Author Question: A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should ... (Read 112 times)

fox · **on:** Jun 25, 2018

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?

a. Measure intake and output every 4 hours.
b. Apply oxygen by mask or nasal cannula. c.
Increase the IV flow rate to 250 mL/hr.
d. Place the client in a high-Fowler's position.

Question 2

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?

a. A 36-year-old who is prescribed long-term steroid therapy
b. A 55-year-old receiving hypertonic intravenous fluids
c. A 76-year-old who is cognitively impaired
d. An 83-year-old with congestive heart failure

pocatato · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
Dehydration most frequently leads to poor cerebral perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimal. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the client too rapidly with IV fluids can lead to cerebral edema. Measuring intake and output and placing the client in a high-Fowler's position will not address the client's problem.

Answer to Question 2

ANS: C
Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration.