Fluid And Electrolyte NCLEX Quiz

Assessing dietary intake is the appropriate nursing intervention for maintaining normal bowel function in a patient suffering from constipation. By assessing the patient's dietary intake, the nurse can identify any deficiencies or excesses in fiber, fluids, and other nutrients that may be contributing to the constipation. This information can then be used to develop a personalized plan to improve the patient's bowel function, such as increasing fiber intake or recommending specific dietary changes.

The correct answer is to administer anti-inflammatory agents as prescribed. Facial grimaces can be a sign of pain, which is commonly experienced by burn trauma patients. Anti-inflammatory agents can help reduce pain caused by cellular injury and inflammation. Keeping the skin clean and dry is important for preventing infection, but it does not directly address the pain caused by cellular injury. Applying warm packs can help reduce edema, but it does not specifically target the pain caused by cellular injury. Therefore, administering anti-inflammatory agents as prescribed is the most appropriate nursing intervention to reduce the pain in this scenario.

Both a patient who has had diarrhea for 2 days and a patient with continuous nasogastric suction are at high risk for fluid volume deficiency. Diarrhea leads to significant fluid and electrolyte loss through frequent watery bowel movements, which can quickly result in dehydration if not adequately managed. Similarly, continuous nasogastric suction can cause significant loss of stomach fluids, which also contain important electrolytes and water, leading to a similar risk of dehydration. Both conditions actively remove substantial amounts of fluid from the body, placing these patients at a heightened risk for fluid volume deficiency.

For a patient, particularly a young adolescent admitted with hyperthermia, the appropriate nursing intervention is to reduce the room temperature. Hyperthermia occurs when the body's heat-regulation system cannot handle excess heat, leading to an elevated body temperature. Reducing the room temperature helps lower the patient's core temperature in a controlled manner, supporting the body's efforts to reach a normal temperature range. This intervention is critical in preventing further complications associated with hyperthermia, such as heat exhaustion or heat stroke, and facilitates more effective body temperature regulation.

An 8-month-old having a fever of 102.3 'F and having diarrhea is at the highest risk for an electrolyte imbalance. Fever and diarrhea can lead to excessive fluid loss and dehydration, which can disrupt the balance of electrolytes in the body. Electrolytes such as sodium, potassium, and chloride are essential for maintaining proper cell function and fluid balance. In infants, who have a higher ratio of body surface area to body weight, fluid and electrolyte imbalances can occur more rapidly and have more severe consequences. Therefore, the combination of fever, diarrhea, and young age puts the 8-month-old at the highest risk for an electrolyte imbalance.

Among the options provided, an old chronic alcoholic is most at risk for hypomagnesemia (low magnesium levels in the blood). Chronic alcohol consumption can lead to significant nutritional deficiencies, including magnesium deficiency. Alcohol affects the body's ability to absorb magnesium from the diet, and frequent alcohol intake can also increase the excretion of magnesium through the kidneys. Moreover, chronic alcoholism is often associated with a poorer overall diet, which compounds the risk of magnesium and other nutritional deficiencies. This combination of factors makes chronic alcoholics particularly susceptible to hypomagnesemia.

A key intervention for preventing constipation, especially following surgery, is ensuring adequate hydration. Encouraging the client to fill a 2-liter bottle with water each night and drink it throughout the next day is an effective way to maintain fluid intake. Proper hydration helps to soften stool, which facilitates easier passage and reduces the risk of constipation. This method is simple, measurable, and encourages consistent hydration habits, making it a practical and effective strategy for managing bowel health post-surgery.

Addison's disease, a condition characterized by the underproduction of adrenal hormones, can lead to hyperkalemia, or elevated blood potassium levels. This occurs because the adrenal hormones, particularly aldosterone, play a crucial role in regulating potassium levels by promoting its excretion through the kidneys. In Addison's disease, the lack of aldosterone results in decreased potassium excretion, leading to an accumulation of potassium in the blood. Therefore, a patient with Addison's disease is more likely to have a potassium level of 5.5, which is higher than the normal range.

Kegel exercises are a suitable intervention for a patient experiencing urinary dribbling because they help strengthen the pelvic floor muscles, which can improve bladder control and reduce urinary leakage. Keeping the skin dry and clean is important for maintaining hygiene, but it does not directly address the issue of urinary dribbling. Using pads or diapers can provide temporary containment, but it does not address the underlying problem or help improve bladder control. Therefore, the most appropriate intervention is to make the client perform Kegel exercises.

In severe burns, the body's response to injury can cause fluid to shift from the intravascular space (blood vessels) to the interstitial space (spaces between cells). This is known as third spacing. Third spacing can lead to fluid accumulation in tissues, such as the abdominal tissue, without a change in weight or a significant difference in intake and output. Therefore, the presence of fluid accumulation in the abdominal tissue without any other significant changes suggests third spacing as the likely cause.