control of cardiovascular activity.