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

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?

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.

2. What is the main water-holding force in the blood capillaries?

A. Capillary blood pressure
B. Sodium in the blood plasma
C. Protein in the blood plasma
D. Chloride in the blood plasma

Correct answer: C

Rationale: The correct answer is C: Protein in the blood plasma. Plasma proteins, especially albumin, create oncotic pressure, which is the main force responsible for holding water within the blood capillaries. Capillary blood pressure (Choice A) is involved in pushing blood through the capillaries, while sodium and chloride in the blood plasma (Choices B and D) are electrolytes and do not play a significant role in the water-holding force within capillaries.

3. A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications should the nurse assess? (Select all that apply.)

A. Urine output of 25 mL/hr
B. Serum potassium level of 5.4 mEq/L
C. Blood osmolality of 250 mOsm/L
D.

Correct answer: A

Rationale:

4. 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:

5. Where is the largest volume of water in the body located?

A. Plasma
B. The fluid inside the cells
C. Interstitial fluid
D. Lymph

Correct answer: B

Rationale: The correct answer is B. The largest volume of water in the body is found inside the cells, known as intracellular fluid. This fluid makes up the majority of the body's total water content. Choices A, C, and D are incorrect because while plasma, interstitial fluid, and lymph are important components of the body's fluid compartments, they do not contain the largest volume of water in the body.