Question 1

The nurse identifies the diagnosis Risk for Impaired Skin Integrity as applicable for a client diagnosed with heart failure.Which assessment finding supports the use of this diagnosis for the client?

Accepted Answer

+3 pitting edema both feet indicates fluid accumulation in the lower extremities, which can lead to skin breakdown and impaired skin integrity. Shortness of breath with ambulation and a productive cough are more indicative of respiratory issues, while heart rate 104 and regular is a cardiovascular assessment finding but does not directly relate to skin integrity.

Question 2

The nurse is caring for a child who weighs 33 lb and has been diagnosed with dehydration.The healthcare provider's orders state that the child is to receive 50 mL/kg of oral fluids for the next 4 hours.How many total mL of fluid should the nurse provide to the client? Calculate to the nearest whole number.
________ mL

Accepted Answer

The answer of The nurse is caring for a child...

Question 3

An increase in blood hydrostatic pressure would result in which fluid volume disturbance?

Accepted Answer

An increase in blood hydrostatic pressure would result in a higher pressure within the capillaries, which would push fluid out through the capillary walls and into the interstitial compartment. This would lead to a fluid volume excess in the interstitial compartment.

Question 4

The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise.Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the session?

Accepted Answer

The correct statement that indicates an appropriate understanding of the preventive techniques taught during the session is that the child needs to stop every 15 to 20 minutes during physical activity to drink fluids. This allows the child to stay hydrated and prevent heat-related illness. Wearing light-colored, loose-fitting clothing is recommended instead of dark clothing. Water is the drink of choice for hydration rather than sugary or caffeinated beverages, and it is necessary to drink fluids throughout the exercise session rather than just at the end.

Question 5

________ is a process whereby fluid and solutes move together across a membrane from an area of higher pressure to one of lower pressure.

Accepted Answer

The process described in the question is filtration. Osmosis is the movement of water molecules from an area of high concentration to an area of low concentration, diffusion is the movement of molecules from an area of high concentration to an area of low concentration, and active transport is the movement of molecules against their concentration gradient requiring energy.

Question 6

Which of the following terms refers to severe,generalized edema,which may occur as a result of fluid volume excess?

Accepted Answer

Anasarca refers to severe, generalized edema that can occur as a result of fluid volume excess throughout the body. Ascites refers specifically to edema in the abdominal cavity. Hypervolemia refers to an excessive volume of blood in the circulatory system. Orthopnea refers to difficulty breathing while lying flat and may be a symptom of heart failure.

Question 7

Which of the following statements is correct with regard to hypercalcemia?

Accepted Answer

Hypercalcemia is often a result of hyperparathyroidism, a condition in which the parathyroid gland produces excessive amounts of parathyroid hormone (PTH). PTH causes an increase in the amount of calcium in the blood by stimulating bone resorption, reducing renal excretion of calcium, and stimulating the activation of vitamin D, which in turn increases calcium absorption from the gastrointestinal tract.

Question 8

The nurse is caring for a client diagnosed with heart failure who is admitted to the medical-surgical unit with acute hypokalemia.Which drug on the client's medication administration record may have contributed to the client's current hypokalemic state?

Accepted Answer

A)Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop)diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.
B)Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop)diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.
C)Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop)diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.
D)Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting (loop)diuretics, amphotericin B, and large doses of some antibiotics. Cortisol is a type of corticosteroid and can cause hypokalemia. Thiazide diuretics, narcotics, and muscle relaxers would not bring about potassium loss to cause hypokalemia.

Question 9

The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery.The nurse is aware that this client is at risk for fluid volume excess.The family asks why the client is at risk for this condition.Which response by the nurse is the most appropriate?

Accepted Answer

A)Antidiuretic hormone (ADH)and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and place stress on the heart and circulatory system. A fluid volume excess should not occur with the proper administration of intravenous fluids. Liver failure is not caused by cardiac surgery. Fluid volume excess is not a result of inactivity.
B)Antidiuretic hormone (ADH)and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and place stress on the heart and circulatory system. A fluid volume excess should not occur with the proper administration of intravenous fluids. Liver failure is not caused by cardiac surgery. Fluid volume excess is not a result of inactivity.
C)Antidiuretic hormone (ADH)and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and place stress on the heart and circulatory system. A fluid volume excess should not occur with the proper administration of intravenous fluids. Liver failure is not caused by cardiac surgery. Fluid volume excess is not a result of inactivity.
D)Antidiuretic hormone (ADH)and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and place stress on the heart and circulatory system. A fluid volume excess should not occur with the proper administration of intravenous fluids. Liver failure is not caused by cardiac surgery. Fluid volume excess is not a result of inactivity.

Question 10

What is the principal mineralocorticoid that assists in regulating the body's serum sodium balance?

Accepted Answer

Aldosterone is the principal mineralocorticoid hormone secreted by the adrenal cortex that assists in regulating the body's serum sodium balance by promoting the reabsorption of sodium ions from the renal tubules of the kidneys into the bloodstream while excreting potassium ions. Antidiuretic hormone is involved in regulating water balance, Parathyroid hormone regulates calcium and phosphate levels, and progesterone is involved in the female reproductive system.

Question 11

A client in the emergency department is being admitted with a diagnosis of fluid volume deficit.When preparing to assess this client,on which body system should the nurse focus to determine the cause of the imbalance?

Accepted Answer

A)The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.
B)The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.
C)The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.
D)The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.

Question 12

A client diagnosed with frequent urinary tract infections is seen in the urology clinic.The nurse reviews the client's medical history and determines that the client is at risk for acute kidney injury.Which items in the client's history support this conclusion? Select all that apply.

Accepted Answer

A)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.
B)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.
C)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.
D)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.
E)Dehydration, renal calculi, and hypertension can all precipitate acute kidney injury (AKI). Ineffective wound healing has not been shown to cause renal failure unless the infection becomes systemic. A low serum albumin does not cause AKI.

Question 13

The nurse is planning care for a client admitted to the unit with a diagnosis of dehydration.The client's lab values indicate a low level of serum sodium.Based on the assessment finding,the nurse determines that Risk for Electrolyte Imbalance is an appropriate nursing diagnosis.Which medical condition supports this nursing diagnosis?

Accepted Answer

Hypotonic dehydration is characterized by a decrease in both sodium and water in the body, leading to an imbalance in electrolytes. This supports the nursing diagnosis of Risk for Electrolyte Imbalance. Isotonic dehydration, on the other hand, results in a loss of only water, while hydrostatic and osmotic pressures are not directly related to dehydration or electrolyte imbalances.

Question 14

A client diagnosed with heart failure is prescribed an oral fluid restriction of 1200 mL per day.How many ounces of fluid would the client be permitted during the day shift?

Accepted Answer

A)When calculating a fluid restriction, 50% of the total daily fluid allowance should be allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shifts, or 33% of the remaining volume can be provided on the evening shift with the balance provided during the night shift. Thus, for a fluid restriction of 1200 mL, the client would be permitted 600 mL of fluid during the day shift. The remaining balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift.
B)When calculating a fluid restriction, 50% of the total daily fluid allowance should be allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shifts, or 33% of the remaining volume can be provided on the evening shift with the balance provided during the night shift. Thus, for a fluid restriction of 1200 mL, the client would be permitted 600 mL of fluid during the day shift. The remaining balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift.
C)When calculating a fluid restriction, 50% of the total daily fluid allowance should be allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shifts, or 33% of the remaining volume can be provided on the evening shift with the balance provided during the night shift. Thus, for a fluid restriction of 1200 mL, the client would be permitted 600 mL of fluid during the day shift. The remaining balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift.
D)When calculating a fluid restriction, 50% of the total daily fluid allowance should be allocated to the day shift. The remaining 50% can be either divided equally between the evening and night shifts, or 33% of the remaining volume can be provided on the evening shift with the balance provided during the night shift. Thus, for a fluid restriction of 1200 mL, the client would be permitted 600 mL of fluid during the day shift. The remaining balance of 600 mL would be split over the evening and night shifts. Depending upon the allocation, the client would either receive 300 mL for both the evening and night shifts or 400 mL of fluid for the evening shift and 200 mL for the night shift.

Question 15

The nurse is caring for a client admitted with a diagnosis of acute kidney injury (AKI).The client asks the nurse,"Are my kidneys failing? Will I need a kidney transplant?" Which response by the nurse is the most appropriate?

Accepted Answer

Option A provides false reassurance and does not address the client's concerns. Option C is not true for all cases of AKI and may cause unnecessary anxiety for the client. Option D puts off the client's question and does not provide helpful information. Option B provides accurate information and reassurance that AKI is often reversible with prompt treatment. It also acknowledges the client's concerns about kidney failure and transplantation.

Question 16

The nurse receives a shift report on a pediatric medical-surgical unit.The nurse has been assigned four clients for the shift.Which client should the nurse plan to assess first based on an increased risk for dehydration?

Accepted Answer

The 15-month-old child with tachypnea is at an increased risk for dehydration because rapid breathing promotes water loss through exhalation. Therefore, the nurse should assess this client first to monitor for signs and symptoms of dehydration, such as decreased urine output or dry mucous membranes.

Question 17

The nurse is caring for a client with a potassium level of 5.9 mEq/L.The healthcare provider prescribes both glucose and insulin for the client.The client's spouse asks,"Why is insulin needed?" Which response by the nurse is the most appropriate?

Accepted Answer

Insulin helps to move potassium from the bloodstream into the cells, lowering blood potassium levels. This is the reason insulin is prescribed for a high potassium level.

Question 18

An older adult client is brought to the emergency department.The client has been experiencing fever,nausea,and vomiting for the past 2 days.The client denies thirst.Urine dipstick indicates a decreased urine specific gravity.Based on this data,which diagnosis should the nurse most anticipate for this client?

Accepted Answer

The symptoms of fever, nausea, vomiting, and decreased urine specific gravity suggest dehydration, which is common in older adults and can lead to serious complications such as electrolyte imbalances and renal failure. Congestive heart failure and fluid overload would typically present with increased urine output, not decreased, and normal aging does not typically cause sudden onset of these symptoms.

Question 19

The nurse is instructing a client diagnosed with heart failure about a prescribed sodium-restricted diet.Which client statement indicates that additional teaching is required?

Accepted Answer

The client statement "I can use as much salt substitute as I want" indicates that additional teaching is required as salt substitutes may contain high amounts of potassium which can be harmful to clients with heart failure. The other statements show that the client understands the instructions given by the nurse.

Question 20

The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months.Which interventions should the nurse recommend to decrease the risk of fluid imbalance? Select all that apply.

Accepted Answer

A)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.
B)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.
C)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.
D)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.
E)Actions to prevent fluid volume deficit during the summer months include increasing fluid intake, drinking flat cola or ginger ale if vomiting, and reducing the intake of caffeinated beverages like coffee and tea. Diet soda often contains caffeine and should thus be avoided. Exercising between the hours of 10 a.m. and 2 p.m. should also be avoided, as this is typically the hottest time of the day.

Quiz 6: Fluids and Electrolytes