Chapter 1: Fluid Volume Excess

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1

A nurse preparing to assess pediatric clients on a step down unit should know that, compared with an adult, an infant has which amount of fluid per total body weight?

More fluid per total body weight

2

A nurse is caring for a client diagnosed hyperaldosteronism. How does aldosterone help regulate sodium and fluid balance?

By increasing sodium reabsorption from the renal tubules.

3

A medical-surgical nurse attends an inservice presentation on fluid and electrolyte imbalances. The nurse should recall that the regulators of fluid balance include which substances? Select all that apply.

  • Sodium
  • Protein
  • Albumin
4

A nurse administers captopril (Capoten) to a client with FVE. The nurse understands that this medication will affect the client's fluid balance by decreasing which of these options?

Fluid overload.

5

Which meal option should a nurse choose for a client with fluid volume excess (FVE) who is placed on a low-sodium diet?

Baked chicken breast, corn-on-the-cob, dinner roll, and milk

6

A nurse is caring for a client diagnosed with congestive heart failure (CHF) secondary to fluid volume excess (FVE). Which factors, if exhibited by the client, should the nurse associate with FVE? Select all that apply.

  • Decreased fluid output
  • Increased sodium intake
7

An older adult client presents to a clinic reporting fatigue, shortness of breath, and restlessness. A nurse assesses the client suspecting fluid volume excess (FVE). Which manifestations, if identified during assessment, should the nurse associate with FVE? Select all that apply.

  • Weight gain
  • Crackles in lungs
  • Increased respirations
8

A nurse assesses a 1-year-old infant hospitalized for syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding should the nurse identify as the most reliable indicator of fluid retention in an infant?

Sudden weight gain

9

A client diagnosed with renal failure experiences an increase of 2% in total body weight over a 48-hour period. How should a nurse classify this increase in weight?

Mild FVE

10

A nurse is recording intake and output for an adult client. The client reports consuming a 600 mL soft drink out of a bottle, has received 500 mL of IV fluids, and has voided 350 mL of urine. Determine the client's intake in milliliters. Record your answer as a whole number. _______

1,100 mL

11

A 185-pound male client with moderate fluid volume excess (FVE) gains 5% of his total body weight over a 2-day period. How many kilograms of weight did the client gain? Record your answer using one decimal place. _______

4.2 kg

12

A health-care provider orders hydrochlorothiazide 3 mg/kg/day in two divided doses by mouth for a 46-pound child with edema secondary to congestive heart failure (CHF). How many milligrams of hydrochlorothiazide should a nurse administer to this child every 12 hours (twice daily)? Record your answer using one decimal place. _______

31.5 mg q/12 hr

13

A health-care provider orders hydrochlorothiazide oral solution 2 mg/kg/day in two divided doses for a 36-pound child with edema secondary to congestive heart failure (CHF). The dose on hand is 10 mg/mL. How many milliliters should a nurse administer to this child every 12 hours? Record your answer using one decimal place. _______

1.6 mL

14

A health-care provider orders spironolactone (Aldactone) 400 mg/day in two divided doses by mouth for a client diagnosed with primary hyperaldosteronism. The dose of spironolactone on hand is 50 mg/tablet. How many tablets should a nurse administer to the client every 12 hours? Record your answer as a whole number. _______

4 tablets

15

A nurse reviews the laboratory report of an adult client who has been taking furosemide (Lasix) alone for the treatment of fluid volume excess (FVE). Which serum potassium level should the nurse anticipate?

2.7 mEq/L

16

A nurse is counseling an obese client who is considering gastric bypass surgery. When discussing the client's risk for fluid and electrolyte imbalances, which information should the nurse teach this client?

An obese person has less fluid than a lean person of the same body weight and is at increased risk for imbalances.

17

A nurse assesses a 3-day-old infant who has had difficulty latching onto its mother's breast. Worrying that her baby is not getting enough to drink, the mother has been giving the infant water from a bottle. Other than an increased intake of water, which factor should the nurse identify as predisposing this infant to fluid imbalances?

Decreased extracellular fluid

18

A nurse is assessing the lungs of a client admitted with gastrointestinal bleeding who is receiving a second unit of blood. The nurse auscultates bilateral crackles in the lower bases of the lungs. The previous nurse had reported clear lung sounds on this client. Which actions should the nurse take immediately? Select all that apply.

  • Slow down the transfusion
  • Notify the health-care provider.
19

A nurse administers digoxin and a loop diuretic to a client diagnosed with fluid volume excess (FVE) related to congestive heart failure (CHF). Why should the nurse identify this client as being at an increased risk for digoxin toxicity?

The potassium-depleting effect of the loop diuretic increases the effect of the digoxin.

20

A nurse administers digoxin to an older adult client diagnosed with atrial fibrillation and systolic heart failure. In addition to administering digoxin to treat the atrial fibrillation, for which other reason should the nurse administer digoxin to this client?

To increase cardiac output

21

A nurse collects data from a client who is receiving digoxin. Which manifestations, if reported by the client, should the nurse associate with the development of digoxin toxicity?

Decreased appetite, nausea, and muscle cramps

22

A nurse is reviewing a client's laboratory data. Which laboratory result should the nurse associate with the development of fluid volume excess (FVE)?

Decreased hematocrit

23

A nurse is preparing to transfuse two units of packed red blood cells to a client with a history of congestive heart failure (CHF). Which infusion rate should the nurse use when performing this infusion?

100 mL/hr

24

A nurse is caring for a client who has a history of multiple chronic illnesses. Which illness should the nurse identify as placing the client at greatest risk for fluid volume excess (FVE)?

End-stage renal disease

25

A nurse evaluates a client who received diuretic therapy for fluid volume excess (FVE). Which finding should indicate to the nurse that the therapy has been effective?

Decrease in body weight

26

After an initial assessment, a nurse suspects that a client has fluid volume excess (FVE) related to left-sided heart failure. Which assessment finding most likely caused the nurse's suspicion?

Peripheral edema2. Persistent nonproductive cough

27

When teaching a client who is taking long-term corticosteroid therapy, which statement by the nurse is correct?

"Corticosteroids may cause you to develop FVE through retention of sodium."

28

A nurse is planning care for a client on fluid restriction because of fluid volume excess (FVE). When caring for the client, which solution should the nurse use when diluting the client's medications?

Smallest volume possible

29

A nurse is preparing to infuse 0.9% normal saline solution intravenously to an infant. To prevent fluid volume excess (FVE), what is the safest way for the nurse to implement this order?

Calculating the drip rate and controlling the infusion using an infusion pump

30

A nurse evaluates a client being treated for fluid volume excess (FVE). The nurse determines that the client's FVE has not resolved as evidenced by which finding?

Crackles increased bilaterally in anterior and posterior lung fields

31

A client, who is on fluid restriction because of acute renal failure, reports discomfort, thirst, and an extremely dry mouth. The client asks a nurse why it is necessary to limit fluids when "I already feel so dry." Which response by the nurse is most appropriate?

"Your kidneys are unable to filter and excrete extra fluid at this time."

32

A nurse evaluating education for a client with fluid volume excess (FVE) determines that the client has demonstrated adequate understanding of the teaching after which statement by the client?

"I will notify my health-care provider if I gain more than 2 pounds in a day."

33

A nurse is developing a care plan for a client with fluid volume excess (FVE) and pitting edema. Based on this information, which nursing diagnosis should the nurse include in this client's care plan?

Risk for Imbalanced Fluid Volume2. Risk for Impaired Skin Integrity

34

A nurse is caring for an older adult client who is experiencing a fluid imbalance. Which age-related changes should the nurse associate with fluid imbalance in an older adult? Select all that apply.

  • Less efficient sodium and water regulation as renal blood flow and glomerular filtration decline
  • Decreased perception of thirst interfering with the thirst mechanism
  • Limited access to fluids because of physical disabilities associated with age-related illnesses
35

A health-care provider orders a 100-mg IV bolus of furosemide (Lasix) for a client diagnosed with fluid volume excess (FVE). To administer this medication safely, which action should the nurse take?

Administer IVP over 5 minutes.

36

A nurse is educating a client regarding a prescribed loop diuretic. Which instructions should the nurse include in the client's education? Select all that apply.

  • Change positions slowly to avoid orthostatic hypotension
  • Notify the health-care provider of weight gain more than 2 pounds in 1 day
  • Use sunscreen and protective clothing when outdoors.
37

When evaluating a client's education regarding furosemide (Lasix), which client statement demonstrates an understanding of the potential side effects of loop diuretics?

"I will notify my health-care provider if I hear a persistent ringing in my ears."

38

A client's IV solution of dextrose 5% in normal saline solution with 20 mEq potassium chloride per liter is infusing at 150 mL/hr as ordered. After 4 hours of infusion, the client begins to report shortness of breath and develops a cough. Which intervention should be the nurse's priority?

Assessing the client's lung sounds

39

A client develops moist crackles and dyspnea while receiving an IV infusion at 150 mL/hr. Based on this information, which intervention should be a nurse's first priority?

Stop the infusion and notify the health-care provider.

40

A medical resident writes orders for a client diagnosed with hypervolemia. Which orders should a nurse question? Select all that apply.

  • Administer oral fluids as tolerated
  • Weigh once per week
  • Administer hypertonic IV fluids as ordered
  • Administer isotonic IV fluids as ordered.
41

A nurse performing a client assessment suspects the client has fluid volume excess (FVE) related to right-sided heart failure. Which finding, if identified in this client, should the nurse associate with the development of right-sided heart failure?

Peripheral edema

42

A nurse is evaluating education for a client with fluid volume excess (FVE). Which statement by the client should indicate to the nurse that the client needs additional education?

"I do not need to worry about my diet because I am taking furosemide (Lasix)."

43

A nurse observes an older adult client who is developing edema because of right-sided heart failure. Without intervention, which physiological events are likely to occur in the development of edema in this client? Order each event in the correct sequence

  1. The right side of the heart weakens and is unable to pump blood efficiently into the pulmonary blood vessels.
  2. The volume of blood in the right side of the heart increases.
  3. As blood backs up into the venous system, venous hydrostatic pressure increases.
  4. Venous hydrostatic pressure causes capillary hydrostatic pressure to increase.
  5. Capillary hydrostatic pressure increases above the hydrostatic pressure in the interstitial space.
  6. Excess filtration of fluid from the capillaries into the interstitial space occurs.
  7. Visible edema forms.
44

A registered nurse (RN) is assigned to care for the following clients. Which client would be most appropriate for the RN to delegate to the licensed practical nurse (LPN)?

An older adult client admitted with dehydration who is receiving IV fluids

45

A nurse assesses the edematous extremities of a 6-month-old client. The nurse should document that the client has which grade of edema with a 6 mm indention?

Grade 3+ edema