The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?

Drink more fluids in the late evening

Increase fluids if your mouth feels dry

If you feel confused, you need to drink more caffeine

More fluids are needed if you feel full

Answer and Explanation

The Correct Answer is B

Choice A reason: This statement is false. Drinking more fluids in the late evening can cause nocturia, which is the need to urinate frequently at night. This can disrupt the sleep cycle and increase the risk of falls.

Choice B reason: This statement is true. Dry mouth is a sign of dehydration and indicates the need for more fluid intake. Older adults may have reduced thirst sensation and may not drink enough fluids throughout the day.

Choice C reason: This statement is false. Caffeine is a diuretic, which means it increases urine output and can worsen dehydration. Confusion is a symptom of dehydration and requires immediate medical attention.

Choice D reason: This statement is false. Feeling full is not a reliable indicator of hydration status. Older adults may have decreased appetite and gastric motility, which can make them feel full even when they are dehydrated.

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Correct Answer is C

Explanation

Choice A reason: This statement is false. IV morphine sulfate is a pain medication that can be given as needed to the postoperative patient. It does not affect the serum sodium level.

Choice B reason: This statement is false. Dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can be used to treat hyponatremia, or low serum sodium level. It provides both glucose and sodium to the patient.

Choice C reason: This statement is true. 5% dextrose in water is a hypotonic solution that can cause further dilution of the serum sodium level. It can worsen the hyponatremia and increase the risk of cerebral edema and seizures.

Choice D reason: This statement is false. Neurologic assessment Q2 hours is a necessary intervention for a patient with hyponatremia, as it can monitor for signs of neurologic deterioration such as confusion, lethargy, or coma.

A. A serum potassium level of 5.6 mEq/L B. A serum sodium level of 142 mEq/L C. A serum sodium level of 138 mEq/L D. A serum potassium level of 2.8 mEq/L

Correct Answer is D

Explanation

Choice A reason: This statement is false. A serum potassium level of 5.6 mEq/L is not a common side effect of furosemide. This value indicates hyperkalemia, or high blood potassium level, which can cause cardiac arrhythmias and muscle weakness. Furosemide is a loop diuretic that causes potassium loss, not retention.

Choice B reason: This statement is false. A serum sodium level of 142 mEq/L is not a common side effect of furosemide. This value is within the normal range of 135-145 mEq/L and does not indicate any problem with sodium balance. Furosemide is a loop diuretic that causes sodium loss, but it is usually compensated by the renin-angiotensin-aldosterone system.

Choice C reason: This statement is false. A serum sodium level of 138 mEq/L is not a common side effect of furosemide. This value is within the normal range of 135-145 mEq/L and does not indicate any problem with sodium balance. Furosemide is a loop diuretic that causes sodium loss, but it is usually compensated by the renin-angiotensin-aldosterone system.

Choice D reason: This statement is true. A serum potassium level of 2.8 mEq/L is a common side effect of furosemide. This value indicates hypokalemia, or low blood potassium level, which can cause cardiac arrhythmias, muscle weakness, and metabolic alkalosis. Furosemide is a loop diuretic that inhibits the reabsorption of sodium and potassium in the ascending loop of Henle, leading to potassium loss in the urine.

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The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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