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concept of nursing 2
Assessment related to fluid balance
| Question | Answer |
|---|---|
| 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 this patient lost? | 10 liters |
| 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 |
| 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 |
| 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 pt 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:
Lightnning54
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