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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct because metabolic alkalosis is characterized by a high pH and a high HCO3-. The client's pH and HCO3- are both high, indicating a metabolic disorder. The condition is uncompensated because the PaCO2 is normal, meaning the respiratory system is not compensating for the metabolic alkalosis.
Choice B reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low HCO3-. The client's pH and HCO3- are both high, indicating alkalosis, not acidosis.
Choice C reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2. The client's pH is high, but PaCO2 is normal, indicating a metabolic problem, not a respiratory one.
Choice D reason: This is incorrect because respiratory acidosis is characterized by a low pH and a high PaCO2. The client's pH is high, and PaCO2 is normal, indicating a metabolic problem, not a respiratory one.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because intracellular fluid is greater than extracellular fluid in a hypertonic state, not an isotonic state. A hypertonic state is when the solute concentration of the extracellular fluid is higher than the intracellular fluid, which causes water to move out of the cells and shrink them.
Choice B reason: This is incorrect because extracellular fluid is less than intracellular fluid in a hypotonic state, not an isotonic state. A hypotonic state is when the solute concentration of the extracellular fluid is lower than the intracellular fluid, which causes water to move into the cells and swell them.
Choice C reason: This is correct because intracellular and extracellular fluid is equal in an isotonic state. An isotonic state is when the solute concentration of the extracellular fluid is the same as the intracellular fluid, which causes no net movement of water across the cell membrane.
Choice D reason: This is incorrect because interstitial fluid is less than the transcellular fluid in a situation of fluid imbalance, not an isotonic state. Interstitial fluid is the fluid that surrounds the cells, while transcellular fluid is the fluid that is contained in specialized cavities, such as cerebrospinal fluid, synovial fluid, or pleural fluid. The amount of transcellular fluid is normally very small compared to the interstitial fluid, but it can increase in certain conditions, such as edema, ascites, or hydrocephalus.
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