Chapter 11: Fluid Balance EAQ Questions (Rationales)

The student nurse is explaining body responses to alterations of fluid balance. Which statement made by the student requires correction? A. "Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." B. "The hypothalamus contains osmoreceptors that are sensitive to changes in blood osmolarity." C. "Antidiuretic hormone (ADH) is released from the posterior pituitary gland in response to changes in blood osmolarity." D. "Aldosterone is secreted by the adrenal cortex whenever sodium levels in the extracellular fluid are low."

A. "Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." Rationale: The student nurse requires correction when stating, "Natriuretic peptides (NPs) are secreted by the kidneys to restore tissue perfusion." NPs are hormones secreted by special cells that line the atria of the heart in response to increased blood volume and blood pressure. The other statements are correct. The hypothalamus contains osmoreceptors that are sensitive to changes in blood osmolarity. Aldosterone is secreted by the adrenal cortex whenever sodium levels in the extracellular fluid are low. ADH is released from the posterior pituitary gland in response to changes in blood osmolarity.

Which total urine output for the previous day would place a patient at risk for accumulating waste products? A. 500 mL B. 700 mL C. 900 mL D. 1100 mL

A. 500 mL Rationale: The minimum amount of urine per day needed to excrete toxic waste products is 400 to 600 mL. This minimum volume is called the obligatory urine output. If the 24-hour urine output falls below the obligatory output amount, wastes are retained and can cause lethal electrolyte imbalances, acidosis, and a toxic buildup of nitrogen. 700 mL, 900 mL, and 1100 mL of total urine output will not place the patient at risk for accumulating waste products.

An older adult patient with a history of renal failure is brought in to the emergency department with sudden onset of acute confusion, worsening muscle weakness in the extremities, abdominal cramps, and a weak, rapid, and thready pulse. What are the immediate nursing interventions to stabilize the patient? Select all that apply. A. Administering diuretics B. Administering 0.9% saline C. Administering anti-psychotics D. Administering calcium channel blockers E. Administering 5% dextrose in 0.45% sodium chloride

A. Administering diuretics B. Administering 0.9% saline E. Administering 5% dextrose in 0.45% sodium chloride Rationale: The patient's symptoms indicate hypernatremia. Administering diuretics that promote sodium loss and administering fluids such as 0.9% saline and 5% dextrose in 0.45% sodium chloride to restore the fluid balance are the immediate interventions needed to stabilize the patient. The patient's acute confusion is caused by high sodium levels, so anti-psychotic drugs should not be administered. Sodium decreases the heart contractibility by retarding the movement of calcium into the heart cells. Therefore calcium channel blockers should not be administered.

When assessing patients for potential fluid imbalances, what factors does the nurse know affect the amount and distribution of body fluids? Select all that apply. A. Age B. Poverty C. Activity D. Gender E. Body fat F. Cognition

A. Age D. Gender E. Body fat Rationale: Factors that affect the amount and distribution of body fluids include age, gender, and body fat. Older adults have less total body water than younger adults. Women of any age have less total body water than men. Obese adults have less total water than lean adults of the same weight because fat cells contain almost no water. Poverty may affect overall nutrition but does not directly affect fluid intake. Activity may result in the need for increased fluids, but fluid distribution is unchanged. Impaired cognition may result in decreased fluid intake, but it does not directly alter distribution of fluids.

What is the preferred diuretic used for patients with hypokalemia? A. Amiloride B. Furosemide C. Bumetanide D. Chlorothiazide

A. Amiloride Rationale: Diuretics that increase the kidney excretion of potassium can cause hypokalemia. A potassium-sparing diuretic may be prescribed to increase the urine output without increasing potassium loss. Amiloride is an example of potassium-sparing diuretic, which is preferred for patients diagnosed with hypokalemia. Furosemide, bumetanide, and chlorothaiazide are examples of high ceiling, loop, or thiazide diuretics. These loop and thiazide diuretics promote excretion of potassium along with water; therefore they are not used in patients diagnosed with hypokalemia.

Which age-related change to fluid balance does the nurse anticipate when conducting a neurologic assessment for an older adult patient? A. Decreased thirst reflex B. Increased urine output C. Increased muscle mass D. Decreased sweat production

A. Decreased thirst reflex Rationale: An age-related neurologic change that impacts fluid balance is a decreased thirst reflex. Urine output, muscle mass, and sweat production may all impact fluid balance, but these are not age-related neurologic changes.

The nurse is assessing an older adult patient during a scheduled health maintenance visit. Which assessment finding, related to fluid balance, does the nurse anticipate? A. Decreased turgor B. Increased elasticity C. Increased oil production D. Decreased risk for injury

A. Decreased turgor Rationale: Due to age-related changes to fluid balance, the nurse anticipates that the older adult patient will have decreased skin turgor. The nurse would anticipate decreased, not increased, elasticity. Older adult patients often have decreased, not increased, oil production, which causes dry and easily damaged skin. There would be an increased risk, not a decreased risk, for injury.

The nurse is providing care to a patient who is experiencing severe nausea, vomiting, and diarrhea. Which is the patient at risk of developing? Select all that apply. A. Dehydration B. Hypertension C. Hypokalemia D. Hypercalcemia E. Hypernatremia

A. Dehydration C. Hypokalemia E. Hypernatremia Rationale: A patient who is experiencing severe nausea, vomiting, and diarrhea is at risk of developing dehydration and electrolyte imbalances such as hypokalemia and hypernatremia. The patient is at risk for hypotension not hypertension. The patient is not a risk of developing hypercalcemia.

Which medication classification does the nurse anticipate being prescribed to help a patient maintain an appropriate fluid balance? A. Diuretics B. Anticoagulants C. Mood stabilizers D. Opioid analgesics

A. Diuretics Rationale: Drug therapy for hypertension management may include diuretic drugs that increase the excretion of sodium so that less is present in the blood, resulting in a lower blood volume and increased urine output. Anticoagulants, mood stabilizers, and opioid analgesics do not play a role in maintaining fluid balance within the body.

Which situation can cause a patient to experience "insensible water loss?" Select all that apply. A. Fever B. Nausea C. Diarrhea D. Dry, hot weather E. Mechanical ventilation F. Increased respiratory rate

A. Fever C. Diarrhea D. Dry, hot weather E. Mechanical ventilation F. Increased respiratory rate Rationale: Insensible water loss occurs through the intestinal tract as diarrhea. It can be caused and/or influenced by dry, hot weather. Insensible water loss occurs through the skin, lungs (increased rate of respirations), and intestinal tract. It is increased in patients who are mechanically ventilated, and it is increased by the presence of fever. Nausea with no accompanying vomiting would not cause insensible water loss.

The nurse is assessing a patient admitted with intractable vomiting. Which assessment findings indicate the patient is also dehydrated? Select all that apply. A. Fever B. Hypertension C. Poor skin turgor D. Pulmonary crackles E. Low blood pressure F. Concentrated urine

A. Fever C. Poor skin turgor E. Low blood pressure F. Concentrated urine Rationale: Signs and symptoms of dehydration include fever, poor skin turgor, low blood pressure, and concentrated urine. Hypertension is associated with fluid volume overload. Pulmonary crackles may occur when the patient is experiencing fluid volume overload, not dehydration.

The nurse is providing care to a patient who is receiving diuretic therapy. Which electrolyte imbalance will the nurse monitor this patient for while providing care? A. Hypokalemia B. Hypercalcemia C. Hypernatremia Hypophosphatemia

A. Hypokalemia Rationale: A patient who is prescribed diuretic therapy will require monitoring for hypokalemia. The nurse would not anticipate hypercalcemia, hypernatremia, or hypophosphatemia for this patient.

Which age-related change of the kidney increases an older adult patient's risk for dehydration? A. Increased water loss B. Increased thirst reflex C. Increased concentrating capacity D. Increased GFR

A. Increased water loss Rationale: Older adult patients are at an increased risk for dehydration caused by increased water loss. The older adult patient has a decreased, not an increased, thirst reflex which places them at risk for dehydration. Decreased, not increased, concentrating capacity and glomerular filtration rate also place the older adult patient at risk for dehydration.

The nurse is teaching a patient with congestive heart failure about monitoring fluid volume in the home setting. What are the best indicators of fluid losses or gains? A. Monitoring daily weights B. Observing ankles for swelling C. Monitoring daily intake and output D. Observing for pulse elevations with activity

A. Monitoring daily weights Rationale: Changes in daily body weight are the best indicators of fluid losses or gains. Swelling of the ankles may occur due to a dependent position or standing for extended periods of time and not necessarily due to alterations in fluid volume. Monitoring intake and output may be useful but it is not as accurate as daily weights. The pulse normally rises with activities and decreases with rest. As such, observing the pulse with activity is not a good indicator of fluid status.

The nurse is teaching a patient with congestive heart failure about monitoring fluid volume in the home setting. What are the best indicators of fluid losses or gains? A. Monitoring daily weights B. Observing ankles for swelling C. Monitoring daily intake and output D. Observing for pulse elevations with activity

A. Monitoring daily weights Rationale: Changes in daily body weight are the best indicators of fluid losses or gains. Swelling of the ankles may occur due to a dependent position or standing for extended periods of time and not necessarily due to alterations in fluid volume. Monitoring intake and output may be useful but it is not as accurate as daily weights. The pulse normally rises with activities and decreases with rest. As such, observing the pulse with activity is not a good indicator of fluid status.

Which is a true statement regarding fluid balance in older adult patients? A. Older adult patients have less total body water B. Older adult patients are prone to hyperkalemia C. Older adult patients are prone to hypernatremia D. Older adult patients have an increased thirst reflex

A. Older adult patients have less total body water Rationale: Older adult patients have less total body water than younger patients, which increases their risk for dehydration. Older adult patients are not prone to hyperkalemia or hypernatremia. Older adult patients have a deceased thirst reflex, which places them at an increased risk for dehydration.

Which condition would stimulate the renin-angiotensin II to maintain fluid balance within the body? A. Shock B. Hypoglycemia C. Hypercalcemia D. Water intoxication

A. Shock Rationale: The renin-angiotensin II pathway is highly stimulated whenever the patient is in shock or when the stress response occurs. This is why urine output is used as an indicator of perfusion adequacy after surgery or any time the patient has undergone an invasive procedure and is at risk for hemorrhage. Hypoglycemia, hypercalcemia, and water intoxication are not conditions that stimulate the renin-angiotensin II to maintain fluid balance within the body.

Which assessment finding would cause the kidneys to secrete renin in order to increase blood pressure and maintain perfusion and fluid balance? A. Sodium 130 mEq/L B. PaO 2 98% on room air C. Blood pressure 130/82 mm Hg D. Heart rate of 88 beats per minute

A. Sodium 130 mEq/L Rationale: A normal level of sodium in the blood is 136 to 145 mEq/L. Hyponatremia, as indicated by a sodium level of 130 mEq/L, would cause the kidneys to secrete renin in order to increase blood pressure and maintain perfusion and fluid balance. A PaO 2 of 98% on room air, a blood pressure of 130/82 mm Hg, and a heart rate of 88 beats per minute are all normal assessment findings and would not cause the secretion of renin.

On the second day of caring for a patient with generalized edema, which change best reflects that the administered diuretic is effective? A. Weight loss of 6 pounds B. Respiratory rate decrease from 24 to 20 C. Urinary output decrease from 600 mL/8 hr to 200 mL/8 hr D. Blood pressure decrease from 138/88 to 126/78 mm Hg

A. Weight loss of 6 pounds Rationale: Weight loss and increased urinary output are primary indicators of the effectiveness of a diuretic. In patients with edema, each pound of weight gained after the first pound equates to 500 mL of retained water, so if water loss occurs with diuretic therapy, weight loss will result. The changes in vital signs may reflect volume loss but are not the best indicators of the effectiveness of a diuretic.

The nurse is providing education to a patient diagnosed with hypertension. Which statement by the nurse is most appropriate to help the patient maintain a normal fluid balance? A. "Increase your intake of water each day to increase urine output." B. "Limit your intake of sodium to decrease the water you are retaining." C. "Foods rich in potassium, such as bananas, will increase urine output." D. "Foods rich in calcium, such as milk, will help to decrease urine output."

B. "Limit your intake of sodium to decrease the water you are retaining." Rationale: The best way for a patient with hypertension to maintain a normal fluid balance is to limit the intake of dietary salt. The reason for this is that a high sodium intake raises the blood level of sodium, causing more water to be retained in the blood volume and raising blood pressure. The patient may be asked to decrease their fluid intake due to edema. Foods rich in potassium and calcium will not help the patient with hypertension maintain a normal fluid balance.

A patient is being monitored for daily weights. The night nurse asks the nursing assistant for the morning weight, and the assistant replies, "She was sleeping so well, I didn't want to wake her to get her weight." How does the nurse respond? A. "Never mind—I will do it myself." B. "Weigh her now. We need her weight daily, at the same time." C. "Fast thinking! She really needs to rest after the night she had." D. "Get the information now, or I'll report you for not doing your job."

B. "Weigh her now. We need her weight daily, at the same time." Rationale: The nurse should educate the nursing assistant as to why obtaining the patient's weight at the same time each day is important. Although the nursing assistant may be hesitant to wake the patient, assessing the patient's fluid balance is more important. The responses of telling the nursing assistant to get the information now or she'll be reported or that the nurse will get the information herself do not demonstrate good leadership. The assistant needs to understand the rationale for waking and weighing the patient. She should not be dismissed and belittled by the nurse.

The nurse is providing care to a female patient who experienced an adverse reaction to a prescribed drug. The patient states, "My husband was on the same dose, and he didn't have any issues." Which response by the nurse is most appropriate? A. "You are probably allergic to the prescribed drug." B. "Women have more fat cells, which causes differences in drug responses." C. "There is no rhyme or reason as to why certain people experience reactions to drugs." D. "Men have less muscle mass, which is probably why your husband didn't have the same reaction."

B. "Women have more fat cells, which causes differences in drug responses." Rationale: Women tend to have more fat cells, which means they have less water. This difference in water distribution explains why men and women have different responses to drugs. Not all adverse reactions indicate a drug allergy. There is evidence that suggests that the muscle versus fat composition of the body does impact individual reaction to drugs. Men have more muscle mass, not less muscle mass, within the body.

Which statement by the nurse is most appropriate when teaching a patient about maintaining fluid balance? A. "If you increase your intake of salt, you are at a greater risk for dehydration." B. "Your intake and output has the most influence on your body's fluid balance." C. "If you decrease your intake of potassium, you are at a greater risk for dehydration." D. "Your prescribed medications have the largest impact on fluid balance within the body."

B. "Your intake and output has the most influence on your body's fluid balance." Rationale: Body fluids are constantly filtered and replaced as fluid balance is maintained through intake and output. An increased sodium intake will increase the risk for fluid overload, not dehydration. An increased rather than decreased intake of potassium places a patient at risk for dehydration. While certain medications, such as diuretics, can impact the body's fluid balance, it is the actual intake and output that has the largest impact on fluid balance.

How much fluid should a healthy adult consume each day to maintain adequate urine output? A. 2 L/day B. 2.3 L/day C. 2.6 L/day D. 2.9 L/day

B. 2.3 L Rationale: 2300 ml = 2.3 L

Which is the expected insensible water loss for a healthy adult each day? A. 250 - 500 ml B. 500 - 1,000 ml C. 1,000 - 1,250 ml D. 1,250 - 1,750 ml

B. 500 - 1,000 ml Rationale: The expected amount of insensible water loss for a healthy adult is 500-1000 mL/day. The other ranges are not accurate in terms of insensible water loss for a healthy adult each day.

The nurse is providing care to several patients on a medical-surgical unit. Which patient is at an increased risk for insensible water loss? A. A patient receiving humidified oxygen by nasal cannula B. A patient receiving continuous gastrointestinal suctioning postoperatively C. A patient with decreased respirations due to opioid administration for pain D. A patient receiving continuous intravenous fluids due to an NPO status for surgery

B. A patient receiving continuous gastrointestinal suctioning postoperatively Rationale: A patient receiving continuous gastrointestinal suctioning postoperatively is at the greatest risk for insensible water loss. A patient receiving humidified oxygen by nasal cannula is not at risk for insensible water loss. Increased respirations, not decreased respirations, would place the patient at risk for insensible water loss. Receiving continuous intravenous fluids due to NPO status for surgery does not place the patient at an increased risk for insensible water loss.

Which hormones play a role in the regulation of sodium balance by the kidneys? Select all that apply. A. Cortisol B. Aldosterone C. Angiotensin D. Natriuretic peptide (NP) E. Antidiuretic hormone (ADH)

B. Aldosterone D. Natriuretic peptide (NP) E. Antidiuretic hormone (ADH) Rationale: Serum sodium levels are regulated by the kidneys under the influence of aldosterone, natriuretic peptide (NP), and antidiuretic hormone (ADH). Low serum sodium levels inhibit the secretion of ADH and NP and trigger the secretion of aldosterone. This increases the serum sodium levels by increasing the reabsorption of sodium and enhancing water loss by the kidney. High serum sodium levels inhibit aldosterone secretion and stimulate the secretion of ADH and NP. These hormones increase the excretion of sodium and reabsorption of water by the kidney. Cortisol and angiotensin do not regulate the serum sodium levels.

Which electrolyte imbalance triggers Aldosterone secretion to maintain fluid balance within the body? A. Decreased serum potassium levels B. Decreased sodium levels in the extracellular fluid C. Increased serum glucose levels D. Increased calcium levels in the extracellular fluid

B. Decreased sodium levels in the extracellular fluid Rationale: Decreased sodium levels in the extracellular fluid (ECF) trigger the secretion of aldosterone from the adrenal cortex. The result is action on the kidney nephrons, triggering them to reabsorb sodium and water from the urine back into the blood. This action increases blood osmolarity and blood volume. This occurs most often in response to hypotension as a result of low blood volume. Aldosterone would be secreted in response to hyperkalemia (increased levels of serum potassium), not decreased serum potassium levels (hypokalemia). Aldosterone secretion is not regulated by changes in either serum glucose or extracellular calcium levels.

What is the neurologic impact of age-related changes on fluid balance? A. Diminished knee reflex B. Diminished thirst reflex C. Diminished cough reflex D. Diminished baroreceptor reflex

B. Diminished thirst reflex Rationale: The neurologic impact of a person's age on fluid balance is a diminished thirst reflex, which results in decreased fluid intake, thereby increasing the risk of dehydration.

Which will the nurse include when documenting a patient's fluid intake for the shift? Select all that apply. A. Emesis B. Enemas C. Oral fluids D. Solid foods E. Irrigation fluids

B. Enemas C. Oral fluids E. Irrigation fluids Rationale: Intake that is considered measurable when documenting a patient's fluid intake for the shift include enemas, oral fluids, and irrigation fluids. Emesis is a measurable output. Solid foods are considered intake but these cannot be measured.

Which will the nurse consider when assessing a patient's insensible water loss? Select all that apply. A. Urine B. Feces C. Emesis D. Respiration E. Perspiration

B. Feces D. Respiration E. Perspiration Rationale: Water loss from the skin (perspiration), lungs (respiration), and stool (feces) is called insensible water loss because there are no mechanisms to control this loss. In a healthy adult, insensible water loss is about 500 to 1000 mL/day. Urine and emesis are not considered insensible water losses.

1. A patient is admitted to the intensive care unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which treatments does the nurse anticipate for this patient? Select all that apply. A. Digitalis (Lanoxin) B. Furosemide (Lasix) C. Tolvaptan (Samsca) D. Conivaptan (Vaprisol) E. Vasopressin (Pitressin) F. Norepinephrine (Levophed)

B. Furosemide (Lasix) C. Tolvaptan (Samsca) D. Conivaptan (Vaprisol) Rationale: The nurse anticipates the health care provider will prescribe furosemide, tolvaptan, and conivaptan to manage SIADH. Furosemide is a loop-diuretic that helps rid the body of excess fluid. Tolvaptan is used to manage hyponatremia with SIADH. Conivaptan acts as an antidiuretic hormone (ADH) inhibitor to help resolve fluid volume overload. Digitalis is a cardiac glycoside that slows and strengthens myocardial contraction, but it has no effect on fluid volume. Vasopressin is contraindicated with SIADH since it is the synthetic form of ADH. Norepinephrine is a powerful peripheral vasoconstrictor used to increase blood pressure.

The nurse is providing care for a patient who has hyperkalemia. Which disease process documented in the patient's medical record is the cause for this electrolyte imbalance? A. Cirrhosis B. Renal failure C. Diabetes mellitus D. Hyperaldosteronism

B. Renal failure Rationale: Kidney disease, such as renal failure, causes a decrease in urine output, causing the patient to retain potassium and develop hyperkalemia. Cirrhosis is associated with hyponatremia, not hyperkalemia. Diabetes mellitus and hyperaldosteronism both cause an increase in urine output, which causes hypokalemia, not hyperkalemia.

The nurse is administering sodium chloride 0.9% (normal saline) intravenously to a patient who is dehydrated. Which assessments does the nurse perform to evaluate the effectiveness of rehydration therapy? Select all that apply. A. Temperature B. Urinary output C. Bowel sounds D. Pulse rate and quality E. Level of consciousness

B. Urinary output D. Pulse rate and quality Rationale: Pulse rate and quality as well as urinary output best reflect improving volume status with rehydration therapy. Temperature, level of consciousness, and bowel sounds are not indicators of an improving volume state, although elevated temperature can worsen dehydration.

Which assessment data is the best indication of perfusion after a surgical procedure? A. Heart rate B. Urine output C. Blood pressure D. Pulse oximetry

B. Urine output Rationale: The renin-angiotensin II pathway is highly stimulated whenever the patient is in shock or when the stress response occurs. This is why urine output is used as an indicator of perfusion adequacy after surgery or any time the patient has undergone an invasive procedure and is at risk for hemorrhage. Although heart rate, blood pressure, and pulse oximetry are also useful when monitoring perfusion, they are not the most important indicator of perfusion adequacy.

The charge nurse on a medical-surgical unit is completing assignments for the day shift. Which patient is assigned to the LPN/LVN? A. 44-year-old with congestive heart failure (CHF) who has gained 3 pounds since the previous day B. 58-year-old with chronic renal failure (CRF) who has a serum potassium level of 6 mEq/L C. 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L D. 80-year-old with 3+ peripheral edema and crackles throughout the posterior chest

C. 76-year-old with poor skin turgor who has a serum osmolarity of 300 mOsm/L Rationale: Although the 76-year-old patient has poor skin turgor, the serum osmolarity indicates that fluid balance is normal; this patient is the most stable of the four patients described and can be assigned to the LPN/LVN. The data about the 44-year-old with CHF who has gained 3 pounds since the previous day indicate reduced stability; assessments and interventions performed by an RN are needed. The data about the 58-year-old patient with CRF and a serum potassium level of 6 mEq/L indicate reduced stability; assessments and interventions performed by an RN are needed. The data about the 80-year-old patient with edema and congested lungs indicate that the patient is not stable, and that assessments and interventions by an RN are needed.

Which hormones are responsible for maintaining fluid balance within the body? Select all that apply. A. Insulin B. Glucagon C. Aldosterone D. Natriuretic peptide (NP) E. Antidiuretic hormone (ADH)

C. Aldosterone D. Natriuretic peptide (NP) E. Antidiuretic hormone (ADH) Rationale: Aldosterone, NP, and ADH are the three hormones that are responsible for maintaining fluid balance within the body. Insulin and glucagon are responsible for maintaining blood glucose levels in the body, not fluid balance.

Which is the most critical fluid to prevent death? A. Urine B. Perspiration C. Blood volume D. Intracellular fluid

C. Blood Volume Rationale: The most important fluids to keep in balance are the blood volume (plasma volume) and the fluid inside the cells (intracellular fluid). Of these two, the most critical fluid balance to prevent death is maintaining blood volume at a sufficient level for blood pressure to remain high enough to ensure adequate perfusion and gas exchange of all organs and tissues. Urine and perspiration both play a role in fluid balance but are not critical fluids to prevent death.

As adults age, which common physiologic change is likely to alter their hydration status? A. Poor skin turgor B. Adrenal gland growth C. Decreased muscle mass D. Increased thirst mechanism

C. Decreased muscle mass Rationale: Decreased muscle mass causes decreased total body water, thus altering hydration status in the older adult. Adrenal growth is not a common age-related change. A decreased, not increased, thirst reflex is a common change related to aging. Poor skin turgor is a sign, not a cause, of altered hydration status.

The nurse is providing care to a patient who is diagnosed with dehydration. Which laboratory finding supports the current diagnosis? A. Hypokalemia B. Hypercalcemia C. Hypernatremia D. Hypomagnesemia

C. Hypernatremia Rationale: Hypernatremia, or an increased level of sodium, supports the diagnosis of dehydration.

Which condition commonly occurs in patients who are on long-term Furosemide therapy? A. Hypocalcemia B. Hypercalcemia C. Hyponatremia D. Hypernatremia

C. Hyponatremia Rationale: Furosemide is a high ceiling or loop diuretic. Prolonged use of this drug to manage fluid overload may cause loss of sodium along with extra water, leading to a decrease in sodium levels, or hyponatremia.

The nurse is reviewing the basic metabolic panel for a patient who was admitted to the medical-surgical unit the previous day. Which finding would place the patient at risk for fluid volume overload? A. Hyperkalemia B. Hypocalcemia C. Hyponatremia D. Hyperchloremia

C. Hyponatremia Rationale: Hyponatremia, or a low level of sodium, increases the patient's risk for fluid volume overload. Hyperkalemia, hypocalcemia, and hypercholoremia do not place the patient at risk for fluid volume overload.

The nurse is providing care to an edematous patient whose blood pressure is 190/110 mm Hg. Which hormone will be secreted in response to the patient's blood pressure in order to increase urine output? A. Insulin B. Aldosterone C. Natriuretic peptides (NPs) D. Antidiuretic hormone (ADH)

C. Natriuretic peptides (NPs) Rationale: An edematous patient experiencing hypertension will require increased fluid output in order to return to homeostasis. The hypertensive state will cause the secretion of NPs, which will inhibit kidney reabsorption of sodium and increase the glomerular filtration rate to increase urine output. Insulin does not exert any effect on fluid balance. Aldosterone and ADH both impact fluid balance but not in response to hypertension.

The nurse is planning care for a 72-year-old resident of a long-term care facility who has a history of dehydration. Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A. Choosing appropriate oral fluids B. Monitoring skin turgor for tenting C. Offering fluids to drink every hour D. Assessing oral mucosa for dryness

C. Offering fluids to drink every hour Rationale: Encouraging a patient to take oral fluids is within the scope of practice for UAP. Assessments of oral mucosa, selection of appropriate fluids, and assessment of skin turgor should be done by licensed nursing staff, who have the needed education and scope of practice to implement these more complex actions.

A patient with a history of hypertension asks the nurse what dietary changes are necessary to make in order to control the blood pressure. What does the nurse include in the instruction? A. Reduce the intake of iron B. Reduce the intake of calcium C. Reduce the intake of sodium D. Reduced the intake of phosphorous

C. Reduce the intake of sodium Rationale: High sodium intake raises the serum sodium level, which causes more water to be retained. This in turn increases the blood volume and raises the blood pressure. Hence, patients who have hypertension are often asked to limit their intake of sodium. Intake of iron, phosphorus, or calcium does not cause water retention in the blood and therefore does not affect the blood pressure.

The nurse is teaching a group of unlicensed assistive personnel (UAP) about fluid intake principles for older adults. What does the nurse tell them? A. "Wake them every 2 hours during the night with a drink." B. "Be careful not to overload them with too many oral fluids." C. "Restrict their fluids in the evening hours if they are incontinent." D. "Offer fluids that meet the patient's dietary restrictions on a regular schedule."

D. "Offer fluids that meet the patient's dietary restrictions on a regular schedule." Rationale: Because of the decreased thirst mechanism, older adults can become dehydrated and should be offered oral fluids every 2 hours. When possible, provide oral fluids that meet the patient's dietary restrictions (e.g., sugar-free, low-sodium, thickened). Risk of overhydration, especially with oral fluids, is minimal. Fluids should never be restricted because the patient is incontinent; this is a common mistake made by UAP in long-term care environments. It is not necessary to disturb older adults during their sleep to offer fluids; however, they should be offered a drink during waking hours at frequent intervals (e.g., every 2 hours).

Which value falls within the range for the minimal amount of urine that needs to be produced in 24 hours? A. 150 ml/day B. 250 ml/day C. 350 ml/day D. 450 ml/day

D. 450 ml/day Rationale: The minimum volume of urine per day needed to excrete toxic waste products is 400 to 600 mL and is called obligatory urine output. Urine output between 100 and 400 mL per day is called oliguria or hypouresis.

Which person attending an all-day outdoor festival on a hot August day is at greatest risk for dehydration? A. 32-year-old man consuming alcoholic beverages B. 28-year-old woman with type 1 diabetes mellitus C. 68-year-old man who frequently wipes sweat from his forehead D. 72-year-old woman appearing to be at least 20 pounds overweight

D. 72-year-old woman appearing to be at least 20 pounds overweight Rationale: The thirst mechanism is less sensitive in older adults, making them more at risk for dehydration. Women of any age have less total body water than men of similar sizes and ages, because men have more muscle mass than women and women have more body fat. (Muscle cells contain mostly water, and fat cells have little water.) In addition, the 72-year-old woman is overweight, with an increased percentage of body fat compared to lean body mass, especially skeletal muscle. An obese person has less total water than a lean person of the same weight because fat cells contain almost no water. Although a 32-year-old man consuming alcohol, a 28-year-old with type 1 diabetes, and a 68-year-old who frequently sweats are at risk for dehydration, they are not as high-risk as the obese older adult.

Which medication may affect the assessment of a patient's fluid balance after a surgical intervention? A. Aspirin once a day B. Digoxin once a day C. Penicillin twice a day D. Angiotensin-converting enzyme inhibitor twice a day

D. Angiotensin-converting enzyme inhibitor twice a day Rationale: Urine output is used as an indicator of perfusion adequacy after surgery or other procedures. Medications used to manage hypertension such angiotensin-converting enzyme (ACE) inhibitors disrupt the renin-angiotensin II pathway, resulting in greater excretion of water and sodium in the urine. This may make it harder to use urine output as a primary measure of perfusion. Aspirin may prolong clotting. Penicillin and digoxin will not affect monitoring fluid balance post-procedure.

Which output source would the nurse exclude from the total output from the previous shift? A. Urine B. Emesis C. Liquid feces D. Lung vaporization

D. Lung vaporization Rationale: Lung vaporization is not a measurable output that the nurse would include on the intake and output totals from the previous shift. Urine, emesis, and liquid feces would all be included in the measurable output from the previous shift.

What route of fluid loss is nonmeasurable? A. Urine B. Feces C. Emesis D. Perfusion

D. Perfusion Rationale: Fluids lost by perspiration and vaporization through the lungs are nonmeasurable. Fluids excreted through feces and urine as well as emesis are fluids lost through body cavities and are measurable fluid excretion.

Which medication can be administered to mimic the effect of antidiuretic hormone (ADH) on the body? A. Insulin B. Calcium C. Potassium D. Vasopressin

D. Vasopressin Rationale: Vasopressin is a medication that mimics the effects of antidiuretic hormone on the body to maintain fluid balance within the body. Insulin is a medication that controls blood glucose levels in the blood. Calcium and potassium are electrolytes that are impacted by fluid balance; however, they are not administered to mimic the effect of antidiuretic hormone.