Chapter 13: Fluid and Electrolytes: Balance and Disturbance
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Extracellular fluid volume deficit Altered blood urea nitrogen (BUN) value Metabolic alkalosis Respiratory acidosis
Correct response: Extracellular fluid volume deficit Explanation: Fluid volume deficit (FVD) occurs when the loss extracellular fluid (ECF) volume exceeds the intake of fluid. FVD results from loss of body fluids and occurs more rapidly when coupled with decreased fluid intake. A cause of this loss is hemorrhage.
A client is to receive hypotonic IV solution in order to provide free water replacement. Which solution does the nurse anticipate administering? Lactated Ringer solution 0.45% NaCl 0.9% NaCl 5% NaCl
Correct response: 0.45% NaCl Explanation: Half-strength saline (0.45%) is hypotonic. Hypotonic solutions are used to replace cellular fluid because it is hypotonic compared with plasma. Another is to provide free water to excrete body wastes. At times, hypotonic sodium solutions are used to treat hypernatremia and other hyperosmolar conditions. Lactated Ringer solution and normal saline (0.9% NaCl) are isotonic. A solution that is 5% NaCl is hypertonic.
The nurse is caring for a client in heart failure with signs of hypervolemia. Which vital sign is indicative of the disease process? Low heart rate Elevated blood pressure Rapid respiration Subnormal temperature
Correct response: Elevated blood pressure Explanation: Indicative of hypervolemia is a bounding pulse and elevated blood pressure due to the excess volume in the system. Respirations are not typically affected unless there is fluid accumulation in the lungs. Temperature is not generally affected.
The nurse is caring for a geriatric client in the home setting. Due to geriatric changes decreasing thirst, the nurse is likely to see a decrease in which fluid location which contains the most body water? Intracellular fluid Extracellular fluid Interstitial fluid Intravascular fluid
Correct response: Intracellular fluid Explanation: About 60% of the adult human body is water. Most body water is located within the cell (intracellular fluid). Due to several physiological changes of aging, geriatric clients have less bodily fluids.
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? dehydration hypervolemia hypercalcemia hyperkalemia
Correct response: dehydration Explanation: Dehydration results when the volume of body fluid is significantly reduced in both extracellular and intracellular compartments. In dehydration, all fluid compartments have decreased volumes; in hypovolemia, only blood volume is low. The most common fluid imbalance in older adults is dehydration. Hypervolemia is caused by fluid intake that exceeds fluid loss, such as from excessive oral intake or rapid IV infusion of fluid. Early signs of hypervolemia are weight gain, elevated BP, and increased breathing effort. Hypercalcemia occurs when the serum calcium level is higher than normal. Some of its signs include tingling in the extremities and the area around the mouth (circumoral paresthesia) and muscle and abdominal cramps. Hyperkalemia is an excess of potassium in the blood. Symptoms include diarrhea, nausea, muscle weakness, paresthesias, and cardiac dysrhythmias.
