A nurse is caring for a client who has a fluid and electrolyte imbalance. The nurse knows that the priority goal of taking care of this client is?

To obtain homeostasis

To prevent infection

To promote mobility

To enhance nutrition

Answer and Explanation

The Correct Answer is A

Choice A reason: Homeostasis is the body’s ability to maintain stable internal conditions, including fluid and electrolyte balance. Imbalances, like hypokalemia or hypernatremia, disrupt cellular function, potentially causing arrhythmias or neurological issues. Restoring homeostasis is the priority, as it addresses the root cause, ensuring proper organ function and preventing complications.

Choice B reason: Preventing infection is important but not the priority in fluid and electrolyte imbalances. Infections may occur secondary to other conditions, but the primary concern is correcting imbalances that affect cellular and organ function. Homeostasis must be achieved first to stabilize the client’s physiological state before addressing infection risks.

Choice C reason: Promoting mobility is relevant for overall health but not the priority in fluid and electrolyte imbalances. Imbalances can cause muscle weakness or arrhythmias, but restoring electrolyte levels takes precedence to ensure safe mobility. Without homeostasis, mobility efforts may be unsafe or ineffective due to physiological instability.

Choice D reason: Enhancing nutrition supports overall recovery but is secondary to correcting fluid and electrolyte imbalances. Nutritional deficiencies may contribute to imbalances, but the immediate goal is restoring homeostasis to prevent acute complications like cardiac or neurological dysfunction. Nutrition can be addressed once the client is stabilized.

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Correct Answer is C

Explanation

Choice A reason: Sensible water loss refers to measurable fluid loss, like urine or sweat. The client’s symptoms, including high serum sodium (153 mEq/L), suggest hypernatremia due to water loss, but sensible losses like urine are reduced (decreased urine output). Insensible losses better explain the unmeasurable fluid deficit in this scenario.

Choice B reason: Major magnesium losses cause hypomagnesemia, leading to tremors or arrhythmias, not typically confusion or hypernatremia. The client’s high sodium and dehydration symptoms point to water loss, not magnesium. Magnesium levels are not provided, and the symptoms align more with fluid imbalance than magnesium deficiency.

Choice C reason: Insensible water loss, from skin and respiration, is unmeasurable and can lead to hypernatremia (serum sodium 153 mEq/L) due to concentrated blood. Dry mucous membranes, decreased urine output, and confusion indicate dehydration from water loss, consistent with insensible losses in elderly patients with reduced thirst perception.

Choice D reason: Low potassium levels (hypokalemia) cause muscle weakness and arrhythmias, not hypernatremia or confusion. The client’s high sodium and dehydration symptoms point to water loss, not potassium imbalance. Potassium levels are not provided, but the clinical picture supports insensible water loss as the primary issue.

A. A 47-year-old who had a colon resection yesterday and is reporting pain B. A 20-year-old 2 days postoperative who refuses to ambulate C. A newly admitted 88-year-old with a 2-day history of vomiting and loose stools D. A 60-year-old who is 3 days post-myocardial infarction and has been stable

Correct Answer is C

Explanation

Choice A reason: Postoperative pain in a 47-year-old is concerning but not immediately life-threatening unless severe or accompanied by other symptoms (e.g., hemorrhage). Pain management is important, but fluid and electrolyte imbalances from vomiting and diarrhea in an elderly client pose a greater immediate risk, requiring urgent assessment.

Choice B reason: Refusal to ambulate in a 20-year-old postoperative client risks complications like thrombosis but is not an acute emergency. Immobility requires intervention, but dehydration and electrolyte imbalances in an elderly client with vomiting and diarrhea are more urgent, as they can rapidly lead to life-threatening hypovolemia.

Choice C reason: An 88-year-old with vomiting and diarrhea for 2 days is at high risk for dehydration, electrolyte imbalances, and hypovolemia, especially given age-related reduced physiological reserves. This can lead to shock or organ failure, making it the highest priority for immediate assessment to stabilize fluid and electrolyte status.

Choice D reason: A stable 60-year-old post-myocardial infarction client is not an immediate priority unless new symptoms arise. Stability suggests no acute changes in cardiac status. Vomiting and diarrhea in an elderly client pose a greater immediate risk due to potential rapid deterioration from fluid loss.

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A nurse is caring for a client who has a fluid and electrolyte imbalance. The nurse knows that the priority goal of taking care of this client is?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 73-year-old hospitalized client demonstrates the following symptoms: dry mucous membranes, decreased urine output, confusion, a serum sodium of 153 mEq/L, and a serum condition difficult to measure. This is indicative of?

Correct Answer is C

Explanation

The oncoming nurse is assigned to the following clients. Which client should the nurse assess first?

Correct Answer is C

Explanation

A nurse is teaching a client with hypertension about dietary modifications. Which recommendation is most appropriate to reduce blood pressure?

A nurse is caring for a client with diabetic ketoacidosis. Which arterial blood gas result is most consistent with this condition?

As the nurse assesses a client’s laboratory values, the following are noted: Sodium 140 mEq/L, Magnesium 0.8 mEq/L, Chloride 107 mEq/L, Potassium 3.6 mEq/L. What electrolyte imbalance is indicated?

Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply)

A nurse is receiving report on a group of clients. Using the ABCD-E priority framework, which of the following clients should the nurse see first?

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A nurse is assessing a client with suspected hypovolemic shock. Which finding is the earliest indicator of this condition?

As the nurse assesses a client’s blood pressure, the patient’s wrist severely flexes inward. The nurse questions the client’s response because this finding may indicate what condition?