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Assessment Related12
Assessment Related To Fluid Balance week 12
| Question | Answer |
|---|---|
| A patient who has been ill with vomiting and diarrhea has experienced a rapid weight loss of 8% of total body weight. How would this be categorized on the dehydration scale? | Severe dehydration |
| Which patients are likely experiencing fluid volume deficit? | An 86-year-old woman with a fever who has dry mucous membranes and decreased urination An infant with diarrhea who has increased respiratory rate, tachycardia, and sunken fontanel A 40-year-old woman with bleeding who has a weak, thready pulse |
| In a patient with fluid volume deficit, which clinical manifestation would be due to decreased interstitial fluid? | Decreased skin turgor |
| The nurse is assessing a patient with fluid volume deficit (FVD). Which clinical manifestation would suggest that the patient is experiencing hypertonic FVD? | The patient has become confused |
| A patient has developed edema. Which descriptions are accurate regarding this manifestation? | Caused by excessive fluid in the interstitial space. Dependent edema occurs in the sacral area of patient on bedrest. Edematous tissue is quite fragile. |
| A patient has developed fluid volume excess. The nurse is aware that the increase in the patient’s interstitial fluids can lead to which manifestation? | Dependent edema |
| The nurse notes that an assigned adult patient has experienced a 5% weight gain over the last 24 hours. Taking the patient’s data into consideration, the nurse concludes that it is fluid weight gain. What degree of excess does this patient have? | Moderate FVE |
| Match the clinical manifestations to their fluid excess category. Edema of the ankles and feet Bounding peripheral pulses and hypertension Shortness of breath, cough | Increased interstitial volume Increased circulating fluid volume Pulmonary cellular edema |
| A nurse is obtaining a health history on a newly-admitted patient. Which patient responses should alert the nurse to the possibility of a fluid volume imbalance? | Weight gain of 2 kg since yesterday morning |
| A patient with vomiting and diarrhea has developed rapid onset isotonic fluid volume deficit. The patient can be expected to have which lab data results? | Elevated RBC Increased BUN and Creatinine |
| The nurse is assessing a 35-year-old patient who is at risk for developing fluid volume excess. Which data would support the presence of FVE in an adult patient? | Crackles auscultated in lung bases |
| Match each laboratory test with the information it provides. Indicator of overall renal function Helps determine hydration status, useful in managing fluid requirements Measure of the oxygen carrying capacity of the blood Measure of the concentration | Blood urea nitrogen, Creatinine' Serum osmolality RBC, H&H Urine osmolality |
| A nurse is asked to assess a patient for fluid volume deficit. The patient reports that he has lost 10 kg of total body weight in the last 48 hours due to vomiting and diarrhea. Based on the relationship between volume and weight, about how much fluid has | 10 liters of fluid |
| The nurse has been assigned to an adult patient with isotonic fluid volume deficit and performing her shift assessment on the patient. The nurse can anticipate which clinical findings? | Hypotension Flat neck veins when supine Low urine output |
| A patient has developed neurologic manifestations related to hypertonic fluid volume deficit. The nurse is aware that these manifestations are caused by what underlying problem? | Increased serum osmolality causes water to shift out of brain cells by osmosis |
| During the morning patient assessment the nurse finds bounding peripheral pulses and jugular venous distention. The nurse is aware that these are clinical manifestations caused by what type of fluid imbalance? | Increased circulating volume |
| A patient who received an excessive volume of hypotonic IV fluid has developed the signs and symptoms of hypotonic FVE. Which neurologic clinical manifestations are consistent with this fluid imbalance? | Seizures Confusion |
| A patient has developed edema as a result of fluid volume excess. The nurse is aware that the underlying cause of this fluid imbalance is which primary cause of edema? | Increased hydrostatic pressure |
| A patient has developed edema. Which descriptions are accurate regarding this manifestation? | Caused by excessive fluid in the interstitial space. Dependent edema occurs in the sacral area of patient on bedrest. Edematous tissue is quite fragile. |
| The nurse suspects that a patient has developed a hypertonic fluid volume deficit from receiving a large volume of hypertonic IV fluids. The nurse should expect to see which lab test result? | Increased BUN and Creatinine Elevated serum osmolality |
| The nurse is admitting a patient with a fluid imbalance. During the patient interview, what questions would be appropriate for the nurse to ask to obtain fluid balance information? | “Have you lost or gained weight recently?” “Do you have a history of renal disease or diabetes mellitus?” "Have you noticed swelling of your hands and feet?” |
| An acutely ill patient is brought into the urgent treatment center by a family member. Which patient assessments would suggest a significant fluid volume deficit? | Elevated serum BUN and creatinine Rapid, weak, thready pulse Dry, cracked lips and furrows on the tongue |
| A patient with vomiting and diarrhea has developed rapid onset isotonic fluid volume deficit. The patient can be expected to have which lab data results? | Elevated RBC Increased BUN and Creatinine |
Created by:
Brandi Sizemore
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