Chapter 2: Fluid Volume Deficit

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Fluid Volume Deficit
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1

A nurse is assessing the fluid status of a client. What should be the client's daily intake?

The same amount as the sensible and insensible output

2

A client is receiving a hypertonic IV solution and develops excess fluid in the intravascular compartment secondary to fluid shifts. What causes this fluid shift?

Osmotic pressure

3

A nurse is caring for a child diagnosed with fluid volume deficit (FVD). The nurse recognizes that increased production of aldosterone and antidiuretic hormone (ADH) caused by FVD results in a decrease in which parameter?

Urine output

4

A full-term infant is placed under phototherapy lights to treat hyperbilirubinemia. Why does this therapy place the infant at increased risk for fluid volume deficit (FVD)?

Increases insensible water loss

5

A health-care provider writes orders for a client diagnosed with fluid volume deficit (FVD) secondary to influenza. Which medication should a nurse plan to administer if the client experiences nausea?

Promethazine (Phenergan)

6

A nurse assesses a client who reports vomiting and diarrhea. Which information is most important for the nurse to obtain?

How long the client has had these symptoms

7

An older adult client has had nausea, vomiting, and diarrhea for 3 days. Assessment by a nurse reveals dry oral mucosa, amber urine, and decreased skin turgor. Which measurement should the nurse obtain to best determine the client's current fluid status?

Blood pressure

8

A client is admitted with fluid volume deficit (FVD) caused by severe blood loss. What should a nurse identify as the most likely rationale for oliguria in this client?

The renin-angiotensin-aldosterone mechanism causes conservation of fluid.

9

Which client should a nurse classify as being at the highest risk for fluid volume deficit (FVD)?

An adult with moderate diarrhea

10

Which urine output value in an adult client should a nurse associate with the development of fluid volume deficit (FVD)?

20 mL/hr

11

A nurse takes the vital signs of a client who collapsed while working outdoors. Which parameter in the client's blood pressure measurement should the nurse associate with fluid volume deficit (FVD)?

Decreasing systolic blood pressure

12

Which action should a nurse who is admitting a client with vomiting and diarrhea initiate first?

Weigh the client.

13

A nurse reviews a care plan for a client and notes an order for a clear liquid diet. Which choice should the nurse offer to this client?

Ginger ale

14

A nurse is teaching clients to evaluate their fluid status by weight. When should the nurse instruct the clients to weigh themselves?

At the same time every morning and after urinating

15

Which intervention should a nurse include when planning care for a confused client with fluid volume deficit (FVD)?

Assist the client to drink fluids every hour.

16

A nurse is calculating a client's intake and output. How should the nurse include the irrigant of the client's continuous bladder irrigation?

Deduct the amount from the urine output

17

How should a nurse include a client's wound drainage when calculating intake and output?

Add the amount to the total output

18

When teaching a client who is breastfeeding a newborn, which instruction should a nurse provide to the new mother to reduce the newborn's risk of developing fluid volume deficit (FVD)?

Maintain adequate fluid intake.

19

A neonate weighing 2,500 gm is to receive a transfusion of packed red blood cells (PRBCs) of 10 mL/kg to replace a fluid volume deficit (FVD) resulting from abruptio placentae at delivery. How many milliliters of PRBCs should a nurse administer to this client? Record your answer as a whole number. _______

25 mL PRBCs

20

A pediatrician writes an order for an infant to receive a minimum of 140 mL of formula every 12 hours. To achieve this, how many milliliters of formula should a nurse administer to the infant every 4 hours? Record your answer using one decimal place. _______

48.5 mL

21

An infant weighing 11 pounds has voided 180 mL at the end of a 12-hour shift. How many mL/kg/hr of urine has this infant voided? Record your answer as a whole number. _______

3 mL/kg/hr

22

A client is admitted to the emergency department with a closed head injury and multiple fractures. Which IV solution should a nurse plan to administer?

0.9% saline solution

23

A nurse suspects that a client who presents to an urgent care center after a reported 3-day history of nausea, vomiting, and diarrhea is severely dehydrated. Which information is most important for the nurse to obtain when assessing this client?

Vital signs

24

Which client information should a nurse associate with a nursing diagnosis of Deficient Fluid Volume Secondary to Dehydration?

Blood pressure 96/54 mm Hg

25

An older adult client who presents at a health-care provider's office reports dizziness and "heart racing" that often occurs when the client is gardening outdoors. Which question should the nurse include in the initial assessment of this client?

"What time of the day and for how long are you gardening?"

26

A client diagnosed with liver failure presents to an acute care facility with moderate ascites and reports shortness of breath. Vital signs are blood pressure 90/50 mm Hg, heart rate 104 bpm and weak, and respiratory rate 26 and shallow. The client's skin and mucous membranes are dry. Based on this information, which nursing diagnosis should be the priority?

Deficient Fluid Volume Related to Third Spacing Fluid Shifts Secondary to Liver Failure

27

Which intervention should a nurse include in the plan of care for a client diagnosed with fluid volume deficit (FVD)?

Monitor for an increase in temperature.

28

A nurse who is planning care for a client with severe fluid volume deficit (FVD) and hyponatremia should anticipate an order for an infusion of which IV solution?

3% saline solution

29

A nurse receives a phone call from the parent of an infant who is listless and has had vomiting and diarrhea for 2 days. Which is the most appropriate instruction for the nurse to give the parent?

Bring the infant to the pediatrician or emergency department.

30

A client has had nausea, vomiting, and diarrhea for 3 days. A nurse suspects the client has fluid volume deficit (FVD) and plans to assess the client for orthostatic hypotension. Which method should the nurse use in this assessment? Place each action in the correct sequence (1–5).

  1. Check the client's blood pressure and pulse rate in the supine position.
  2. Check the client's blood pressure and pulse rate in the sitting position.
  3. Check the client's blood pressure and pulse rate in the standing position.
  4. Compare the client's blood pressure and pulse rates.
  5. Document the results of the assessments
31

Which urine output value in an adult client should a nurse associate with the development of fluid volume deficit (FVD)?

700 mL/day or 29 mL/hr

32

A nurse is planning care for a confused, otherwise healthy, 70-kilogram adult client at risk for fluid volume deficit (FVD). What is the minimum number of milliliters of fluid per day that the nurse should plan for the client to ingest? Record your answer using a whole number. _______

2,100 mL/day

33

A pregnant client with hyperemesis gravidarum has had continuous nausea and vomiting for 3 days. IV fluid replacement is planned. A nurse should anticipate orders from the client's obstetrician for which type of IV solution?

Isotonic

34

A nurse is caring for a client diagnosed with fluid volume deficit (FVD) secondary to diabetic ketoacidosis (DKA) who is experiencing nausea, vomiting, and abdominal pain. A health-care provider orders NPO status for the client to decrease nausea and vomiting, and begins to write orders for IV fluid replacement therapy. Which IV solutions should the nurse identify as appropriate for this client? Select all that apply.

  • Dextrose 5% in water
  • Dextrose 5% in normal saline solution
  • 0.45% saline solution
  • Lactated Ringer's solution
35

A nurse caring for a client who is hypovolemic anticipates orders from a health-care provider for IV fluid replacement therapy. Which IV solutions should the nurse identify as appropriate for this client? Select all that apply.

  • Normal saline solution
  • Lactated Ringer's solution
36

A nurse planning oral rehydration for a client with fluid volume deficit (FVD) should include which choices for a clear liquid diet? Select all that apply.

  • Diet ginger ale
  • Chicken bouillon
  • Grape juice
37

A nurse who is calculating intake and output from 0700 to 1900 for a client with fluid volume deficit (FVD) notes that the client has ingested two 120-mL portions of juice, 240 mL of water, and 240 mL of milk and has been receiving IV 0.9% saline solution at 100 mL/hr via electronic pump. The client has voided 275 mL, 300 mL, and 200 mL of urine and has vomited twice with an estimated volume of 100 mL at each occurrence. The client has also had one liquid stool measuring 300 mL. What should the nurse enter on the intake and output record for this time period? Record your answers as whole numbers.

Intake _1,920 mL_ Output _1,275 mL_

38

A nurse is evaluating IV fluid administration orders for a client with fluid volume deficit (FVD) secondary to vomiting. Which IV solutions should the nurse identify as appropriate for this client? Select all that apply.

  • 0.9% saline solution
  • Lactated Ringer's solution
39

A nurse plans to assess the skin turgor of a young adult client. In which location should the nurse assess the skin turgor of this client?

  1. Forehead
  2. Sternum
  3. Abdomen
  4. Thigh

Sternum

40

For which potential complication should a nurse monitor in a client who is receiving IV hypotonic saline solution?

Mental status changes

41

Which vital sign reading should a nurse associate with the development of fluid volume deficit (FVD)?

80/60 mm Hg, P 110 bpm, RR 24

42

Which clinical manifestation should a nurse associate with effective IV fluid replacement therapy for a client diagnosed with fluid volume deficit (FVD)?

Urine output of 50 mL/hr

43

Which order given for a client with a closed head injury, multiple fractures, and blood loss should a nurse question?

Vital signs every 4 hours

44

A nurse who is assessing intake and output for a client with severe burns notes the client's intake is 2,000 mL greater than output. Which rationales should the nurse associate with this discrepancy? Select all that apply.

  • The client is experiencing vasoconstriction
  • The client is experiencing increased insensible output
  • The client is experiencing third spacing.
45

Which manifestations should a nurse associate with the development of fluid volume deficit (FVD) in a client receiving diuretic therapy? Select all that apply.

  • Dry oral mucosa
  • Hypotension