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?

Choice A reason: This statement is true. Kayexalate is a medication that binds to potassium in the colon and exchanges it for sodium, thereby lowering the blood potassium level. It also has a laxative effect, which helps to eliminate the excess potassium in the stool.

Choice B reason: This statement is false. Kayexalate does not have a diuretic effect, which means it does not increase urine output or fluid loss. Diuretics are medications that act on the kidneys and help to remove excess fluid and sodium from the body.

Choice C reason: This statement is false. Kayexalate does not lower the blood sodium level, but rather increases it. This is because it exchanges potassium for sodium in the colon, which adds more sodium to the bloodstream.

Choice D reason: This statement is false. Kayexalate does not cause diarrhea, but rather a laxative effect, which means it stimulates bowel movements and softens the stool. Diarrhea is a condition where the stool is watery and frequent, and can cause dehydration and electrolyte imbalance.

Choice A reason: This statement is false. Edema is a sign of fluid overload, not fluid deficit. Edema occurs when fluid accumulates in the interstitial space due to increased capillary hydrostatic pressure or decreased plasma oncotic pressure. Edema is more common in patients with heart failure, liver disease, or kidney disease¹.

Choice B reason: This statement is false. Skin turgor is a measure of skin elasticity and hydration. It can be affected by factors such as age, skin condition, and ambient temperature. Skin turgor is not a reliable indicator of fluid balance, as it can be normal in patients with mild to moderate hypovolemia².

Choice C reason: This statement is false. Urine output is a measure of kidney function and fluid excretion. It can be influenced by factors such as fluid intake, diuretics, hormones, and renal diseases. Urine output is not a sensitive indicator of fluid balance, as it can be normal or even increased in patients with hypovolemia due to compensatory mechanisms.

Choice D reason: This statement is true. Daily weight is a measure of body mass and fluid status. It can reflect changes in fluid balance more accurately than other methods, as long as the weight is measured at the same time, on the same scale, and with the same clothing each day. A decrease in weight can indicate fluid loss due to hypovolemia.