A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

Continue the normal saline IV at 75 mL/hour and encourage increased oral fluid intake.

Slow the normal saline to a keep open rate while contacting the healthcare provider.

Review the client's medications to see if the client can be given a PRN diuretic.

Instruct the client to withhold oral fluids and report the symptoms to the provider.

Answer and Explanation

The Correct Answer is A

Choice A reason: Continuing the normal saline IV at 75 mL/hour and encouraging increased oral fluid intake is the appropriate action. The client is showing signs of dehydration, such as dry mucous membranes and inelastic skin turgor, indicating a need for more fluids. Ensuring proper hydration through both IV and oral routes is essential.

Choice B reason: Slowing the normal saline to a keep open rate while contacting the healthcare provider is not appropriate in this situation. The client needs more fluids, not less. Reducing the IV rate could exacerbate dehydration.

Choice C reason: Reviewing the client's medications to see if the client can be given a PRN diuretic is not suitable for a client showing signs of dehydration. Diuretics would further decrease fluid volume and worsen the symptoms.

Choice D reason: Instructing the client to withhold oral fluids and report the symptoms to the provider is contrary to managing dehydration. The client needs increased fluid intake to address the signs of dehydration effectively.

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Correct Answer is A

Explanation

Choice A reason: Taking a walk with the client is an effective intervention for addressing agitation and restlessness in a client with Alzheimer's disease. Physical activity can help reduce anxiety and agitation, and walking provides a safe and structured way for the client to expend energy while being closely supervised.

Choice B reason: Sitting the client in a recliner may provide temporary comfort, but it does not address the underlying agitation and restlessness. The client may still attempt to leave the room and become more frustrated if their movement is restricted.

Choice C reason: Administering a sleeping medication can have sedative effects, but it should not be the first-line intervention for agitation and restlessness in clients with Alzheimer's disease. Non-pharmacological approaches, such as walking, should be tried first. Sedatives can also increase the risk of falls and other complications.

Choice D reason: Moving the client to a locked unit may be necessary for safety in some cases, but it should not be the initial intervention for agitation and restlessness. The goal is to use less restrictive interventions first to manage the client's behaviour.

A. Serum potassium 5.0 me/L (5.0 mmol/L), serum sodium 138 me/L (138 mmol/L). B. Serum potassium 4.5 me/L (4.5 mmol/L), serum sodium 140 me/L (140 mmol/L). C. Serum potassium 3.5 me/L (3.5 mmol/L), serum sodium 142 me/L (142 mmol/L). D. Serum potassium 3.0 me/L (3.0 mmol/L), serum sodium 149 me/L (149 mmol/L).

Correct Answer is D

Explanation

Choice A reason: Serum potassium of 5.0 me/L and serum sodium of 138 me/L are within normal ranges and do not reflect the expected electrolyte imbalances due to dehydration from vomiting and diarrhea.

Choice B reason: Serum potassium of 4.5 me/L and serum sodium of 140 me/L are also within normal ranges. This does not reflect the typical imbalance caused by dehydration.

Choice C reason: Serum potassium of 3.5 me/L and serum sodium of 142 me/L are normal values. They do not indicate the electrolyte disturbances expected with dehydration from vomiting and diarrhea.

Choice D reason: Serum potassium of 3.0 me/L indicates hypokalaemia (low potassium), and serum sodium of 149 me/L indicates hypernatremia (high sodium). These imbalances are expected in a client with a history of fever, vomiting, and diarrhea, as these conditions can lead to loss of potassium and concentration of sodium due to dehydration.

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A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the evening shift, a client with Alzheimer's disease becomes agitated, restless, and repeatedly attempts to leave the room unattended. Which intervention should the nurse implement?

Correct Answer is A

Explanation

A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained. Which laboratory results should the nurse expect?

Correct Answer is D

Explanation

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