Question 1

A patient is admitted to the emergency department (ED)for fluid volume deficit.Which body system should the nurse focus to determine the cause of this imbalance when assessing this patient?

Accepted Answer

The gastrointestinal system plays a major role in fluid balance as it is responsible for absorbing fluids and nutrients from the food that we eat. Any disruption in the gastrointestinal system, such as vomiting, diarrhea, or poor oral intake can lead to fluid volume deficit. Therefore, the nurse should focus on the gastrointestinal system to determine the cause of this imbalance in the patient.

Question 2

A patient with acute renal failure has jugular vein distention,lower extremity edema,and elevated blood pressure.Based on this data,which nursing diagnosis is the most appropriate?

Accepted Answer

Jugular vein distention and lower extremity edema are signs of excess fluid volume, which is a common complication of acute renal failure. Elevated blood pressure could also be a result of excess fluid volume. Therefore, the most appropriate nursing diagnosis would be Excess Fluid Volume.

Question 3

The nurse is planning care for the patient with acute renal failure.The nurse plans the patient's care based on the nursing diagnosis of Excess Fluid Volume.Which assessment data supports this nursing diagnosis?

Accepted Answer

Pitting edema in the lower extremities can indicate excess fluid volume, which is a common complication of acute renal failure. Wheezing in the lungs may indicate respiratory issues, generalized weakness may be a sign of muscle wasting or malnutrition, and positive bowel sounds are a normal finding. However, pitting edema indicates an accumulation of excess fluid in the tissues.

Question 4

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

Accepted Answer

The statement "I can use as much salt substitute as I want" indicates a misunderstanding or lack of knowledge about sodium restriction. Salt substitutes can contain high amounts of potassium, which can also be problematic for those with heart failure. The patient should be instructed to use salt substitutes in moderation and under the guidance of their healthcare provider.

Question 5

The nurse is caring for a patient admitted with hypertension and chronic renal failure who receives hemodialysis three times per week.The nurse is assessing the patient's diet and notes the use of salt substitutes.When teaching the patient to avoid salt substitute,which rationale supports this teaching point?

Accepted Answer

Salt substitutes often contain potassium chloride, which can be harmful to patients with chronic renal failure who are receiving hemodialysis. Excessive potassium intake can potentially lead to hyperkalemia, which can cause heart arrhythmias and even cardiac arrest. Therefore, patients with chronic renal failure who receive hemodialysis should avoid salt substitutes.

Quiz 8: Fluid and Electrolyte Management

A patient is admitted to the emergency department (ED) for fluid volume deficit.Which body system should the nurse focus to determine the cause of this imbalance when assessing this patient?

A patient with acute renal failure has jugular vein distention,lower extremity edema,and elevated blood pressure.Based on this data,which nursing diagnosis is the most appropriate?

The nurse is planning care for the patient with acute renal failure.The nurse plans the patient's care based on the nursing diagnosis of Excess Fluid Volume.Which assessment data supports this nursing diagnosis?

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