Nclex Style: Nursing Fundamentals - Fluids and Electrolytes

Normal serum level for K+ (potassium)

*normal potassium levels: 2.5-5.3 mEq/L*

The nurse is providing discharge instructions to a client going home on 80mg of furosemide​ (Lasix), a loop​ diuretic, twice a day. Which teaching should be included in these​ instructions? (Select all that​ apply.) A. ​"Rise slowly from lying or sitting​ position." B. ​"Take in the morning and at​ bedtime." C. Take with water​ only." D. ​"Do not take at the same time as other​ medications." E. ​"Avoid using nonsteroidal​ anti-inflammatory drugs​ (NSAIDs)."

"rise slowly from ling or sitting position" & "avoid NSAIDS" Rationale: Teaching for the client and the family of the client who is prescribed furosemide includes the​ following: bullet Unless​ contraindicated, maintain a fluid intake of 2 to 3​ L/day. bullet Rise slowly from lying or sitting positions because a fall in blood pressure may cause lightheadedness. bullet Take it in the morning​ and, if ordered twice a​ day, in the late afternoon to avoid sleep disturbance. bullet Take it with food or milk to prevent gastric distress. bullet NSAIDs interfere with the effectiveness of loop diuretics and should be avoided.

The nurse plans to preserve renal perfusion in a client with chronic kidney disease​ (CKD). Which intervention should the nurse implement for this​ client? A. Administer an​ angiotensin-converting enzyme inhibitor as prescribed. B. Assess the arteriovenous fistula on every shift. C. Monitor white blood cell count. D. Monitor protein intake.

A. Administer an​ angiotensin-converting enzyme inhibitor as prescribed. Rationale: Administering an​ angiotensin-converting enzyme​ *(ACE) inhibitor will reduce systemic hypertension and preserve renal function.* Assessing the arteriovenous fistula is an important nursing intervention to preserve the patency of the fistula and reduce the risk of​ infection, not to preserve renal perfusion. The kidney with chronic disease is unable to excrete protein​ by-products, causing the multisystemic effects of uremia. Monitoring the​ client's protein intake will address these effects but does not directly preserve renal perfusion. An increase in white blood cells can indicate infection but does not directly affect renal perfusion.

The nurse reviews a list of clients waiting to be seen in a community health clinic. Which client should the nurse identify as experiencing the most common cause of an electrolyte imbalance in​ adolescents? A. A​ 17-year-old female with diarrhea after gastroenteritis B. A​ 16-year-old male who is not drinking enough at wrestling practice C. A​ 14-year-old male who is losing water through increased insensible water loss D. A​ 16-year-old female participating in heavy exercise to lose weight for a school dance

A. A​ 17-year-old female with diarrhea after gastroenteritis Rationale: The most common reason for electrolyte imbalances and FVD in children and adolescents is diarrhea or gastroenteritis. Heavy​ exercise, insensible​ loss, and not drinking enough are also potential causes of electrolyte imbalance and​ FVD, but they are not the prominent reasons in adolescents.

A client is prescribed furosemide. Which information should the nurse provide about this​ medication? A. Check weight daily. B. Decrease potassium in the diet. C. Take the medication at bedtime. D. Increase sodium intake.

A. Check weight daily. Rationale: Daily weight is recommended for a client taking furosemide. Increasing sodium intake and decreasing potassium intake can lead to fluid and electrolyte imbalances. It would be recommended to take furosemide in the morning due to the diuresis effect of the medication.

The nurse reviews the care needs for a group of clients. Which condition should the nurse realize occurs from a fluid volume​ deficit? A. Diarrhea B. Water intoxication C. Hypertension D. Kidney failure

A. Diarrhea

The nurse reviews the care needs for a group of clients. Which condition should the nurse realize occurs from a fluid volume​ deficit? A. Diarrhea B. Water intoxication C. Kidney failure D. Hypertension

A. Diarrhea ​Rationale: Fluid volume​ deficit, or​ dehydration, can occur when excessive amounts of fluids are lost through diarrhea or vomiting. Kidney failure causes water​ retention, leading to fluid volume​ excess, not deficit. Water intoxication results from excessive fluid intake and leads to fluid volume excess. Fluid volume​ excess, not​ deficit, can result in hypertension.

The healthcare provider prescribes calcium gluconate for a client. For which electrolyte imbalance should the nurse assess this​ client? A. Hypermagnesemia B. Hyponatremia C. Hypernatremia D. Hypochloremia

A. Hypermagnesemia Rationale: Calcium gluconate is used to treat hypermagnesemia. Hypernatremia is treated with fluid replacement. Hypochloremia is treated by increasing dietary salt and adding chloride to the IV fluid. Hyponatremia is treated by increasing dietary sodium and administering​ sodium-containing IV fluids.

The nurse is assessing a client with fluid volume deficit. Which finding should the nurse identify that supports fluid volume​ deficit? A. Increased hematocrit B. Wheezes upon auscultation C. Edema D. Weight gain

A. Increased hematocrit Rationale: Increased hematocrit is a finding consistent with fluid volume deficit. Edema and weight gain are consistent with fluid volume overload. Wheezes upon auscultation of the lungs is not related to fluid imbalances.

The nurse is caring for a hospitalized client who is experiencing​ anxiety-related hyperventilation. When calculating the​ client's intake and​ output, where would the nurse anticipate the need for an adjustment in fluid​ loss? A. Insensible loss B. Feces C. Urine D. Sweat

A. Insensible loss Rationale: With increased​ respirations, the client will experience a​ greater-than-normal insensible loss of fluid through the lungs. Hyperventilation will not affect the amount of fluid lost through the​ urine, sweat, or feces.

The nurse is administering a blood transfusion to a client who is hemorrhaging. In which fluid compartment should the nurse identify that the client is experiencing a​ deficit? A. Intravascular fluid B. Transcellular fluid C. Intracellular fluid D. Interstitial fluid

A. Intravascular fluid ​Rationale: Blood loss causes a deficit in the intravascular fluid​ compartment, which is a subcompartment of extracellular fluid​ (ECF). Transcellular and interstitial​ fluids, along with​ lymph, make up the other compartments of ECF. Intracellular fluid is the other major fluid compartment in the body.

The nurse is evaluating the laboratory work of a client who is receiving replacement therapy for hypokalemia. Which value should the nurse identify that evaluates the effectiveness of the replacement​ therapy? A. Serum potassium 4.2​ mEq/L B. Serum chloride 100​ mEq/L C. Serum potassium 2.3​ mEq/L D. Serum calcium 9.2​ mEq/L

A. Serum potassium 4.2​ mEq/L Rationale: Hypokalemia is a potassium level less than 3.5​ mEq/L. A serum potassium of 4.2​ mEq/L indicates improvement in hypokalemia. Serum chloride and serum calcium are not used to evaluate potassium level. *normal potassium levels: 2.5-5.3 mEq/L*

The nurse is teaching a marathon runner about the importance of maintaining fluid and electrolyte balance. Which situation puts runners at a higher risk for fluid and electrolyte​ imbalances? A. The use of electrolyte replacement fluids during a race B. The significant loss of water during a lengthy exercise session C. The additional calcium taken by using calcium tablets to strengthen bones D. The increase of protein intake prior to a race

A. The use of electrolyte replacement fluids during a race Rationale: It is common for athletes to use electrolyte replacement fluids during exercise. The nurse should be sure that the athlete understands that these fluids could alter the delicate balance of individual electrolytes. Supplemental protein and calcium intake do not typically affect fluid and electrolyte balance. Although water is lost during​ sweating, it does not usually create issues during exercise.

The nurse realizes that as chronic kidney disease​ (CKD) progresses, the kidney loses the ability to eliminate metabolic wastes. Which way should the nurse expect a client with this disease to eliminate wastes other than through the​ kidneys? A. Via the skin B. Via tears C. Via respirations D. Via the bowel

A. Via the skin ​Rationale: Metabolic wastes that accumulate in the blood may be eliminated through the skin in the form of uremic frost. The​ bowel, tears, and respirations cannot eliminate metabolic waste.

The nurse is caring for a client with third spacing. Which information should the nurse use to explain this health problem to the​ client's family? A. ​"Fluid in the blood vessels is unavailable for the body to​ use." B. ​"Fluid moves into the fatty tissue under the​ skin." C. ​"Fluid moves into the space in the body​ cells." D. ​"Fluid leaves the body through increased​ urination."

A. ​"Fluid in the blood vessels is unavailable for the body to​ use." ​Rationale: In third​ spacing, fluid moves from the vascular space into an area where it is not available to support normal physiological functioning. The fluid may move into the peritoneal space or​ pleura, where it is trapped. The unavailable fluid in third spacing may be located in the bowel or peritoneal cavity. The fluid loss that can be attributed to third spacing may be difficult to detect because the​ client's weight may remain stable and intake and output records may not indicate a fluid loss. Fluid does not leave the body or enter the intracellular space or subcutaneous tissue.

A client is being discharged following the placement of an AV fistula. The nurse is providing discharge instructions to the client regarding the fistula. Which should the nurse share during this​ session? A. ​"The fistula will not be functional for dialysis for a​ month." B. ​"This fistula is created by joining two arteries​ together." C. ​"This is temporary access for​ dialysis." D. ​"The fistula will heal within a​ week."

A. ​"The fistula will not be functional for dialysis for a​ month." Rationale: For​ longer-term vascular​ access, an arteriovenous​ (AV) fistula​ (an artificial connection between a vein and an​ artery) is created. In preparation for fistula​ formation, the nondominant arm is not used for venipuncture or blood pressure measurement during renal failure. The fistula is created by surgical anastomosis of an artery and​ vein, usually the radial artery and cephalic vein. It takes about a month for the fistula to mature so that it can be used.

The nurse reviews the stages of chronic kidney disease​ (CKD) before caring for a client with the disorder. Which stage of CKD should the nurse identify as occurring when the kidneys are unable to excrete metabolic waste and maintain fluid and electrolyte balance​ adequately? A. ​End-stage renal disease B. Renal insufficiency C. Corneal failure D. Decreasing renal reserve

A. ​End-stage renal disease Rationale: Chronic renal disease​ (CKD) progresses slowly. Loss of function may not be recognized for many years.​ End-stage renal​ disease, or stage​ 5, is the stage where the kidneys are finally unable to excrete metabolic wastes and to regulate fluid and electrolyte balance adequately.

The nurse is discussing management of acute kidney injury​ (AKI) with the client. Which would describe the key goal to managing this​ condition? A. Maintaining fluid and electrolyte balance B. Eating more vegetables that are low in iron C. Avoiding the use of diuretics D. Drinking more fluids

A. maintaining fluid and electrolyte balance Rationale: If a client develops​ AKI, maintaining the fluid and electrolyte balance is a key goal in managing the condition. Drinking more fluids could place the client at risk for fluid overload. Diuretics may be ordered for a client who is retaining a significant amount of fluid. Increasing the amount of iron in the diet is necessary if the client is not getting the daily requirement in the foods they are consuming.

The nurse is treating a client with a serum potassium level of​ 6.7mEq/L who is already on restricted potassium intake. Which medication may be ordered to reduce the neuromuscular effects of this increased serum​ level? A. Calcium chloride B. Lactated Ringer C. ​H2-receptor antagonist D. Antibiotic

A. calcium chloride Rationale: Hyperkalemia may require active intervention as well as restricted potassium intake. When the serum potassium level is greater than 6.0dash 6.5 ​mEq/L, manifestations of its effect on neuromuscular function​ develop, including muscle​ weakness, nausea and​ diarrhea, electrocardiographic​ changes, and possible cardiac arrest. With significant​ hyperkalemia, calcium​ chloride, bicarbonate, and insulin and glucose may be given intravenously to reduce serum potassium levels by moving potassium into the cells. An​ H2-receptor antagonist helps prevent gastrointestinal hemorrhage by decreasing gastric acid production. An antibiotic would be used to treat infection. Lactated Ringer would be used in children with AKI for fluid replacement.

The nurse creates a plan of care for a client with​ end-stage renal disease​ (ESRD). To what should the nurse pay particular attention when planning this​ care? A. Meal planning when dietary modifications are required B. Monitoring input and output C. Medication regimens and their side effects D. Daily weights

A. meal planning when dietary modifications are required ​Rationale: The nurse should involve the client in meal planning if dietary modifications are required. The nurse can provide teaching about the medication​ regimen, but the client is not usually involved in planning these regimens. Weighing the client and monitoring input and output are interventions carried out by the​ nurse, with little involvement by the client.

The nurse notes that the plan of care for a client with acute kidney injury​ (AKI) instructs them to reposition the client every 2 hours while in bed. Which is the rationale behind this​ instruction? A. To avoid skin breakdown B. To keep the client awake C. To keep skin dry D. To avoid bone fractures

A. to avoid skin breakdown Rationale: Turning the client frequently and providing good skin care help to avoid skin breakdown. Edema decreases tissue perfusion and increases the risk of skin​ breakdown, especially in clients who are older or debilitated. Frequent repositioning has no bearing on bone fractures. The client should be kept dry to assist in avoiding skin breakdown. Repositioning is not done to disturb or keep the client awake

The nurse is caring for an older client. Which early sign of a fluid volume deficit should the nurse identify in this​ client? A. Brittle hair B. Change in mental status C. Poor skin turgor D. Dry skin

B. Change in mental status ​Rationale: Change in mental status or mentation is an early sign of FVD in the older adult. Skin turgor can be difficult to assess due to normal changes with aging. Dry skin and brittle hair are signs of chronic dehydration.

The nurse is teaching a client ways to prevent fluid imbalances. Which fluids should the nurse encourage the client to​ avoid? A. Juice B. Coffee C. Pedialyte D. Water

B. Coffee ​Rationale: Coffee should be avoided due to its diuretic effects.​ Water, Pedialyte, and juice are acceptable drinks to avoid fluid imbalances.

A nurse is caring for a client who has lost a large percentage of circulating body fluids as a result of excessive diuresis. Which medication would the nurse anticipate this client​ needing? A. Diuretic B. Crystalloid C. Electrolyte supplement D. Colloid

B. Crystalloid Rationale: Colloids expand fluid volume by the replacement of proteins or other large molecules. Diuretics are used to promote urine​ output, particularly associated with fluid overload. Electrolyte supplements are used to replace lost electrolytes. Crystalloids contain both electrolytes and other substances that mimic the​ body's extracellular fluid. These medications will assist in the replacement of depleted fluids while promoting urine output.

A client with dehydration secondary to poor fluid intake has a 1 kg weight loss and voids 20 mL in the last hour. Which action should the nurse take​ first? A. Document these normal findings B. Discuss a fluid challenge with the healthcare provider C. Infuse 100 mL of normal saline per the standing order D. Encourage to increase oral intake of water

B. Discuss a fluid challenge with the healthcare provider Rationale: The weight loss and low urine output indicate fluid volume deficit. These findings indicate the need for a fluid challenge. A fluid challenge may be performed to evaluate fluid volume when urine output is low and cardiac or renal function is questionable. A fluid challenge helps to prevent fluid volume overload resulting from IV fluid therapy when cardiac or renal function is compromised. These are not normal findings and require intervention. Drinking water or administration of 100 mL of normal saline are not appropriate interventions for this client.

The nurse instructs a client with fluid volume excess about dietary choices. Which meal choice should indicate to the nurse that teaching was​ effective? A. Egg​ whites, ham,​ grits, and white bread B. Egg​ whites, turkey​ bacon, oatmeal, and wheat toast C. ​Eggs, ham, mixed​ fruit, and wheat bread D. ​Eggs, sausage,​ grits, and white bread

B. Egg​ whites, turkey​ bacon, oatmeal, and wheat toast A meal of egg​ whites, turkey​ bacon, oatmeal, and wheat toast is the best choice to decrease the amount of​ sodium, because turkey bacon has the least amount of sodium. Choices that contain​ sausage, bacon, or ham are high in sodium and should be avoided.

The lab work of a client with chronic kidney disease​ (CKD) shows an *elevated serum potassium level.* Which *prescription* should the nurse anticipate receiving from the healthcare​ provider? A. Intravenous potassium chloride B. Intravenous glucose C. Oral vitamin D D. Oral calcium carbonate

B. Intravenous glucose Rationale: A method to lower blood potassium levels is to administer intravenous glucose and insulin. The insulin drives the glucose into body cells. The glucose takes the potassium with it into the​ cells, thereby lowering blood potassium levels. Potassium supplements would not be prescribed for a client with an elevated potassium level. Oral calcium carbonate is a​ phosphorus-binding agent and reduces the phosphate level in the blood. Vitamin D is given to increase the absorption of calcium.

The school nurse notes that a​ school-age child is experiencing mild heat exhaustion after playing outside during recess. Which recommendation should the nurse make to help prevent future occurrences of​ heat-related illness? A. Teach children to drink water only before recess. B. Move afternoon recess to a cooler morning hour. C. Encourage children to drink water when they feel thirsty. D. Provide a time for children to rest after recess.

B. Move afternoon recess to a cooler morning hour.

The nurse is caring for a client with suspected fluid volume excess. Which change in the serum osmolality should the nurse use as confirmation of this health​ problem? A. Slight increase B. Remains the same C. Slight decrease D. Large increase

B. Remains the same​ Rationale: During fluid volume​ excess, the body retains both sodium and water. This causes the blood serum to remain isotonic and serum osmolality to remain the same.

A client has a serum sodium level of 140​ mEq/L, hematocrit level of​ 31%, and generalized edema. Which intervention should the nurse make a priority for this​ client? A. Encourage to drink ginger ale B. Restrict fluid intake C. Increase sodium intake in the diet D. Prepare to administer a blood transfusion

B. Restrict fluid intake​ Rationale: The​ client's laboratory values and symptoms indicate excessive fluid volume. The priority would be to restrict fluid. The other actions are not appropriate for excessive fluid volume.

The nurse describes the increased risk of gastrointestinal bleeding to a client with AKI. Which factor should the nurse inform the client about with regard to​ medication? (Select all that​ apply.) A. ​Over-the-counter calcium carbonate​ (Tums) is​ helpful." B. ​"Avoid magnesium-based​ antacids." C. ​"Regular doses of antacids are​ indicated." D. ​"Drink milk to coat the stomach prior to taking​ medication." E. ​"Take antacids at​ bedtime."

B. ​"Avoid magnesium-based​ antacids." C. ​"Regular doses of antacids are​ indicated." ​Rationale: The client with AKI has an increased risk of GI​ bleeding, probably related to the stress response and impaired platelet function. Regular doses of antacids​ (although not ones that are magnesium​ based), histamine​ H2-receptor antagonists​ (e.g., famotidine,​ ranitidine), or a proton pump inhibitor​ (e.g., omeprazole​ [Prilosec]) are often ordered to prevent GI hemorrhage. All​ medications, including​ over-the-counter medications, should be discussed with the healthcare provider to see if they are contraindicated in their medical condition. Milk will not coat the stomach or protect the gastric mucosa.

A pregnant client telephones the clinic for help because of vomiting for over 15 hours and is feeling lightheaded and dizzy. Which advice should the nurse provide to this​ client? A. ​"See your healthcare provider for a prescription for an​ antiemetic." B. ​"Head to the local emergency​ department." C. ​"Switch from water to ginger ale or ginger tea to prevent​ nausea." D. ​"Drink one fourth cup of oral rehydration fluid every 15dash 20 minutes until vomiting​ stops."

B. ​"Head to the local emergency​ department." Rationale: Pregnant clients with *hyperemesis gravidarum* are at significant risk for electrolyte imbalances. The client should be directed to the emergency department for evaluation and rehydration. Oral rehydration fluids and ginger products will likely not be effective to rehydrate the client. An antiemetic may be effective to minimize​ nausea, but it does not address the immediate issue of the potential electrolyte imbalance.

A client with chronic kidney disease​ (CKD) is experiencing Kussmaul respirations. Which acid- base imbalance should the nurse suspect the client is​ experiencing? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

B. metabolic acidosis Rationale: As renal failure​ advances, the kidney loses the ability to excrete hydrogen ions. The buffering action of the kidney becomes impaired. This leads to metabolic acidosis. *Kussmaul respirations​ (increasing rate and​ depth)* are the​ body's attempt to *compensate for the acidosis.* Metabolic alkalosis occurs with an increased excretion of hydrogen ions. Respiratory acidosis occurs with retention of carbon dioxide. Respiratory alkalosis occurs with an increased loss of carbon dioxide.

The nurse reviews the results of diagnostic tests performed on a client with suspected chronic kidney disease​ (CKD). Which stage of the disease should the nurse suspect the client is experiencing when the glomerular filtration rate​ (GFR) is mildly​ decreased? A. Stage 3 B. Stage 2 C. Stage 1 D. Stage 4

B. stage 2 Rationale: A client with mildly decreased GFR is diagnosed with stage 2 chronic kidney disease. GFR in stage 1 is increased. GFR in stage 3 is moderately decreased. GFR in stage 4 is severely decreased.

The nurse discusses the risk of developing chronic kidney disease​ (CKD) with a group of nursing students. Which population group should the nurse emphasize as being most at risk for developing this​ disorder? A. Hispanic Americans B. Caucasian Americans C. African Americans D. Asian Americans

C. African Americans Rationale: African Americans are nearly three times as likely to develop CKD as Caucasian Americans. This is much greater than the risk for Asian Americans and Hispanic Americans to develop the disease.

The nurse is discussing medications with a client with acute kidney injury​ (AKI) upon discharge. Which should be included in the​ teaching? A. Avoid taking blood pressure medication at night. B. Avoid taking iron supplementation. C. Avoid taking NSAIDS. D. Avoid taking acetaminophen​ (Tylenol).

C. Avoid taking NSAIDS. Rationale: All drugs that either are directly nephrotoxic or may interfere with renal perfusion​ (e.g., potent​ vasoconstrictors) should be avoided.​ NSAIDs, nephrotoxic​ antibiotics, and other potentially harmful drugs are avoided throughout the course of AKI. Iron supplementation can be continued if the client is not receiving the required amount in the foods they consume. Acetaminophen can be taken for​ discomfort, as it does not contain the same chemical​ make-up as the NSAIDS. The client should take their blood pressure medication as ordered by the healthcare provider.

A client who received a kidney transplant 18 months ago is demonstrating progressive​ azotemia, proteinuria, and hypertension. Which disorder should the nurse suspect the client is​ experiencing? A. Acute rejection of the kidney B. Pyelonephritis C. Chronic rejection of the kidney D. Glomerulonephritis

C. Chronic rejection of the kidney Rationale: The symptoms described are those of progressive renal failure. This means that the transplanted kidney is failing. Acute rejection develops within months of the transplant. Chronic rejection occurs months or years after the transplant. Glomerulonephritis and pyelonephritis are infections of the kidney.

The nurse plans care for a client with fluid volume deficit. Which direction should the nurse provide to nursing assistive personnel about turning and repositioning this​ client? A. Every 30 minutes B. Every 90 minutes C. Every 120 minutes D. Every 180 minutes

C. Every 120 minutes​ Rationale: Turning the client every 2 hours​ (120 minutes) and monitoring for evidence of skin breakdown are nursing interventions to prevent alterations in skin integrity. 30 minutes is too often and would be very disruptive to the client. 90 minutes is also too soon. 180 minutes is too long and poses a risk to the​ client's skin.

A client with nausea and vomiting has orthostatic​ hypotension, dry​ skin, flat neck​ veins, and a urine specific gravity of 1.060. Which diagnosis should the nurse use to guide this​ client's care? A. Tissue​ Perfusion: Peripheral, Ineffective​ (NANDA-I ©2014) B. Gas​ Exchange, Impaired C. Fluid​ Volume: Deficient D. Skin​ Integrity, Impaired

C. Fluid​ Volume: Deficient ​ Rationale: The​ client's symptoms and urine specific gravity indicate deficient fluid volume. The other diagnoses are not the priority for the client at this time.

A client is experiencing​ fatigue, headache, and nausea and vomiting and has a decrease in deep tendon reflexes. Which electrolyte imbalance should the nurse suspect is causing this​ client's symptoms? A. Hyperchloremia B. Hypokalemia C. Hypercalcemia D. Hypomagnesemia

C. Hypercalcemia Rationale: Hypercalcemia is an increase in serum calcium level. Clinical manifestations of this condition include​ fatigue, weakness, decreased tendon​ reflexes, headache, impaired​ cognition, anorexia, nausea and​ vomiting, lethargy,​ polyuria, muscle​ weakness, constipation, and cardiac dysrhythmias.​ Hypomagnesemia, hyperchloremia, and hypokalemia do not produce these clinical manifestations.

A client with heart failure has distended neck​ veins, dependent​ edema, and respiratory crackles on assessment. Which prescription should the nurse anticipate being prescribed for this​ client? A. Chest​ x-ray B. Continuous EKG monitoring C. Intravenous Lasix 20 mg now D. Infuse 1000 mL of normal saline

C. Intravenous Lasix 20 mg now​ Rationale: The client is demonstrating signs of fluid volume excess. *Treatment of this disorder includes diuretics to remove excess fluid.* Normal saline would exacerbate this​ client's health problem. A chest​ x-ray may be required if the diuretic does not help remove excess fluid from the lungs. *Continuous EKG monitoring does not address excess fluid.*

The nurse is assessing a young child in the community clinic. Which sign indicates to the nurse that the child is experiencing mild​ dehydration? A. Concentrated urine B. Dry mucous membranes C. Restless D. ​Cool, dry skin

C. Restless Rationale: Mild dehydration can be difficult to detect in young children because they tend to not show any​ symptoms, though they may be alert or restless. Mucous membranes and skin tends to remain warm and moist and urine does not always appear concentrated.

The nurse is reviewing the fluid needs for a group of clients. Which characteristic of the intracellular fluid compartment of the body should the nurse​ identify? A. Makes about one third of total body fluid in adults B. Includes cerebrospinal and peritoneal fluids C. Serves as a medium for metabolic processes D. Divides into​ intravascular, interstitial, and transcellular fluids

C. Serves as a medium for metabolic processes Rationale: The intracellular fluid compartment makes up about two thirds of total body fluid in adults and is found within cells. It is a medium for metabolic processes. Extracellular fluid makes up the other one third of total body fluid and is divided into​ intravascular, interstitial, and transcellular fluids. Cerebrospinal and peritoneal fluids are examples of transcellular fluids.

The nurse is assessing the urinalysis of a client with fluid volume deficit. On which component of the urinalysis should the nurse focus to determine the​ client's fluid​ balance? A. Nitrites B. Glucose C. Specific gravity D. Leukocyte esterase

C. Specific gravity Rationale: Specific gravity measures the concentration of urine. Glucose found in the urine is indicative of diabetes mellitus. Nitrites in the urine indicate a possible bacterial infection. Leukocyte esterase also can be indicative of a possible bacterial infection.

The nurse is preparing material on fluid compartments in the body. Which fluids should the nurse identify as the components of extracellular​ fluid? A. ​Intracellular, interstitial, and intravascular fluids B. ​Intravascular, interstitial, and intracellular fluids C. ​Intravascular, interstitial, and transcellular fluids D. ​Transcellular, intracellular, and extracellular fluids

C. ​Intravascular, interstitial, and transcellular fluids Rationale: Body fluids found outside of the cell include​ intravascular, interstitial, and transcellular fluids.​ Conversely, intracellular fluids are found inside the cell.

To determine a blood and tissue type match between donor and recipient in kidney​ transplants, human leukocyte antigens are compared. How many antigens should the nurse expect to be reported for a donor to be a​ "perfect" match? A. Seven B. Five C. Six D. Four

C. six Rationale: Six antigens are considered a perfect match in blood and tissue typing for kidney transplantation.

The nurse reviews findings from the assessment of a client with​ end-stage renal disease​ (ESRD). Which finding should the nurse identify as the most common cardiac complication of this​ disease? A. Hypolipidemia B. Cardiomyopathy C. Systemic hypertension D. Tetralogy of Fallot

C. systemic hypertension Rationale: *Hypertension results from excess fluid​ volume, increased​ renin-angiotensin activity, and increased peripheral vascular resistance.* Hyperlipidemia, not​ hypolipidemia, often occurs with ESRD. Heart​ failure, not​ cardiomyopathy, results from ESRD. Tetralogy of Fallot is a congenital heart abnormality not caused by ESRD.

The nurse is providing care to a client diagnosed with chronic renal failure. Which cardiovascular assessment finding should the nurse identify that supports this​ diagnosis? A. Anemia B. Decreased white blood cell count C. Systemic hypertension D. Hyperkalemia

C. systemic hypertension Rationale: The cardiovascular assessment finding that supports the diagnosis of chronic renal failure is systemic hypertension. Anemia is a hematologic symptom of chronic renal failure. A decreased white blood cell count is a manifestation of chronic renal failure that affects the immune system. Hyperkalemia occurs as the result of the effects of chronic renal failure on fluids and electrolytes.

A​ 63-year-old man is admitted with postrenal acute kidney injury​ (AKI) because of a kidney stone. Vascular volume and renal perfusion have been restored and he is on fluid restriction. During the past 24​ hours, he has voided 250 mL of urine. He has not had any other type of output. How much fluid should the client receive over the next 24​ hours? A. 2750 mL B. 1250 mL C. 3000 mL D. 750 mL

D. 750 mL​ Rationale: Once vascular and renal perfusion has been​ restored, fluid intake for clients with AKI is usually restricted because the kidneys cannot eliminate fluids normally. Fluid intake is calculated for these clients by adding the amount of output for the previous 24 hours to 500 mL to allow for insensible losses. The​ client's output for the past 24 hours was 250​ mL; added to 500​ mL, the fluid volume calculation equals 750 mL. A fluid intake of​ 1250, 2750, or 3000 mL would be too much fluid for the client and would put the client at risk for fluid overload.

The nurse is determining a​ client's fluid balance. Which method should the nurse use to identify this​ client's fluid volume excess or​ deficit? A. Blood pressure B. Intake and output C. Skin turgor D. Daily weight

D. Daily weight​ Rationale: Daily weight is the best indicator of fluid volume excess or deficit. Skin​ turgor, blood​ pressure, and intake and output are assessments that would be included in the care of a client with fluid​ imbalances, but daily weight is the best indicator of changes in fluid status.

A young adult client receiving peritoneal dialysis feels fat and unattractive. Which action should the nurse use to help the client cope with a disturbed body​ image? A. Provide written information regarding the technical aspects of the dialysis procedure. B. Recommend speaking with adolescents who also have developed chronic renal failure. C. Recommend increasing physical activity to manage weight. D. Encourage expression of feelings related to the disease and treatment and their impact on life.

D. Encourage expression of feelings related to the disease and treatment and their impact on life. Rationale: An appropriate intervention for a client with a disturbed body image is to encourage the expression of feelings related to the disease process and the treatments. While support groups are​ encouraged, the nurse would not recommend that the client speak to an adolescent client with chronic renal failure. While offering written information regarding treatment is​ important, this intervention is not appropriate for a client with disturbed body image. Telling the client to increase physical activity to avoid gaining weight is not therapeutic.

The nurse is monitoring the fluid and electrolyte status of a client receiving intravenous colloids. For which imbalance should the nurse assess this​ client? A. Fluid deficit B. Hyperkalemia C. Hypernatremia D. Fluid overload

D. Fluid overload ​Rationale: The client receiving intravenous​ (IV) colloids or any IV fluid is at risk for fluid overload. It​ is, therefore, important to monitor the client for manifestations of fluid overload. Fluid​ deficit, hyperkalemia, and hypernatremia do not typically result when infusing colloids.

A client is experiencing symptoms of severe gastroenteritis. Which intravenous fluid order should the nurse anticipate being prescribed for this​ client? A. ​5% dextrose in​ 0.45% NaCl B. ​5% dextrose in water C. ​0.45% NaCl D. Lactated Ringers

D. Lactated Ringers ​Rationale: Clients with dehydration secondary to gastroenteritis​ (vomiting and/or​ diarrhea) are experiencing isotonic fluid loss and require isotonic electrolyte​ replacement, which includes either lactated Ringer or normal saline. A solution of​ 5% dextrose in​ 0.45% NaCl,​ 5% dextrose in​ water, and​ 0.45% NaCl is used to treat total body water​ deficits, not isotonic fluid loss.

The nurse prepares intravenous fluid for a client. Which mechanism should the nurse recall that represents the movement of fluid across cell membranes from an area of less concentration to an area of higher​ concentration? A. Diffusion B. Active transport C. Filtration D. Osmosis

D. Osmosis Rationale: Osmosis is the movement of water across cell​ membranes, from the​ less-concentrated solution to the​ more-concentrated solution. Filtration is the process by which fluid and solutes move together across a membrane from one compartment to another. Active transport is a process by which substances move across the cell membrane and must combine with a carrier for​ transportation, requiring metabolic energy. With​ diffusion, the molecules move from a solution of higher concentration to a solution of lower concentration.

The nurse is planning care for a client with chronic kidney disease​ (CKD). Which precautions should the nurse implement for this​ client? A. Contact B. Droplet C. Airborne D. Standard

D. Standard Rationale: Because a client with chronic renal failure is at risk of​ infection, healthcare providers should use standard precautions to provide care. The other types of precautions are not appropriate for a client with chronic renal failure.

A client experiencing hyperkalemia is scheduled for dialysis. The nurse anticipates an order for insulin to help lower the serum potassium level. Which beneficial action does this medication have for this​ client? A. Lowers the blood glucose rate B. Acts as an anticoagulant C. Pulls fluid from the cells D. Drives the potassium back into the cells

D. drives the potassium back into the cell Rationale: Glucose and insulin are administered to the client with hyperkalemia to help drive potassium back into the intracellular​ fluid, reducing the amount of potassium in the blood. Potassium supplements would only increase the​ client's potassium levels. Insulin is used to control the blood glucose rate in a diabetic client. Insulin is not known to draw fluid from the cells or act as an anticoagulant.

The nurse reviews intake and output with a graduate nurse. Which statement by the graduate nurse should cause the nurse​ concern? A. ​"Any time the client​ vomits, I need to add that number to the​ output." B. ​"I would need to record liquid feces as​ output." C. ​"I should document the amount of tube irrigation as​ intake." D. ​"I would not count ice cream as fluid intake because it is​ frozen."

D. ​"I would not count ice cream as fluid intake because it is​ frozen." Rationale: Accurate measurement and recording of fluid​ I&O provides important data about the​ client's fluid balance. Ice cream would be considered intake because it is a food that becomes liquid at room temperature. The other answers are appropriate. Other intake includes all oral​ fluids, ice​ chips, IV​ fluids, IV​ medications, tube​ feedings, and catheter or tube irrigants. Output would include urinary​ output, vomitus, liquid​ feces, tube​ drainage, and wound drainage.

The nurse is providing care to a client diagnosed with chronic renal failure. Which assessment finding should the nurse expect if uremia is​ present? (Select all that​ apply.) A. Pruritus B. Yellow color on the sclera C. Moist skin D. Crystals noted on the skin surface E. Bruising on upper extremities

Pruritus and crystals noted on the skin Rationale: High levels of urea mixing with sweat can result in uremic​ frost, crystallized deposits of urea on the skin. The condition will cause pruritus. Bruising is a common manifestation of chronic renal​ failure, but this manifestation is caused by impaired platelet function. Clients with​ end-stage renal disease​ (ESRD) may develop a yellowish tinge to the skin because of retained pigmented​ metabolites, but a yellowed sclera is significant of other disease processes. Dry skin with poor turgor is a common dermatologic assessment in clients with ESRD.

A client with​ end-stage renal disease​ (ESRD) is experiencing uremia. Which prescription should the nurse expect to receive from the healthcare​ provider? (Select all that​ apply.) A. Physical therapy care consult B. Arterial blood gas monitoring C. Increased fluids D. Begin dialysis E. Serum electrolytes

abg's monitoring, begin dialysis, serum electrolytes Rationale: Uremia is a manifestation of ESRD that occurs when metabolic wastes build up in the blood. Dialysis is often the only option for treatment. ABGs and serum electrolytes are monitored to assess for complications of uremia. Fluids should be​ restricted, not increased. A dietary consult might be​ necessary, but not a physical therapy consult at this time.

The nurse is describing to a colleague how the accumulation of metabolites in the blood from renal failure affects the body. Which effect should the nurse​ include? A. Altered electrolyte balance B. Decreased levels of nitrogenous wastes in blood C. Increased pain D. Bradycardia

altered electrolyte balance Rationale: Renal failure is a condition in which the kidneys are unable to remove accumulated metabolites from the​ blood, resulting in altered fluid and electrolyte balance and aciddash base balance. Increased pain in a client with renal failure would not cause an alteration in the amount of metabolites. Heart palpitations are caused by​ stress, physical​ exertion, too much​ caffeine, and the use of stimulants. Decreased blood volume is usually caused by bleeding or dehydration.

The nurse is reviewing discharge instructions with a client with acute renal injury​ (AKI). Which diet instruction should the nurse​ include? (Select all that​ apply.) A. Eat foods high in potassium. B. Eat​ low-phosphorus foods. C. Eat foods low in saturated fat. D. Eat foods low in potassium. E. Eat​ high-calcium foods.

eat foods low in phosphorous, low in saturated fat, low in potassium, high in calcium ​ Rationale: Clients with AKI experience electrolyte imbalances. The client with AKI is at particular risk for hyperkalemia caused by impaired potassium excretion and hyperphosphatemia. Calcium and phosphate have a reciprocal relationship in the​ body; as the level of one​ rises, the level of the other falls.​ Therefore, the client should eat foods high in calcium and low in phosphate. Saturated fats are known to raise the levels of cholesterol and therefore should be eaten in moderation.

The nurse is explaining to the client the most common causes of acute kidney injury​ (AKI). Which cause should the nurse​ present? (Select all that​ apply) A. Fluid overload B. Chemical imbalance C. Exposure to nephrotoxins D. Insufficient blood supply E. Dehydration

exposure to nephrotoxins, ischemia (insufficient blood supply) *Other causes of AKI include major​ surgery, sepsis, and severe pneumonia.* ​Rationale: The most common causes of acute kidney injury​ (AKI) are ischemia​ (insufficient blood​ supply) and exposure to nephrotoxins​ (substances that damage nerves or nerve​ tissue). Because of the amount of blood that passes through​ them, the kidneys are particularly vulnerable to these factors. A fall in blood pressure or volume can cause ischemia of kidney tissues. Nephrotoxins in the blood damage renal tissue directly.

The nurse provides dietary teaching to a client with chronic kidney disease. Which food should the nurse inform the client about that contains protein of high biologic​ value? (Select all that​ apply.) A. Fish B. Legumes C. Poultry D. Milk E. Peanut butter

fish, poultry and milk Rationale: Animal sources of protein​ are meat, poultry, fish, eggs, milk,​ cheese, and yogurt which are proteins of high biologic value.​ Plants, legumes, grains,​ nuts, seeds, and vegetables provide proteins of low biologic value.

A client is receiving hemodialysis for renal failure. Which clinical information should indicate to the nurse that the client is experiencing an excess in fluid​ volume? (Select all that​ apply.) A. Full and bounding pulse B. Weight gain of 2 kg C. Pulse of 62 bpm D. Temperature 100.1degrees F E. Blood pressure​ 172/90 mmHg

full and bounding pulse, weight gain of 2kg, blood pressure 172/90 mmHg ​Rationale: Pulse​ volume, blood​ pressure, and body weight all increase with fluid volume excess. Temperature and pulse rate both increase with fluid volume deficit.

The nurse is caring for a client with acute kidney injury​ (AKI). Which condition should the nurse recognize as a possible cause for this​ disease? (Select all that​ apply.) A. Cerebrovascular disease B. Hemorrhage C. Severe heart failure D. Major trauma E. Radiologic contrast media

hemorrhage, heart failure, major trauma, radiologic contrast media Rationale: Major​ trauma, heart​ failure, and hemorrhage are all possible risks and causes for AKI because they can reduce blood flow to the kidneys. Radiologic contrast media can be nephrotoxic and cause AKI. Cerebrovascular disease is not a risk factor for AKI because it does not reduce blood flow to the kidneys and it does not cause nephrotoxicity.

The nurse preceptor is teaching a new graduate about conditions that can cause damage to the renal parenchyma and nephrons resulting in acute kidney injury​ (AKI). Which condition should the nurse preceptor​ include? (Select all that​ apply.) A. Hypertension B. Hemolysis C. Vasculitis D. Glomerulonephritis E. Dehydration

htn, hemolysis, vasculitis, glomerularnephritis Rationale: Hypertension,​ hemolysis, glomerulonephritis, and vasculitis cause acute damage to the renal parenchyma and​ nephrons, leading to intrarenal AKI. Dehydration causes prerenal AKI and does not cause damage to the renal parenchyma and nephrons.

A client has been experiencing severe diarrhea for nearly a week. On which areas should the nurse focus when assessing this​ client? (Select all that​ apply.) A. Oral cavity B. Endocrine system C. Ears D. Cardiovascular system E. Skin

oral cavity, cardiovascular system, skin Rationale: Physical assessment for fluid and electrolyte status focuses on the​ skin, oral cavity and mucous​ membranes, eyes, cardiovascular and respiratory​ systems, and neurological and muscular status. The ears and endocrine system are not a particular focus of fluid and electrolyte status assessment.

The nurse is performing an assessment on a client with fluid volume excess. Which finding should the nurse identify that supports fluid volume​ excess? (Select all that​ apply.) A. Tenting of skin B. Pitting edema C. Weight gain D. Thirst E. Crackles on auscultation

pitting edema, weight gain, crackles on auscultation ​Rationale: Pitting​ edema, weight​ gain, and crackles in the lungs upon auscultation are indicative of fluid volume excess. Tenting of skin and thirst are found in fluid volume deficit.

A nurse is caring for a pregnant woman. Which physiologic condition may occur during pregnancy and is related to the development of acute kidney injury​ (AKI) that should concern the​ nurse? (Select all that​ apply.) A. Preeclampsia B. Hypoglycemia C. Hydronephrosis D. Hyperemesis gravidarum E. Hypertension

preeclampsia, hydronephrosis, hyperemesis gravidarum ​Rationale: During​ pregnancy, glomerular filtration rate increases​ significantly, perhaps by as much as​ 50%. This leads to a decrease in baseline serum creatinine and other changes associated with the increased blood volume that pregnancy brings. AKI in pregnant women is often related to the same etiologies as are identified in the general population.​ However, there are unique etiologies that manifest themselves throughout the pregnancy cycle. Over​ 90% of women develop a physiologic hydronephrosis of​ pregnancy, and this can promote urinary​ stasis, lead to urinary tract​ infection, and ultimately lead to AKI. In​ addition, in the first​ trimester, hyperemesis gravidarum and placenta previa may lead to​ AKI, and as pregnancy​ progresses, pregnancy-induced​ hypertension, preeclampsia, and eclampsia stress the​ kidneys, leading to​ proteinuria, hydronephrosis, and AKI.

The nurse is completing a health history on a client admitted with acute renal failure. Which information should the nurse​ collect? (Select all that​ apply.) A. Previous transfusion reactions B. Chronic diseases C. Reports of weight loss D. Recent exposure to nephrotoxic medications E. Reports of anorexia

previous transfusion reactions, chronic diseases, recent exposure to nephrotoxic medications, reports of anorexia ​Rationale: When completing a health history on a client with acute renal​ failure, the nurse needs to collect information on recent exposure to nephrotoxic medications​ (e.g., nonsteroidal​ anti-inflammatory drugs​ [NSAIDs] and some chemotherapeutic​ drugs); previous transfusion​ reactions; chronic diseases such as diabetes​ mellitus, heart​ failure, and kidney​ disease; and reports of anorexia. The nurse needs to collect information on reports of weight​ gain, not weight loss.

The nurse is completing a physical assessment with a client. On which part of the body should the nurse focus when determining fluid and electrolyte​ status? (Select all that​ apply.) A. Ears B. Skin C. Endocrine system D. Oral cavity E. Cardiovascular system

skin, oral cavity and cardiovascular system

A client diagnosed with acute kidney injury​ (AKI) is experiencing hyperkalemia. Which medication should the nurse anticipate being prescribed to this​ client? (Select all that​ apply.) A. Sodium bicarbonate B. Insulin C. Glucose D. ​Angiotensin-converting enzyme​ (ACE) inhibitors E. Calcium chloride

sodium bicarb, insulin, glucose, calcium chloride ​Rationale: The nurse should anticipate that calcium​ chloride, sodium​ bicarbonate, insulin, and glucose would be prescribed to treat the​ client's hyperkalemia. Calcium​ chloride, sodium​ bicarbonate, and insulin can be used to reduce serum potassium levels by moving potassium into the cells. Calcium is also administered to correct hypocalcemia and reduce hyperphosphatemia.​ (Calcium and phosphate have a reciprocal relationship in the​ body; as the level of one​ rises, the level of the other​ falls.) An ACE inhibitor is used to treat​ hypertension, not hyperkalemia.

A client with chronic kidney disease​ (CKD) has a potassium level of 6.5​ mEq/dL. Which prescription should the nurse anticipate receiving for this​ client? (Select all that​ apply.) A. Intravenous​ 50% dextrose solution B. Potassium 30​ mEq/L in 100 mL intravenous over 2 hours C. Sodium polystyrene sulfonate D. Intravenous regular insulin E. Sodium bicarbonate

sodium polystyrene sulfonate, iv insulin, sodium bicarbonate, iv %0% dextrose solution Rationale: *Sodium polystyrene sulfonate* is a​ potassium-ion exchange resin that *removes potassium by exchanging sodium ions for potassium in the small bowel*. A combination of *regular​ insulin, bicarbonate, and glucose​ (dextrose) facilitates the movement of potassium ions into the cells to decrease serum potassium levels.*A serum potassium level of 6.5​ mEq/L is​ hyperkalemic,* so potassium replacement is not appropriate.

The nurse reviews the complications of chronic kidney disease​ (CKD) with a group of new graduate nurses. Which complication should the nurse include in the​ teaching? (Select all that​ apply.) A. Celiac disease B. Uremic encephalopathy C. Osteodystrophy D. Anemia E. Diabetes insipidus

uremic encephalopathy, osteodystrophy, anemia ​Rationale: In​ CKD, the kidneys produce less​ erythropoietin, which results in anemia. The kidney loses the ability to excrete metabolic waste​ products, so they build up in the blood​ (uremia). These waste products cause changes in the central nervous system known as uremic encephalopathy. Decreased vitamin D synthesis and decreased calcium absorption leads to bone resorption and remodeling that leads to osteodystrophy. Diabetes insipidus and celiac disease are not complications of CKD.

For which reason did the nurse place a chair scale in the room of a client who has been admitted with acute kidney injury​ (AKI)? (Select all that​ apply.) A. To utilize standard technique B. Because chair scales are the most accurate C. Limited availability of equipment D. Because equipment calibration can vary E. To ensure an accurate weight

utilize standard technique, because equipment calibration can vary, to ensure accurate weight Rationale: Weigh the client daily or more frequently as ordered. Use standard technique​ (same scale,​ clothing, or​ coverings) to ensure accuracy. Rapid weight changes are an accurate indicator of fluid volume​ status, particularly in the client with oliguria. Any drastic shift in weight of a client with AKI indicates some malfunction and can adversely affect other organs and the treatment program.

Which data should the nurse collect when completing a physical examination on a client experiencing acute kidney injury​ (AKI)? (Select all that​ apply.) A. Weight B. History of diabetes mellitus C. Skin color D. Reports of edema E. Lung sounds

weight, skin color and lung sounds ​Rationale: When completing a physical examination on a client experiencing acute renal​ failure, the nurse needs to note the​ client's weight, skin​ color, and lung​ sounds, which may indicate fluid volume excess. Reports of edema and having a history of diabetes mellitus are information collected when obtaining a​ client's health history.

A client with chronic kidney disease​ (CKD) has hypertension. Which class of medications should the nurse expect to be prescribed for this​ client? A. Calcium channel blocker B. Vasodilator C. Beta blocker D. ACE inhibitor

​D. ACE inhibitor Rationale: ACE inhibitors are the treatment of choice for hypertension associated with chronic kidney disease. They suppress the​ renin-angiotensin-aldosterone system and slow the progress of renal disease. Calcium channel​ blockers, beta​ blockers, and vasodilators are other classes of medications that are used to treat hypertension.

The nurse is caring for a​ critically-ill client who experienced significant blood loss during surgery. Which concern related to the​ client's risk for prerenal acute kidney injury​ (AKI) should the nurse consider the priority​? A. Hyperperfusion B. Urinary obstruction C. Fluid overload D. Diminished cardiac output

​diminished cardiac output Rationale: Prerenal AKI results from conditions that affect renal blood flow and perfusion. Any disorder that significantly decreases vascular​ volume, cardiac​ output, or systemic vascular resistance can affect renal blood flow. Prerenal AKI is​ common, particularly in clients who experience trauma or surgery or are critically ill. The kidneys normally receive 20dash ​25% of the cardiac output to maintain the glomerular filtration rate​ (GFR), the rate at which fluid is filtered through the kidneys. A drop in renal blood flow to less than​ 20% of normal causes the GFR to fall.​ Hypoperfusion, not​ hyperperfusion, would be a concern. Obstruction is a concern with postrenal​ AKI, not prerenal. Dehydration due to fluid loss would be the​ concern, not fluid overload

A client is experiencing severe diarrhea. Which data should indicate to the nurse that the client is experiencing fluid volume​ deficit? (Select all that​ apply.) A. Weight gain B. Increased heart rate C. Poor skin turgor D. Orthostatic hypotension E. Increased urine output

​increased heart rate, poor skin turgor, orthostatic hypotension Rationale: Orthostatic​ hypotension, increased heart​ rate, and poor skin turgor are acute manifestations of fluid volume deficit. Increases in urine output and weight gain are not acute manifestations of fluid volume deficit.