Deck 11: Clients with Fluid Imbalances

Question 1

The nurse has a client who received large amounts of IV fluids during and following surgery, yet the client's urinary output is low and the client is agitated. The nurse realizes the IV fluid that most likely has caused this problem is

A) D₅W.
B)0.9% NS.
C)0.45% NS.
D) 3% saline.

Answer 1

D₅W.

Question 2

A client with severe malnutrition has pedal edema and ascites. The nurse notes that the weight is unchanged for the last 2 days. The most appropriate action by the nurse is to

A) ask the assistive personnel to re-weigh the client.
B) assess vital signs, level of consciousness, and urine output.
C) call the physician to request IV diuretics.
D) have biomedical engineering check the scale.

Answer 2

assess vital signs, level of consciousness, and urine output.

Question 3

A client has a serum sodium level of 115 mEq/L. The nurse has initiated a slow IV infusion of hypertonic saline solution per IV pump in a large vein. Which other intervention should the nurse implement as a priority?

A) Assess the client for dysphagia.
B) Have on-hand a calcium-channel blocker in case of overdose.
C) Initiate seizure and safety precautions.
D) Start a second IV in case the first one infiltrates.

Answer 3

Initiate seizure and safety precautions.

Question 4

The nurse anticipates that an order for an isotonic intravenous (IV) solution will read

A)0.45% sodium chloride.
B)0.9% sodium chloride.
C) 3% sodium chloride.
D) 5% dextrose in water.

Question 5

A client who regularly exercises vigorously is being discharged from the emergency department after suffering from dehydration that was corrected. The nurse would realize that the client needs additional instructions when the client says

A) "Drinking water too fast just goes through the kidneys and doesn't help."
B) "I will try to avoid exercising outside in high humidity."
C) "OK, I'll stop trying to lose weight by wearing sweats all summer long."
D) "When I get thirsty, I know to stop and drink something then."

Question 6

The nurse who is caring for a client prescribed diuretics and fluid restriction to control edema can most easily evaluate the effectiveness of the medical protocol by

A) calculating plasma osmolality.
B) careful weight assessment.
C) checking the lab report on serum sodium level.
D) measuring the ankle circumference.

Question 7

When assessing the laboratory values for an assigned client with fluid excess, the nurse finds the value that is consistent with this diagnosis to be

A) BUN 12 mg/dl.
B) hematocrit of 46%.
C) plasma osmolality of 285 mOsm/kg.
D) plasma sodium level of 129 mEq/L.

Question 8

A client has hypervolemic hyponatremia. The assessment finding the nurse would find inconsistent with this condition is

A) dysrhythmias
B) hypotension.
C) jugular vein distention.
D) S3 gallop.

Question 9

The nurse notes that a client with renal disease has a plasma osmolality of 200 mOsm/kg and a plasma sodium level of 122 mEq/L. The nurse would further assess the client for other manifestations of

A) extracellular fluid volume excess.
B) hyperosmolar fluid volume deficit.
C) intracellular fluid volume excess.
D) iso-osmolar fluid volume deficit.

Question 10

A client with hyponatremia is on a fluid restriction diet and complains of extreme dry mouth. Interventions the nurse can include in the plan of care include (Select all that apply)

A) encouraging the client to take warm, not cold, fluids.
B) giving the client ice chips instead of water.
C) increasing the frequency of oral care.
D) instructing the client to hold ice chips in the mouth.
E) using a commercial mouthwash every 2 hours.

Question 11

A client is taking an IV diuretic for fluid volume excess. Which of the following assessments should the nurse report to the physician?

A) Decrease in edema
B) Decrease in potassium level
C) Increase in urine output
D) Weight loss

Question 12

The nurse makes the evaluation that the intake of one of the adult clients in her care is adequate when she measures the total daily intake as

A) 750 ml.
B) 900 ml.
C) 1000 ml.
D) 2000 ml.

Question 13

A client had a stroke and is now being tube-fed. An important intervention the nurse should include in the care plan related to fluid and electrolyte balance is to

A) consult with a dietitian about providing sufficient calories.
B) check the sodium concentration of the formula.
C) prevent too-rapid infusion by using a feeding pump.
D) provide 1 ml of water per 1 kilocalorie of formula.

Question 14

A client has gastroenteritis and frequent diarrhea. The nurse should assess the client for (Select all that apply)

A) bradycardia.
B) decrease in blood pressure.
C) decrease in urine output.
D) temperature of 96° F.
E) tenting of skin.

Question 15

A client with dehydration is being weighed on a standing scale next to the bed. The most important action by the nurse is to

A) assist the client to prevent falls.
B) calibrate the scale per manufacturer's directions.
C) document the weight and compare it with prior ones.
D) explain to the client what is going to happen.

Question 16

The nurse working with elderly clients in a nursing home assesses them for dehydration closely because the clients (Select all that apply)

A) are more susceptible to developing ascites and anasarca.
B) experience interactions among drugs they may take for chronic illnesses.
C) have a decreased proportion of body water as compared to fat.
D) may be demented and not realize they need to drink.
E) probably have a diminished sense of thirst.

Question 17

A nurse is caring for four clients who are at risk for or who have an actual fluid volume deficit. Which client should the nurse assess first? The nurse should first assess the client who

A) is confused and spits out oral foods/fluids.
B) is on a tube-feeding running at 85 ml/hour.
C) was admitted with polyuria.
D) has diarrhea and now is restless.