The nurse caring for a frail 92-year-old dehydrated patient should add to the plan of care:
Potential for over-hydration related to excessive thirst
Potential for diarrhea related to dehydration
Potential for pulmonary congestion related to excessive fluid intake
Potential for fall related to confusion
The Correct Answer is D
Choice A reason: This is incorrect because over-hydration is unlikely in a dehydrated patient. Over-hydration is a condition where the body has too much water, which can cause hyponatremia, edema, and cerebral swelling.
Choice B reason: This is incorrect because diarrhea is a cause, not a consequence, of dehydration. Diarrhea is the frequent and watery passage of stool, which can lead to fluid and electrolyte loss.
Choice C reason: This is incorrect because pulmonary congestion is also unlikely in a dehydrated patient. Pulmonary congestion is a condition where the lungs are filled with fluid, which can cause dyspnea, cough, and crackles.
Choice D reason: This is correct because fall is a potential complication of dehydration. Dehydration can cause confusion, dizziness, weakness, and hypotension, which can increase the risk of falling and injuring oneself.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: For an average adult, the total intake should be approximately equal to the total output every day¹². Therefore, if the patient's total output is 2200 mL, the total intake should also be around 2200 mL.
Choice B reason: 3000 mL is more than the recommended daily fluid intake for an average adult, which is about 2500 mL³. If the patient's intake is higher than their output, they may develop fluid overload or edema.
Choice C reason: 3800 mL is much more than the recommended daily fluid intake for an average adult, which is about 2500 mL³. If the patient's intake is higher than their output, they may develop fluid overload or edema.
Choice D reason: 2400 mL is slightly less than the recommended daily fluid intake for an average adult, which is about 2500 mL³. However, if the patient's intake is lower than their output, they may develop dehydration or electrolyte imbalance.
Correct Answer is A
Explanation
Choice A reason: This is correct because an electrolyte is a substance that dissociates into ions when dissolved in water, and can conduct electricity. Some examples of electrolytes in the body are sodium, potassium, calcium, chloride, and bicarbonate.
Choice B reason: This is incorrect because an electrolyte is not a solid or a gas, but a dissolved substance. Electrolytes are essential for maintaining fluid balance, nerve impulses, muscle contractions, and acid-base balance in the body.
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