Question 1 of 8
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Which patient condition would the nurse associate with an increased risk for fluid imbalance? Select all that apply. One, some, or all options may be correct.
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- Dysfunctional swallowingAn inability to ingest and swallow foods and fluids normally puts the patient at increased risk for fluid imbalance.
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- Kidney dysfunctionKidney dysfunction can lead to either fluid volume deficit or excess, depending on the underlying pathophysiology.
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- Frequent exposure to extreme heatThe patient who is exposed to extreme heat may be at increased risk of insensible fluid loss because of environmental exposure.
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- Ankle fractureA patient with an ankle fracture is unlikely to experience a fluid imbalance, unless there is a secondary underlying condition.
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- Need for mechanical ventilationThe patient on a mechanical ventilator is at risk for excess insensible fluid loss.
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- Three-day history of diarrheaPersistent diarrhea over a 3-day period could lead to excessive fluid and electrolyte losses.
Question 2 of 8
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Which assessment data provides the most accurate indication of a change in fluid volume status?
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- Daily intake and outputMonitoring intake and output will help ensure the patient is receiving adequate fluid and monitoring kidney function; however, assessment of this will not accurately monitor a change in fluid retention or loss.
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- Blood pressure fluctuationsBlood pressure should be monitored; however, this will not accurately measure a change in fluid status as well as other methods do.
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- Skin turgorSkin turgor may be used in the assessment of dehydration in some cases; however, it would not be used to assess fluid excess.
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- Daily weightMonitoring daily weight is the most accurate measure of any change in fluid status. If fluid was retained, weight will increase. If fluid was lost, weight will decrease.
Question 3 of 8
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After an episode of emesis, which characteristics of the contents will the nurse document in the patient’s health record? Select all that apply. One, some, or all responses may be correct.
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- VolumeThe amount of the vomitus should be part of the care note because this may help determine how much fluid the patient has lost.
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- ColorThe color of the vomitus should be part of the care note because this may help determine the contents of the vomitus.
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- ContentsThe contents of the vomitus should be part of the care note because this may help plan future care of the patient and help determine the cause of vomiting.
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- SmellThe odor of the vomitus should be part of the care note because this may be an indicator of what caused vomiting.
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- TemperatureThe temperature of the vomitus does not need to be observed or noted.
Question 4 of 8
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Which provider prescription will the nurse anticipate for the older adult patient who reports frequent vomiting over the past 3 days?
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- Provide a regular diet.A regular diet is not indicated in a patient who is already vomiting. Bowel rest is needed, with slow rehydration, building back up to a regular diet.
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- Change diet to nothing by mouth (NPO).NPO until the vomiting subsides is expected care. The patient needs bowel rest and fluid replacement by an alternate route.
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- Initiate a rapid intravenous (IV) fluid infusion.Although IV fluid infusion is a likely prescription, it would be a gentle infusion with frequent reassessment to be sure the patient is tolerating it. Rapid IV infusions are avoided in older adults because of the potential for cardio-respiratory complications.
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- Place the patient in a supine position.The patient must be positioned to avoid aspiration. Lying supine will increase the risk of aspiration of vomited material.
Question 5 of 8
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Which condition, if noted in the patient’s history, suggests the nurse would assess for diarrhea? Select all that apply. One, some, or all options may be correct.
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- Lactose intoleranceLactose intolerance may cause diarrhea, especially if the patient is choosing to eat lactose-containing foods.
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- PregnancyA healthy pregnancy is not usually associated with diarrhea.
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- Bowel tumorA bowel tumor could cause diarrhea if it is partially blocking the bowel and only liquid components can pass through.
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- Food intoleranceFood intolerances could cause diarrhea. The irritant food source causes local inflammation and increases transit time through the bowel.
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- AnorexiaAnorexia is not usually a cause for diarrhea.
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- Irritable bowel syndromeIrritable bowel syndrome may be associated with diarrhea. Chemical and food irritants lead to gastric mucosal inflammation and increased transit time.
Question 6 of 8
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Which pathophysiological factor likely contributes to generalized edema in a patient with sepsis?
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- Proteins leaking into interstitial spacesProteins leaking into interstitial spaces cause fluid to shift to the area and stay there instead of moving back into capillaries.
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- Prolonged feverProlonged fever does not contribute to generalized edema. Prolonged fever will lead to fluid volume deficit if appropriate replacement hydration is not provided.
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- Increased lymphatic circulationObstruction of the lymphatic system contributes to edema. Increased lymphatic circulation can actually improve cases of edema.
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- Decreased histamine releaseThe patient with sepsis will likely have an increase in histamine release rather than a decrease. It is this increase in histamine release that leads to accumulation of edema.
Question 7 of 8
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Which action will the nurse take for the patient with dependent edema in the lower extremities?
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- Help the patient dangle legs at bedsideDependent edema is aggravated by gravity, so dangling the legs is not a helpful action for the nurse to take. This can actually worsen the edema.
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- Place elastic stockings on lower legsDependent edema of the legs is managed with elastic compression stockings. These stockings will help mobilize fluid and encourage venous return.
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- Offer small amounts of fluidsOffering small amounts of liquids does not play a role in the management of dependent edema.
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- Monitor hematocritMonitoring hematocrit may be part of the plan of care for many patients with fluid volume imbalances, but this action will not help in the direct management of dependent edema.
Question 8 of 8
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Which category of medication would the nurse anticipate administering to the patient with a fluid volume excess?
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- AntihistamineAntihistamines can be used to treat nausea and vomiting but will not assist in the management of fluid overload.
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- DiureticA diuretic prompts the kidneys to increase the excretion of fluid, making it an appropriate medication to assist in the management of fluid overload.
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- AnticholinergicAnticholinergics are used to manage nausea and vomiting.
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- PhenothiazinesPhenothiazines are used to manage nausea and vomiting.