Nclexrn Quiz: Nutrition And Hydration
20 questions · exam conditions
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Nutrition And HydrationQuestion 1 of 20

A 62-year-old client with dysphagia after a mild stroke is on a mechanical-soft diet with nectar-thick liquids. The client has a persistent cough when drinking and has consumed only 600 mL of fluids in 24 hours. Assessment: urine dark and concentrated, BP 110/66 mm Hg, HR 98/min. Labs: sodium 149 mEq/L. Which action should the nurse take FIRST to address the client's nutritional needs?

Request a speech-language pathology swallow re-evaluation and hold thin liquids until reassessed
Encourage the client to drink unthickened water between meals to increase hydration
Document the intake and reassess hydration status at the end of the shift
Delegate to assistive personnel to feed the client quickly to increase total intake
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Nclexrn Quiz: Nutrition And Hydration

Practice Nutrition And Hydration in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

What this quiz covers

This quiz focuses on Nutrition And Hydration, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

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Question 1

A 62-year-old client with dysphagia after a mild stroke is on a mechanical-soft diet with nectar-thick liquids. The client has a persistent cough when drinking and has consumed only 600 mL of fluids in 24 hours. Assessment: urine dark and concentrated, BP 110/66 mm Hg, HR 98/min. Labs: sodium 149 mEq/L. Which action should the nurse take FIRST to address the client's nutritional needs?

  1. Request a speech-language pathology swallow re-evaluation and hold thin liquids until reassessed (correct answer)
  2. Encourage the client to drink unthickened water between meals to increase hydration
  3. Document the intake and reassess hydration status at the end of the shift
  4. Delegate to assistive personnel to feed the client quickly to increase total intake
Explanation: This question tests clinical judgment in managing aspiration risk with inadequate hydration in dysphagia. The client shows signs of aspiration (persistent cough when drinking) despite prescribed texture modification, with resulting dehydration (dark concentrated urine, elevated sodium 149 mEq/L, inadequate fluid intake 600 mL/24 hours). Option A is correct because requesting swallow re-evaluation and holding thin liquids addresses the immediate safety concern of aspiration while ensuring appropriate texture modifications are determined to meet hydration needs safely. Option B is dangerous as it encourages unthickened liquids that are causing coughing/aspiration; Option C delays intervention for a client already showing dehydration; Option D increases aspiration risk by rushing feeding and is inappropriate delegation. The clinical principle is prioritizing airway protection while ensuring adequate hydration through appropriate texture modifications determined by expert swallow evaluation. In dysphagia management, always stop textures causing coughing/aspiration, request SLP re-evaluation for texture changes, consider alternative hydration methods if needed, and monitor for signs of both dehydration and aspiration pneumonia.

Question 2

A 33-year-old client is 12 hours post-operative after a bowel resection. The client has hypoactive bowel sounds, reports abdominal bloating, and has not passed flatus; IV fluids are infusing, and the client is NPO. Labs: glucose 102 mg/dL, Na 139 mEq/L, K 3.8 mEq/L. Which action should the nurse take FIRST to address the client's nutritional needs?

  1. Assess for return of bowel function by auscultating bowel sounds and asking about flatus before advancing diet (correct answer)
  2. Advance the diet to a regular diet despite the lack of flatus to prevent postoperative catabolism and support healing
  3. Delegate to assistive personnel to provide a high-protein snack and monitor for tolerance after the client requests food
  4. Obtain a prealbumin level to evaluate nutritional status and determine protein requirements before deciding to advance the diet
Explanation: The client's hypoactive bowel sounds, abdominal bloating, and lack of flatus after bowel resection point to postoperative ileus. The client is NPO with IV fluids, so nutrition is temporarily supported; oral intake should not begin until bowel function returns. Auscultating for bowel sounds and asking about flatus before advancing the diet is the first step because it determines readiness for oral intake and prevents aspiration or anastomotic complications. Advancing to a regular diet despite absent flatus is unsafe; preventing catabolism or supporting healing does not override the need for bowel recovery. Delegating a high-protein snack to assistive personnel is inappropriate while the client is NPO, and it does not include the nurse's assessment of bowel function. Obtaining a prealbumin level may describe nutritional status, but it does not indicate bowel motility or readiness for diet, so it is not the first action. The priority is to verify return of bowel function before resuming enteral nutrition.

Question 3

A 4-year-old child has a diagnosed peanut allergy and is admitted for asthma exacerbation. The child is underweight (BMI <5th percentile) and the parent reports the child "won't eat" in the hospital. Which dietary modification should the nurse implement IMMEDIATELY?

  1. Delegate food selection entirely to the parent without nurse verification
  2. Offer high-protein peanut butter shakes to promote weight gain
  3. Encourage the child to eat only clear liquids until appetite improves
  4. Ensure all meals and snacks are peanut-free and verify ingredient lists before offering foods (correct answer)
Explanation: This question tests clinical judgment in nutrition and hydration management. The priority concern is underweight status in a child with peanut allergy, compounded by hospital refusal to eat. Ensuring peanut-free meals and verifying ingredients is the highest priority to prevent anaphylaxis while promoting intake. Offering peanut butter, clear liquids, or delegating without verification are incorrect as they risk exposure or inadequate nutrition. This applies the principle of prioritizing allergen safety in pediatric nutrition. A transferable strategy is to collaborate with dietary services for safe, appealing options and involve parents in meal planning for allergic children.

Question 4

A 47-year-old client is post-operative after gastric surgery and reports dumping symptoms (cramping and dizziness) after meals. The client has lost 3 kg in 1 month. Which dietary modification should the nurse implement IMMEDIATELY?

  1. Delegate teaching to dietary services and do not reinforce instructions
  2. Encourage high-sugar beverages with meals to increase calories quickly
  3. Increase intake of very hot liquids to slow gastric emptying
  4. Teach the client to eat small, frequent meals and avoid drinking fluids with meals (correct answer)
Explanation: This question tests clinical judgment in nutrition and hydration management. The priority concern is dumping syndrome causing symptoms and weight loss post-gastric surgery. Teaching small, frequent meals and avoiding fluids with meals is the highest priority to slow gastric emptying and improve tolerance. Encouraging high-sugar or hot liquids, or delegating without reinforcement are incorrect as they exacerbate symptoms. This applies the principle of symptom-specific dietary education for post-surgical complications. A transferable strategy is to instruct on meal separation from fluids and monitor weight in clients with dumping syndrome.

Question 5

A 79-year-old client with mild dementia is admitted from an assisted living facility with confusion and weakness. The client has dry mucous membranes, poor skin turgor, and has had 300 mL of dark amber urine over the last 8 hours; vital signs: T 36.8°C (98.2°F), HR 108/min, BP 92/58 mm Hg, RR 18/min. Labs: Na 150 mEq/L, BUN 34 mg/dL, creatinine 1.2 mg/dL. What is the PRIORITY nursing intervention for this client's hydration status?

  1. Offer 120 mL (4 oz) of oral water every hour while awake
  2. Initiate an IV line and begin isotonic fluids per facility protocol or provider order, then reassess vital signs and urine output (correct answer)
  3. Request a dietitian consult to increase daily fluid intake goals
  4. Delegate to assistive personnel to obtain a daily weight and record intake and output
Explanation: This question tests clinical judgment in nutrition and hydration management. The priority concern is dehydration, evidenced by dry mucous membranes, poor skin turgor, low urine output, tachycardia, hypotension, hypernatremia, and elevated BUN/creatinine ratio. Initiating an IV line and administering isotonic fluids is the highest priority action to rapidly correct fluid volume deficit and improve perfusion in this elderly client with signs of severe dehydration. Offering oral water, requesting a dietitian consult, or delegating weights and I&O are lower priority as they do not address the immediate need for rehydration or require prior stabilization. This applies the principle of prioritizing ABCs and immediate interventions for life-threatening conditions like hypovolemia. A transferable strategy is to always assess hydration status using clinical signs and labs, then intervene promptly with IV fluids when oral intake is insufficient in vulnerable populations.

Question 6

A 68-year-old client is post-operative day 2 after hip surgery and is receiving opioids for pain. The client reports constipation and poor appetite; intake has been <800 mL/day. Labs: Na 145 mEq/L, BUN 28 mg/dL. Which action should the nurse take FIRST to address the client's nutritional needs?

  1. Request an order for parenteral nutrition due to low intake
  2. Keep the client NPO until the first bowel movement occurs
  3. Delegate to assistive personnel to administer a PRN laxative without assessing the client
  4. Encourage increased oral fluids and fiber as tolerated and promote early ambulation to support bowel function (correct answer)
Explanation: This question tests clinical judgment in nutrition and hydration management. The priority concern is constipation and poor intake from opioids and low fluid/fiber, indicated by symptoms and mild dehydration labs. Encouraging fluids, fiber, and ambulation is the highest priority to promote bowel motility and hydration. Keeping NPO, delegating laxatives without assessment, or requesting PN are incorrect as they could worsen issues or are unnecessary. This applies the principle of non-pharmacologic interventions first for post-op complications. A transferable strategy is to integrate mobility and dietary fiber with hydration to prevent constipation in immobilized clients on opioids.

Question 7

A 60-year-old client with chronic liver disease has decreased appetite and reports feeling full quickly. Assessment shows ascites and muscle wasting; weight increased 4 kg in 2 weeks. Labs: albumin 2.6 g/dL, Na 130 mEq/L. The nurse should QUESTION which dietary order?

  1. Low-sodium diet
  2. Small, frequent meals
  3. High-salt snacks to stimulate appetite (correct answer)
  4. Protein intake as tolerated per plan of care
Explanation: This question tests clinical judgment in nutrition and hydration management. The priority concern is malnutrition amid fluid overload in liver disease, shown by decreased appetite, ascites, muscle wasting, weight gain, low albumin, and hyponatremia. The nurse should question high-salt snacks as they could worsen ascites and hyponatremia. Low-sodium diet, small frequent meals, and protein as tolerated are appropriate to support nutrition without fluid retention. This applies the principle of aligning orders with pathophysiology like portal hypertension. A transferable strategy is to balance protein needs with sodium restrictions, using ascites monitoring in liver disease clients.

Question 8

A 66-year-old client with chronic constipation reports drinking only coffee and eating little fiber. The client has hard, dry stools and abdominal discomfort; intake is about 600 mL/day. Labs: Na 147 mEq/L. What is the PRIORITY nursing intervention for this client's hydration status?

  1. Encourage increased water intake and replace some caffeinated beverages with non-caffeinated fluids as tolerated (correct answer)
  2. Restrict fluids to prevent electrolyte imbalance
  3. Delegate to assistive personnel to provide a high-protein diet
  4. Request an order for an enema before addressing fluid intake
Explanation: This question tests clinical judgment in nutrition and hydration management. The priority concern is dehydration contributing to constipation, shown by low intake, hard stools, discomfort, and hypernatremia. Encouraging increased water and replacing caffeinated drinks is the highest priority to soften stools and correct fluid balance. Restricting fluids, delegating high-protein, or requesting an enema first are incorrect as they could worsen dehydration or overlook root causes. This applies the principle of addressing hydration as foundational to bowel health. A transferable strategy is to promote non-caffeinated fluids and fiber intake, monitoring bowel patterns in clients with chronic constipation.

Question 9

A 81-year-old client with limited mobility has a stage 2 pressure injury on the sacrum. The client eats about 30% of meals and has lost 5% of body weight in 1 month; labs: albumin 2.8 g/dL. Which action should the nurse take FIRST to address the client's nutritional needs?

  1. Initiate high-protein, high-calorie oral nutrition supplements with meals and snacks per facility protocol (correct answer)
  2. Wait for weekly weights to confirm ongoing weight loss before intervening
  3. Delegate to assistive personnel to turn the client every 2 hours instead of addressing nutrition
  4. Request an order for total parenteral nutrition as the first option
Explanation: This question tests clinical judgment in nutrition and hydration management. The priority concern is malnutrition delaying pressure injury healing, indicated by low intake, weight loss, and low albumin. Initiating high-protein, high-calorie supplements is the highest priority to promote tissue repair. Waiting for weights, delegating turning only, or requesting TPN first are lower priority or overlook oral options. This applies the principle of optimizing nutrition for wound healing in immobile clients. A transferable strategy is to use oral supplements as first-line for protein-calorie deficits, evaluating wound progress and labs in pressure injury cases.

Question 10

A 29-year-old client is post-operative day 1 after appendectomy and is tolerating ice chips. The client reports hunger and has active bowel sounds; vital signs are stable. Which action should the nurse take FIRST to address the client's nutritional needs?

  1. Advance the diet to clear liquids per post-op protocol and monitor for nausea or vomiting (correct answer)
  2. Initiate total parenteral nutrition to prevent negative nitrogen balance while the client remains NPO
  3. Obtain a serum prealbumin level before changing the diet to assess the client's protein stores
  4. Delegate to assistive personnel to bring a regular meal tray and encourage the client to eat
Explanation: The priority is to safely advance oral intake in a client who shows readiness: tolerating ice chips, reports hunger, has active bowel sounds, and stable vital signs. Advancing the diet to clear liquids per post-op protocol and monitoring for nausea or vomiting directly meets nutritional needs while watching for intolerance. Initiating total parenteral nutrition is disproportionate and invasive; it is reserved for clients who cannot use the gastrointestinal tract, and this client's GI function supports enteral feeding. Obtaining a serum prealbumin level before changing the diet delays nutrition and is not a prerequisite for routine diet progression; prealbumin is not a timely indicator for this decision. Delegating to assistive personnel to bring a regular meal tray skips the prescribed clear-liquid step; a regular diet can be too much for a newly advanced GI tract, and the tray should follow the ordered diet progression. Thus, clear-liquid advancement is the first and safest action.

Question 11

A 54-year-old client is postoperative day 3 after abdominal hysterectomy and reports constipation and poor appetite. Assessment: abdomen mildly distended, hypoactive bowel sounds, passing flatus, pain controlled with opioids. Intake has been low; the client drank 800 mL in the last 24 hours. Labs: sodium 146 mEq/L, BUN 28 mg/dL. Which action should the nurse take FIRST to address the client's nutritional needs?

  1. Encourage increased oral fluids and ambulation as tolerated to promote bowel motility (correct answer)
  2. Initiate a high-fiber diet immediately, including raw vegetables and bran cereal
  3. Obtain an abdominal x-ray order before implementing bowel interventions
  4. Delegate to assistive personnel to administer a PRN laxative
Explanation: This question tests clinical judgment in managing postoperative constipation with dehydration. The client has opioid-induced constipation with concurrent dehydration evidenced by low fluid intake (800 mL/24 hours), elevated sodium (146 mEq/L), and elevated BUN (28 mg/dL), which worsens constipation by hardening stool. Option A is correct because encouraging increased oral fluids addresses both the dehydration and helps soften stool for easier passage, while ambulation stimulates peristalsis - both are safe first-line interventions for postoperative constipation with passing flatus. Option B is premature as high-fiber foods can worsen distention and discomfort when hydration is inadequate; Option C is unnecessary when the client is passing flatus and has only mild distention; Option D inappropriately delegates medication administration and doesn't address the underlying dehydration. The clinical principle is addressing dehydration as a primary cause of constipation before advancing to more aggressive interventions, using a stepwise approach in postoperative bowel management. For postoperative constipation management, implement the 'fluid-first' approach: increase fluids to 2-3 L/day, encourage ambulation, add fiber only after adequate hydration, then consider laxatives if conservative measures fail.

Question 12

A 45-year-old client is post-operative day 1 after an open colectomy. The client is NPO with an NG tube to low suction, reports nausea, and has had 900 mL NG output in the last 12 hours; vital signs: HR 104/min, BP 100/64 mm Hg. Labs: K 3.1 mEq/L, Cl 94 mEq/L. Which action should the nurse take FIRST to address the client's nutritional needs?

  1. Advance the diet to clear liquids as tolerated to promote caloric intake, giving antiemetics as needed for nausea.
  2. Delegate oral care and comfort measures to assistive personnel to maintain oral moisture while the client remains NPO.
  3. Obtain a 24-hour dietary recall to identify baseline eating patterns and guide a postoperative nutrition plan.
  4. Notify the provider of the electrolyte results and anticipate potassium replacement and IV fluid adjustment. (correct answer)
Explanation: The client has had 900 mL NG output, is tachycardic with a low blood pressure, and has hypokalemia and hypochloremia. These findings indicate significant fluid and electrolyte depletion that can threaten cardiac function. The priority is to notify the provider of the electrolyte results and anticipate potassium replacement and IV fluid adjustment; this addresses the physiologic imbalance before nutrition can be safely resumed. Advancing the diet to clear liquids with antiemetics is unsafe because the client is NPO with NG suction, and oral intake cannot begin until bowel recovery and electrolyte balance are addressed. Delegating oral care and comfort measures helps maintain oral moisture but does not correct hypokalemia or provide nutrition. Obtaining a 24-hour dietary recall may be part of a later nutrition workup, but it is not the first response to acute NG losses and abnormal labs. Therefore, reporting the electrolyte values and preparing for potassium and IV fluid therapy is the only choice that addresses the immediate threat.

Question 13

A 70-year-old client in a long-term care facility has had decreased oral intake for 3 days due to influenza. Assessment shows cracked lips, dry tongue, and orthostatic hypotension; vital signs: supine BP 118/70 mm Hg, standing BP 96/60 mm Hg, HR 112/min. Labs: Na 148 mEq/L. What is the PRIORITY nursing intervention for this client's hydration status?

  1. Start a voiding diary to track urine output and reassess hydration status in 8 hours
  2. Encourage small, frequent sips of oral rehydration solution and monitor for aspiration risk (correct answer)
  3. Delegate to assistive personnel to offer ice chips at frequent intervals and document intake
  4. Request an order for a multivitamin to improve appetite and support nutritional intake
Explanation: The client's cracked lips, dry tongue, orthostatic hypotension, tachycardia, and hypernatremia indicate clinically significant dehydration. The priority is to begin safe, effective rehydration while protecting the airway: encourage small, frequent sips of an oral rehydration solution and monitor for aspiration. A voiding diary with reassessment in 8 hours does not replace lost fluid and delays needed correction. Ice chips, even when offered frequently and documented, provide negligible fluid and no electrolyte replacement. A multivitamin may support appetite but will not correct hypernatremia or the fluid deficit. Therefore, direct oral rehydration with aspiration monitoring is the highest-priority nursing intervention.

Question 14

A 3-month-old infant is brought to the clinic with 1 day of diarrhea. The parent reports fewer wet diapers and difficulty feeding. Assessment: sunken anterior fontanel, dry mucous membranes, capillary refill 4 seconds, HR 168/min, weight decreased from 6.2 kg to 5.8 kg. What is the PRIORITY nursing intervention for this client's hydration status?

  1. Teach the parent to dilute the usual formula with extra water to provide additional free water
  2. Initiate oral rehydration solution in small, frequent amounts and monitor for continued signs of dehydration (correct answer)
  3. Collect a stool sample for culture before beginning fluid therapy so the causative organism can be identified
  4. Delegate to assistive personnel to weigh diapers for output measurement and document the results
Explanation: This infant has moderate dehydration: weight dropped from 6.2 kg to 5.8 kg (>5% loss), with sunken fontanel, dry mucosa, delayed capillary refill, and tachycardia. The priority is to correct the fluid deficit promptly, so initiating oral rehydration solution in small, frequent amounts is best; it replaces water and electrolytes, and monitoring for continued dehydration tells you whether escalation to IV therapy is needed. Diluting formula with extra water is unsafe: it provides free water without balanced electrolytes and can cause hyponatremia while also lowering caloric intake. Collecting a stool sample for culture before beginning fluid therapy delays treatment and puts the infant at risk, even though culture may be useful later. Weighing diapers and documenting output helps evaluate the response, but it does not replace fluids and is not the priority. Thus the correct intervention is the oral rehydration solution with close monitoring.

Question 15

A 73-year-old client is admitted with dehydration after 2 days of vomiting. Assessment: sunken eyes, dry mucous membranes, and poor skin turgor; vital signs: HR 116/min, BP 88/54 mm Hg. Labs: Na 152 mEq/L, BUN 40 mg/dL, creatinine 1.4 mg/dL. What is the PRIORITY nursing intervention for this client's hydration status?

  1. Start an IV and prepare to administer isotonic fluids per protocol or provider order, monitoring for improvement in perfusion (correct answer)
  2. Encourage the client to drink 240 mL of water every 15 minutes, using small frequent sips to minimize vomiting
  3. Delegate to assistive personnel to obtain a urine specimen for specific gravity, which will guide the selection of IV fluids
  4. Provide education about avoiding spicy foods and other gastrointestinal irritants to reduce nausea and prevent further fluid loss
Explanation: This client shows signs of severe hypovolemia: tachycardia, hypotension, hypernatremia, and elevated BUN/creatinine. The priority is to rapidly expand intravascular volume with isotonic IV fluids while monitoring perfusion. Encouraging oral water is inadequate and may not be tolerated due to vomiting; obtaining a urine specific gravity is a diagnostic measure that delays treatment; dietary education does not address the acute fluid deficit. Only IV isotonic fluid administration directly corrects the volume loss and improves hemodynamic stability.

Question 16

A 67-year-old client with heart failure is admitted with shortness of breath and edema. Current weight is 3 kg above baseline; lung sounds reveal crackles at bases. Labs: Na 132 mEq/L. The nurse should QUESTION which dietary order?

  1. Fluid restriction of 1.5 L/day to reduce preload and ease the client's breathing
  2. Low-sodium diet limited to 2 g/day to minimize fluid retention and support diuretic therapy
  3. Encourage 3 L/day of oral fluids to thin secretions (correct answer)
  4. Daily weights obtained at the same time each morning to track volume status trends
Explanation: This client is in fluid overload: weight gain, crackles, edema, and hyponatremia all point to excess volume. Your job is to spot the order that would make this worse. Encouraging 3 L/day of oral fluids would add more volume, worsening congestion and dilutional hyponatremia—so that is the order to question. The fluid restriction of 1.5 L/day is a standard approach to reduce preload and ease breathing; it fits the overload picture, so it is not the one to question. A low-sodium diet limited to 2 g/day also limits fluid retention and supports diuretics, making it appropriate care. Daily weights at the same time each morning are a monitoring tool, not a treatment order, and they help track volume trends—so they do not need to be questioned. The key is to evaluate each order against the client's fluid status: anything that adds volume is dangerous, while anything that reduces or tracks volume is appropriate.

Question 17

A 74-year-old client is receiving enteral feedings via NG tube after a stroke. The client has crackles at the right base and a new cough; gastric residual volume is 350 mL. Vital signs: T 37.9°C (100.2°F), RR 22/min. Which action should the nurse take FIRST to address the client's nutritional needs?

  1. Document the assessment and continue the feeding at the current ordered rate, then recheck residual volume in 2 hours.
  2. Increase the feeding rate to meet the client's caloric goals while keeping the head of bed elevated at 45 degrees.
  3. Delegate to assistive personnel to flush the nasogastric tube with water and continue the current feeding at the prescribed rate.
  4. Stop the feeding, elevate the head of bed, and assess for aspiration before resuming or notifying the provider. (correct answer)
Explanation: The crackles, new cough, fever, and high residual volume all suggest aspiration in an NG-fed client, so the first action is to protect the airway: stop the feeding, elevate the head of bed, and assess for aspiration before resuming the feeding or notifying the provider. This is the only option that halts the ongoing risk. The option that documents and leaves the current ordered feeding running while rechecking later delays the assessment and keeps delivering formula. The option that increases the feeding rate, even with the head of bed at 45 degrees, prioritizes caloric goals over airway safety and can worsen aspiration. The option that delegates a flush and continues the current feeding still leaves the aspiration risk active and fails to provide the nurse's own assessment. After assessment, the provider should be notified and feeding resumed only when safe.

Question 18

A 70-year-old client is postoperative day 2 after hip fracture repair. The client is alert but reports nausea and has eaten less than 25% of meals. Assessment: weight 60 kg, urine output 20 mL/hr for the last 4 hours, BP 104/62 mm Hg, HR 102/min; mucous membranes dry. Labs: BUN 30 mg/dL, creatinine 1.1 mg/dL, sodium 147 mEq/L. What is the PRIORITY nursing intervention for this client's hydration status?

  1. Administer prescribed antiemetic and encourage oral fluids as tolerated
  2. Start an IV line and administer an isotonic fluid bolus per protocol or prescribed orders, then reassess urine output (correct answer)
  3. Measure daily weights for the next 3 days to trend fluid status
  4. Delegate to assistive personnel to offer ice chips every hour
Explanation: This question tests clinical judgment in managing postoperative dehydration with oliguria. The client shows signs of significant dehydration with oliguria (20 mL/hr for 4 hours), hypotension (104/62), tachycardia (102/min), elevated BUN (30 mg/dL), and hypernatremia (147 mEq/L), indicating prerenal acute kidney injury risk. Option B is correct because administering an isotonic fluid bolus rapidly addresses the hypovolemia causing decreased renal perfusion, with immediate reassessment of urine output to evaluate response to treatment. Option A addresses the nausea but doesn't provide rapid enough fluid resuscitation for oliguria; Option C monitors trends but doesn't intervene for the acute problem; Option D is inadequate for correcting significant fluid deficit and inappropriate delegation. The clinical principle is recognizing oliguria (<0.5 mL/kg/hr) as a medical emergency requiring rapid fluid resuscitation to prevent acute kidney injury. In postoperative clients with oliguria, immediately assess volume status, administer IV fluid bolus (typically 500-1000 mL isotonic solution), monitor urine output hourly, and evaluate for other causes if no response.

Question 19

A 79-year-old client with mild dementia is admitted from an assisted living facility with 2 days of poor oral intake due to "not feeling thirsty." Assessment: dry mucous membranes, poor skin turgor, urine output 15 mL/hr, BP 92/54 mm Hg, HR 112/min, weight down 1.8 kg (4 lb) from last week. Labs: sodium 151 mEq/L, BUN 34 mg/dL, creatinine 1.3 mg/dL. What is the PRIORITY nursing intervention for this client's hydration status?

  1. Offer small sips of water and recheck intake in 1 hour
  2. Initiate prescribed isotonic IV fluids and monitor vital signs and urine output closely (correct answer)
  3. Request a urine specific gravity test before starting any fluids
  4. Delegate to the assistive personnel to encourage the client to drink fluids frequently
Explanation: This question tests clinical judgment in managing severe dehydration in an elderly client with dementia. The client presents with critical signs of dehydration including oliguria (15 mL/hr), hypotension (92/54 mm Hg), tachycardia (112/min), hypernatremia (151 mEq/L), and elevated BUN (34 mg/dL), indicating hypovolemia requiring immediate intervention. Option B is correct because initiating isotonic IV fluids addresses the immediate life-threatening hypovolemia and allows for rapid rehydration while monitoring vital signs and urine output ensures safe fluid resuscitation. Option A (small sips of water) is inadequate for severe dehydration and would take too long to correct the fluid deficit; Option C delays necessary treatment as the clinical picture already confirms dehydration; Option D inappropriately delegates a critical intervention and oral fluids alone cannot correct severe dehydration quickly enough. The clinical principle applied is prioritizing immediate intervention for hemodynamic instability before addressing underlying causes. When managing dehydration in elderly clients, always assess for severity indicators (vital signs, urine output, labs) and intervene rapidly with IV fluids for severe cases while monitoring for fluid overload.

Question 20

A 82-year-old client taking a thiazide diuretic for hypertension reports weakness and poor appetite. Assessment: BP 118/70 mm Hg, HR 88/min, mucous membranes moist, no edema. Labs: sodium 138 mEq/L, potassium 2.9 mEq/L, chloride 97 mEq/L. The provider writes several diet-related orders. The nurse should QUESTION which dietary order?

  1. Encourage foods high in potassium such as bananas, oranges, and potatoes
  2. Implement a low-sodium diet of 2 g/day
  3. Restrict oral fluids to 1,000 mL/day (correct answer)
  4. Offer small, frequent meals to improve intake
Explanation: This question tests clinical judgment in identifying inappropriate dietary orders for a client with medication-induced hypokalemia. The client has significant hypokalemia (2.9 mEq/L) from thiazide diuretic use, which requires potassium replacement, not fluid restriction that could worsen electrolyte imbalances. Option C should be questioned because restricting fluids to 1,000 mL/day is inappropriate for a client on diuretics with no signs of fluid overload (no edema, normal BP, moist mucous membranes) and could lead to dehydration and worsen electrolyte imbalances. Option A is appropriate as increasing dietary potassium helps correct the deficiency; Option B is reasonable for hypertension management; Option D may help improve overall intake in an elderly client with poor appetite. The clinical principle is avoiding fluid restriction in clients on diuretics unless there's evidence of fluid overload, as this can precipitate dehydration and worsen electrolyte imbalances. When managing clients on diuretics, encourage adequate fluid intake (usually 2-3 L/day unless contraindicated), increase dietary potassium, and monitor electrolytes regularly to prevent complications.