Fluid Volume Deficit | Fluid and Electrolytes NCLEX & Nursing School Exams Like A Boss

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Fluid Deficit – Notes

Fluid Deficit – Slides

FLUID VOLUME DEFICIT NCLEX QUIZ QUESTIONS

Question 1: During an assessment of a newly admitted patient, the nurse notes that the client’s heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The patient’s spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?

1. Dehydration
2. Fluid Overload
3. Hypernatremia
4. Hypokalemia

 

Question 2: The nurse is caring for a client with a diagnosis of dehydration, and the patient is receiving intravenous (IV fluids). Which assessment data would indicate to the nurse that the dehydration remains unresolved?

1. An oral temperature of 98.6 F
2. A urine specific gravity of 1.050
3. A urine output that is pale yellow
4. A blood pressure of 120/80 mmHg

 

Question 3: A nurse is assisting in the care of a group of clients on the clinical nursing unit. The nurse monitors the fluid balance of a client who has which of the following diagnoses and is most at risk for fluid volume deficit?

1. Ileostomy
2. Hypertension
3. Congestive Heart Failure
4. Acute Renal Failure

 

Question 4: An older adult client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which of the following manifestations that correlates with this client’s fluid imbalance?

1. Flat neck veins
2. Lung crackles
3. Increased blood pressure
4. Decreased pulse

FLUID VOLUME DEFICIT NCLEX QUIZ ANSWERS

Question 1: During an assessment of a newly admitted patient, the nurse notes that the client’s heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The patient’s spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition?

1. Dehydration
2. Fluid Overload
3. Hypernatremia
4. Hypokalemia

When a patient is dehydrated, the heart rate increases in an attempt to maintain blood pressure. Blood pressure reflects orthostatic changes caused by the reduced blood volume, and when the patient stands, he may experience dizziness because of insufficient blood flow to the brain. Alterations in mental status also may occur. The oral mucous membranes, usually moist are dry and may be covered with a thick, pasty coating. These findings are not manifestations of the conditions noted in the other options.

 

Question 2: The nurse is caring for a client with a diagnosis of dehydration, and the patient is receiving intravenous (IV fluids). Which assessment data would indicate to the nurse that the dehydration remains unresolved?

1. An oral temperature of 98.6 F
2. A urine specific gravity of 1.050
3. A urine output that is pale yellow
4. A blood pressure of 120/80 mmHg

The patient who is dehydrated will have a urine specific gravity greater than 1.030 (if the gravity is high, they are likely DRY). Normal values for urine specific gravity are 1.010 to 1.030. The temperature and blood pressure are normal. Pale yellow urine is also a normal finding.

 

Question 3: A nurse is assisting in the care of a group of clients on the clinical nursing unit. The nurse monitors the fluid balance of a client who has which of the following diagnoses and is most at risk for fluid volume deficit?

1. Ileostomy
2. Hypertension
3. Congestive Heart Failure
4. Acute Renal Failure

The client with an ileostomy is at risk for fluid volume deficit due to increase gastrointestinal losses. Other causes of fluid volume deficit include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient intravenous fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. Clients who have heart failure or renal failure are at risk for fluid volume excess. Hypertension is unrelated to the subject of the question.

 

Question 4: An older adult client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client for which of the following manifestations that correlates with this client’s fluid imbalance?

1. Flat neck veins
2. Lung crackles
3. Increased blood pressure
4. Decreased pulse

A client with dehydration has a fluid volume deficit, which can be reflected by flat neck veins. Other findings are increased pulse and respirations weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The manifestations noted in options 2, 3, and 4 indicate fluid volume excess.