Fluid

Results Reporter Summary: 60% correct 6 correct out of 10 4 incorrect answers 0 unanswered questions 1) Wrong Which of the following clients is at highest risk for developing fluid volume deficit? The correct answer: A 76-year-old client who has an NG tube to low suction following colon cancer surgery Your answer: A 30-year-old client jogging in 50-degree weather Rationale: Infants and the elderly can't compensate as well for fluid losses. Clients with NG suction (loss of fluid and electrolytes in fairly proportional amounts) are at greater risk for fluid volume deficit. The elderly client with NG suction has both risk factors, while the child's age is the only risk factor. The client taking glucocorticoids is predisposed to sodium and fluid retention rather than fluid loss. The 30-year-old jogger is a young adult in a moderate climate, which lowers the risk from exertion alone. Cognitive Level: Analysis Nursing Process: Analysis; Test Plan: PHYS 2) Correct Which of the following statements should not be included in an education program for the elderly about prevention of dehydration during hot weather? Your answer: "Use your thirst as a guide to the amount of fluid you should be drinking." Rationale: With aging, the thirst mechanism becomes less effective. Significant fluid can be lost before thirst is triggered, so the elderly should not rely solely on thirst to indicate when they need to drink fluids. All of the other choices should be included in this type of education program. Cognitive Level: Application Nursing Process: Implementation; Test Plan: HPM 3) Correct An adult client in the clinic complains of a cough, fever, nausea, and vomiting for three days. Examination reveals dry tongue and oral mucosa, and concentrated urine. The client also reports feeling weak and dizzy. Which vital sign measurement would provide the best indicator of current fluid status? Your answer: BP and pulse in lying and standing positions Rationale: The client has symptoms of fluid volume deficit and hypovolemia. The presence of postural hypotension when rising from a lying position indicates the presence of significant hypovolemia. The other vital signs are important but do not directly reflect circulating fluid volume. Cognitive Level: Analysis Nursing Process: Assessment; Test Plan: PHYS 4) Correct An intravenous (IV) infusion of normal saline is being initiated for a 10-month-old infant diagnosed with fluid volume deficit. The order states to deliver a 200 mL bolus, then reduce the fluid rate to 30 mL/hour. How should the nurse implement this therapy? Your answer: Control the fluid infusion rate using an infusion pump, checking it often.

Rationale: An infusion pump should be used to control IV fluid rates on infants receiving IV fluids to avoid accidental fluid overload. Infusing by gravity and monitoring only every hour does not protect from this risk, since the bolus may be completed in less than half an hour. Placing responsibility for monitoring IV infusions on the mother is not ethical, safe, or legally advisable. Cognitive Level: Analysis Nursing Process: Implementation; Test Plan: SECE 5) Correct A 40-year-old client is hospitalized for gastrointestinal (GI) bleeding. Orders include nasogastric tube (NGT) placement with irrigations until the returns are clear. Which fluid should be used for the NG irrigations? Your answer: Normal saline Rationale: Normal saline is an isotonic fluid that prevents fluid shifts into or out of the GI tract. Option 1 (3% saline) is hypertonic and could pull water from the GI tract, resulting in water loss. D5W and plain water are hypotonic and could be pulled into GI tissue as well as wash electrolytes out of the GI tract, resulting in water intoxication. Cognitive Level: Application Nursing Process: Implementation; Test Plan: SECE 6) Wrong A 70-year-old client with a past medical history of hypertension and myocardial infarction is in the hospital following stomach surgery. Vital signs have been stable and an IV of D51/2NS is infusing at 100 mL/hour. The client now complains of trouble breathing, has a moist cough, and pulse oximetry reading has fallen to 92%. What action should the nurse take first? The correct answer: Slow the intravenous rate to 10 to 20 mL/hour. Your answer: Assess legs and arms for pitting edema. Rationale: A moist cough, dyspnea, and falling pulse oximetry reading in a client with a history of heart disease are signs of developing pulmonary edema secondary to fluid volume overload. The first action should be to reduce IV fluid intake to prevent more fluid from accumulating in the lungs, then further assessment can be done, emergency actions taken, and the physician contacted. Cognitive Level: Analysis Nursing Process: Implementation; Test Plan: SECE 7) Correct A 45-year-old client diagnosed with fluid volume overload due to acute kidney dysfunction is placed on a 1,000 mL fluid restriction per 24-hour period. The client asks the nurse, "Why there is such a severe fluid restriction when I already have dry lips and mouth?" Which response by the nurse is best? Your answer: "Your kidneys are not able to eliminate extra fluid right now, so fluid intake has to be limited to protect your heart and lungs from being overloaded with fluid." Rationale: Option 2 provides accurate information in simple terms without unduly alarming client. Option 4 is technically correct but is stated in an abrupt and alarming manner. Option 1 offers no explanation to facilitate understanding. Option 3 assigns the client blame for the current condition without providing a clear explanation for the fluid restriction. Cognitive Level: Application Nursing Process: Implementation; Test Plan: PSYC 8) Wrong Which of the following is the best indicator of an excessive response to diuretic therapy? The correct answer: Elevated blood urea nitrogen (BUN) and hematocrit (HCT) and an 8-pound weight loss in 24 hours. Your answer: Decreased BUN and HCT and an 8- pound weight loss in 24 hours

Rationale: An excess response to diuretic therapy results in an excess loss of water and electrolytes in the urine, leaving the blood hemoconcentrated and causes a high BUN and HCT. The water loss results in an acute weight loss. Weight gain indicates ineffective response to diuretic therapy. Cognitive Level: Analysis Nursing Process: Assessment; Test Plan: PHYS 9) Wrong A client is receiving an intravenous (IV) infusion of 0.0225% NS intravenously at 50 mL/hour. During such an infusion, what is especially important to monitor to detect complications of therapy? The correct answer: Mental status and orientation Your answer: Urine output and concentration Rationale: 1/4 NS (0.225% saline) is a hypotonic solution that provides free water to the cells. Cerebral cells are especially sensitive to fluid gains from hypotonic fluids. If infused too rapidly, the cerebral cells will be the first to gain fluid too quickly, resulting in neurological changes. Monitoring the client for urine output, edema, and oral cavity dryness are important, but this reflects a response to IV therapy rather than detection of a complication. Cognitive Level: Analysis Nursing Process: Assessment; Test Plan: PHYS 10) Correct When an adult is receiving an intravenous (IV) infusion of 3% saline, what are the monitoring priorities for the early detection of complications of therapy? Your answer: Neurological status, lung sounds, and serum sodium levels Rationale: Three percent (3%) saline is very hypertonic and, if infused too rapidly, will increase serum sodium and osmolality, causing high volumes of water to be pulled into vessels from cells. This results in cellular dehydration and vascular volume overload. Serum sodium levels, neurological status, and lung function should be closely monitored. Although daily weights are important, they do not provide information leading to early detection of complications of therapy. Vital signs, serum glucose levels, urine specific gravity, oxygen saturation, and peripheral edema provide later indications of complications of therapy. Cognitive Level: Analysis Nursing Process: Evaluation; Test Plan: SECE