A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?

Measure intake and output every 4 hours.

Apply oxygen by mask or nasal cannula.

Increase the IV flow rate to 250 mL/hr.

Place the client in a high-Fowler's position.

Answer and Explanation

The Correct Answer is C

A. Measure intake and output every 4 hours: While monitoring intake and output is important, it is not the first priority in this case. The client is exhibiting confusion due to dehydration, and immediate action is needed to correct the fluid deficit.

B. Apply oxygen by mask or nasal cannula: While oxygen may be necessary if the client shows signs of hypoxia, dehydration-induced confusion is primarily related to fluid imbalance rather than oxygenation issues. Administering fluids is the immediate priority.

C. Increase the IV flow rate to 250 mL/hr: Increasing the IV flow rate to rapidly administer fluids is the most immediate intervention to correct dehydration. Restoring fluid volume will help to resolve the confusion and address the underlying issue of dehydration.

D. Place the client in a high-Fowler's position: This position is typically used to assist with breathing or to improve respiratory function, but it does not address dehydration. Fluid resuscitation should be the first action to address confusion related to dehydration.

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Correct Answer is D

Explanation

A. 5.8 mEq/L: A potassium level of 5.8 mEq/L is still elevated, indicating that the sodium polystyrene sulfonate (Kayexalate) has not been fully effective in lowering the potassium to a normal range.

B. 5.5 mEq/L: While this level is slightly lower than 5.8 mEq/L, it still remains elevated above the normal range. It indicates some reduction in potassium, but it is not yet within the desired range.

C. 6.2 mEq/L: A potassium level of 6.2 mEq/L is critically high and reflects a lack of effectiveness of the Kayexalate treatment. This level is very high suggesting that the medication has not worked.

D. 4.9 mEq/L: A potassium level of 4.9 mEq/L is within the normal range (3.5-5.0 mEq/L). This indicates that the sodium polystyrene sulfonate (Kayexalate) has been effective in lowering the potassium to a safe and normal level.

A. Metabolic acidosis B. Respiratory acidosis C. Metabolic alkalosis D. Respiratory alkalosis

Correct Answer is B

Explanation

A. Metabolic acidosis: Metabolic acidosis is caused by an accumulation of acid or loss of bicarbonate, not by carbon dioxide retention. While hypoventilation can cause a buildup of CO2, this condition is primarily associated with respiratory acidosis.

B. Respiratory acidosis: Hypoventilation leads to the retention of carbon dioxide (CO2), which increases the concentration of carbonic acid in the blood, causing a decrease in blood pH. This results in respiratory acidosis, making it the correct acid-base imbalance to focus on.

C. Metabolic alkalosis: Metabolic alkalosis occurs when there is an excess of bicarbonate or a loss of hydrogen ions, and it is not related to the retention of CO2 from hypoventilation.

D. Respiratory alkalosis:This occurs when excessive CO2 is exhaled due to hyperventilation, not hypoventilation. Hypoventilation results in CO2 retention, which leads to acidosis, not alkalosis.

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A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a critically high potassium level (Normal is 3.5-5.0 mEq/L). The client has received sodium polystyrene sulfonate (Kayexalate). The nurse determines the medication's effectiveness if the client's repeat serum potassium level is:

Correct Answer is D

Explanation

A patient is hypoventilating and retaining carbon dioxide. On which acid-base imbalance should the nurse focus when caring for this patient?

Correct Answer is B

Explanation

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