Fluid Practice

What does a nurse identify as the priority short-term goal for a toddler with dehydration caused by diarrhea? 1. Improvement of fluid balance 2. Continuation of an antidiarrheal diet 3. Preservation of perianal skin integrity 4. Retention of weight appropriate for height

1. Improvement of fluid balance

The nurse monitors a patient with prolonged vomiting for fluid volume deficit, recognizing that fluid shifts which occur as a result of vomiting include 1.fluid movement from the cells into the interstitial space and the blood vessels. 2.fluid movement from the vascular system, causing cellular swelling and rupture. 3.an overload of extracellular fluid with a significant increase in intracellular fluid volume. 4.excretion of large amounts of interstitial fluid with depletion of extracellular fluids and fluid movement out of the cells.

1.fluid movement from the cells into the interstitial space and the blood vessels.

While caring for a patient with a protein deficiency, the nurse evaluates that the patient's condition is improving, based upon finding 1.decreased edema. 2.improved skin turgor. 3.decreased hematocrit. 4.decreased blood pressure.

decreased edema

The most reliable index of volume status when caring for a patient with a fluid imbalance is 1.skin turgor. 2.presence of edema. 3.hourly urine output. 4.daily weight patterns.

daily weight patterns

The RN calculates that the client's insensible fluid loss is approximately 500 mL/day. The nurse explains to the client that they are referring to fluid losses that (Select all that apply): 1. From the nasogastric tube and wound drain 2. From the foley catheter and nasogastric tube 3. From wound drain and skin 4. From the skin and lungs 5. Can be accurately measured 6. Can't be accurately measured.

2 and 6 Insensible fluid losses cant be measured because they occur through the skin and the lungs/ Sensible losses an be measured (wound drainage, GI tract losses, and urine).

A nurse is caring for a client who is receiving serum albumin. What indicates that the albumin is effective? 1. Improved clotting of blood 2. Formation of red blood cells 3. Activation of white blood cells 4. Maintenance of oncotic pressure

4. Maintenance of oncotic pressure

A toddler is admitted to the pediatric unit with diarrhea and severe dehydration. After several days of treatment the child is evaluated. What clinical findings indicate that the child is rehydrated? Select all that apply. 1. Decreased hematocrit 2. Increase in daily weight 3. Negative blood cultures 4. Increased sedimentation rate 5. Decreased blood urea nitrogen level

1,2,5

A 6-month-old infant is admitted to the pediatric unit with severe diarrhea. What nursing assessment is Most indicative of dehydration? 1. Level anterior fontanel 2. Decreased urine output 3. Warm skin temperature 4. Slow labored respirations

2. Decreased urine output

What clinical finding does a nurse expect when assessing a 4-month-old infant with gastroenteritis and moderate dehydration? 1. Urine output of 50 mL/hr 2. Depressed anterior fontanel 3. History of allergies to certain formulas 4. Capillary refill time of less than 2 seconds

2. Depressed anterior fontanel

The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that the purpose of the albumin is to: 1.Provide nutrients. 2. Increase protein stores. 3. Elevate the circulating blood volume. 4. Divert blood flow away from the liver temporarily.

3. Elevate the circulating blood volume

A 28-year-old female is admitted with severe bleeding from a fractured pelvis. Which IV fluid does the nurse anticipate as the most appropriate for use to replace potential fluid losses? a. 0.9% sodium chloride (0.9%NaCl) b. 3% sodium chloride (3%NaCl) c. 5% dextrose in water (D5W) d.5% dextrose in lactated ringers (D5LR

A. 0.9% NaCl

When administering albumin intravenously, the nurse considers that body water will shift from the: A. Interstitial compartment to the extracellular compartment. B. Intravascular compartment to the interstitial compartment. C. Extracellular compartment to the intracellular compartment. D. Intracellular compartment to the intravascular compartment.

Intracellular compartment to the intravascular compartment

A nurse recalls that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of: A. Osmosis B. Diffusion C. Active transport D. Hydrostatic Pressure

Osmosis

A client with ascites is schedules to receive albumin. To the greatest therapeutic effect, the nurse expects what infusion rate and what oral fluid intake? A. Slow IV rate and liberal fluid intake B. Slow IV rate and restrict fluid intake C. Rapid IV rate and withheld fluid intake D. Rapid IV rate and moderate fluid intake

Slow IV rate and restrict fluid intake.

The client has undergone an exploratory laparotomy and subsequent removal of a large intestinal tumor. A nasogastric tube is in place and IV fluids are infusing at 150 mL/hr via an IV pump. Which data should be reported to the health care provider? A. The pump keeps sounding an alarm that the high pressure has been reached. B. Intake is 1800 mL, NGT output is 550 mL, and Foley output 950 mL. C. On auscultation, crackles and rales in all lung fields are noted. D. Client has no pedal edema and an increasing level of consciousness.

C. On auscultation, crackles and rales in all lung fields are noted.

The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that the purpose of the albumin is to: A. Provide nutrients B. Increase protein stores. C. Elevate the circulating blood volume. D. Divert blood flow away from the liver temporarily.

Elevate the circulating blood volume.

If you were walking across the Sahara with an empty canteen, the amount of antidiuretic hormone (ADH) secreted would most likely: A. Increase B.Decrease C.Stay the same

A. Increase Your body would most likely be dehydrated, so it would try to retain as much fluid as possible. To retain fluid, ADH secretion increases.

A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which is the most appropriate response by the nurse? A. "The fluid is an adverse reaction to chemotherapy." B. "A decrease in activity has allowed extra fluid to accumulate in the tissues." C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues." D. "Chemotherapy has increased your blood pressure, and fluid was forced out into the tissues."

C. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues."

A 2-month-old infant is admitted to the pediatric unit with gastroenteritis and dehydration. Which assessment finding should the nurse anticipate? 1.Bulging fontanels 2.Marked restlessness 3.Resilient tissue turgor 4.Tachycardia

Tachycardia

During shift report, the nurse is told that a patient who has suffered a stroke has also developed diabetes insipidus (DI). The nurse concludes that this patient is now at risk for which of the following: a. Fluid volume deficit because of excess urine output b. Fluid volume excess because of inadequate urine output c. Hyperglycemia because of poor insulin production d. Hypoglycemia because of excess insulin production

b. Fluid volume excess because of inadequate urine output

A client with a serum sodium of 115 mEq/l has been receiving 3% NS at 50 mL/hr for 16 hours. The client complains of feeling tired and short of breath. Which of the following is the priority? A. Turn down the infusion B. Check the latest sodium level C. Assess for signs of fluid overload D. Place a call to the physician

c.Assess for signs of fluid overload.

A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous solution will be prescribed initially? A. 3% sodium chloride B. 0.9% sodium chloride C. 5% dextrose and 0.9% sodium chloride D. 5% dextrose and lactated ringer's

0.9 sodium chloride

A patient has a nursing diagnosis of fluid volume excess and is being treated with furosemide. Which assessment finding would indicate that the problem was resolved? a.Lungs clear to auscultation b.Pitting edema c.Bounding pulse d.Orthostatic hypotension

A. Lungs clear to auscultation

A nurse is assessing a young infant who is dehydrated. Which clinical sign is the Most important indication of the degree of dehydration? 1.Dry skin 2. Weight loss 3.Sunken fontanel 4.Decreased urine output

weight loss

A client with ascites is scheduled to receive albumin. To have the greatest therapeutic effect, the nurse expects what infusion rate and what oral fluid intake? 1. Slow intravenous (IV) rate and liberal fluid intake 2. Slow IV rate and restricted fluid intake 3. Rapid IV rate and withheld fluid intake 4. Rapid IV rate and moderate fluid intake

2. Slow IV rate and restricted fluid intake

When administering albumin intravenously to a client with cirrhosis, the nurse expects what fluid shift? 1. Interstitial compartment to extracellular compartment 2. Intravascular compartment to interstitial compartment 3. Interstitial compartment to intravascular compartment 4. Extracellular compartment to intracellular compartment

3. interstitial compartment to the intravascular compartment

Liver disease is characterized by decreased plasma proteins in the blood and obstruction of venous return to the heart. The nurse recognizes that these two factors result in 1.dehydration. The increased venous hydrostatic pressure forces more fluid through the kidney to be excreted. 2.vascular overload. Both the plasma oncotic pressure and the venous hydrostatic pressure are increased, keeping fluid in the vascular space. 3.edema. Both decreased plasma oncotic pressure and increased venous hydrostatic pressure cause movement of fluid into the interstitium. 4.normal fluid balance. Fluid movement is equalized by the decreased plasma oncotic pressure and the increased venous hydrostatic pressure.

3.edema. Both decreased plasma oncotic pressure and increased venous hydrostatic pressure cause movement of fluid into the interstitium.