Fluid and Electrolytes > Fundamentals
Exam Review
Distribution of Body Fluids
Total Questions : 6
Showing 6 questions, Sign in for moreA nurse is teaching a client about the importance of maintaining fluid and electrolyte balance. Which of the following statements by the client indicates a need for further teaching?
Explanation
Choice A reason:
This statement is correct. Fluids and electrolytes help transport nutrients and oxygen to the cells by maintaining blood volume and pressure. They also help maintain the acid-base balance of the blood and other body fluids.
Choice B reason:
This statement is correct. Fluids and electrolytes help regulate body temperature by allowing heat to be distributed evenly throughout the body and by facilitating sweating, which cools the body. They also help lubricate the joints by providing synovial fluid, which reduces friction and inflammation.
Choice C reason:
This statement is correct. Fluids and electrolytes help digest food by providing saliva, gastric juice, bile, pancreatic juice, and intestinal secretions, which break down food and absorb nutrients. They also help excrete wastes from the body by forming urine, feces, sweat, and breath, which eliminate excess fluids, electrolytes, toxins, and carbon dioxide.
Choice D reason:
This statement indicates a need for further teaching. Fluids and electrolytes do not help increase body fat or lower blood pressure. Body fat is determined by the balance between calorie intake and expenditure, not by fluid intake. Blood pressure is influenced by many factors, such as cardiac output, vascular resistance, blood volume, and hormone levels, not by fluid intake alone. Fluid intake can affect blood pressure only if it causes overhydration or dehydration, which are both abnormal conditions that should be avoided.
A nurse is assessing a client who has dehydration. Which of the following findings should the nurse expect? (Select all that apply.)
Explanation
Choice A reason:
Decreased skin turgor is a sign of dehydration because the skin loses elasticity when the body loses water. The nurse can assess this by pinching the skin on the back of the hand or the forehead and observing how quickly it returns to its normal position. If it takes longer than a few seconds, it indicates decreased skin turgor.
Choice B reason:
Increased heart rate is a sign of dehydration because the heart has to work harder to pump blood when the blood volume is low. The body also tries to compensate for the fluid loss by increasing the heart rate and constricting the blood vessels.
Choice C reason:
Crackles in the lungs are not a sign of dehydration, but rather a sign of fluid overload or pulmonary edema. Crackles are caused by fluid accumulation in the alveoli, which interferes with gas exchange and produces a crackling sound when breathing. This choice is incorrect.
Choice D reason:
Low urine output is a sign of dehydration because the kidneys try to conserve water by producing less urine. The urine also becomes more concentrated and darker in color when the body is dehydrated.
Choice E reason:
Dry mucous membranes are a sign of dehydration because the body loses moisture from the mouth, nose, and eyes when it is dehydrated. The nurse can assess this by looking at the lips, tongue, and oral cavity for dryness and cracking.
A nurse is caring for a client who has a high fever and is at risk for fluid volume deficit. The nurse should monitor the client for which of the following signs of fluid loss?
Explanation
Choice A reason: Feeling thirsty all the time is a sign of dehydration, not fluid loss. Dehydration occurs when the body does not have enough water and other fluids to carry out its normal functions. Dehydration can be caused by excessive sweating, vomiting, diarrhea, fever, or decreased water intake.
Choice B reason:
Gaining 2 pounds since yesterday is a sign of fluid retention, not fluid loss. Fluid retention occurs when the body holds on to extra water and salt in the tissues or blood vessels. Fluid retention can be caused by heart failure, kidney disease, liver disease, hormonal changes, or certain medications.
Choice C reason:
Having trouble breathing when lying down is a sign of orthopnea, not fluid loss. Orthopnea is a condition where a person feels short of breath when lying flat. Orthopnea can be caused by heart failure, lung disease, obesity, or sleep apnea.
Choice D reason:
Feeling dizzy when standing up is a sign of orthostatic hypotension, which is a possible sign of fluid loss. Orthostatic hypotension is a condition where the blood pressure drops when changing position from lying or sitting to standing. This can cause dizziness, lightheadedness, or fainting. Orthostatic hypotension can be caused by hypovolemia, which is a decrease in the volume of blood in the body due to fluid loss. Fluid loss can occur from bleeding, vomiting, diarrhea, sweating, or burns.
A nurse is reviewing the laboratory results of a client who has metabolic acidosis. The nurse should expect to see which of the following changes in the client's electrolyte levels?
Explanation
Choice A reason:
Decreased sodium is not a typical feature of metabolic acidosis. Sodium levels may be low, normal or high depending on the cause and severity of the acidosis, as well as the fluid status of the patient. Sodium is not directly involved in the acid-base balance of the body.
Choice B reason:
Increased potassium is a common finding in metabolic acidosis, especially in renal failure. This is because acidosis causes hydrogen ions to move into cells in exchange for potassium ions, which move out of cells into the blood. Also, impaired kidney function reduces the excretion of potassium in the urine.
Choice C reason:
Decreased calcium is not a typical feature of metabolic acidosis. Calcium levels may be low, normal or high depending on the cause and severity of the acidosis, as well as the presence of other disorders affecting calcium metabolism. Calcium is not directly involved in the acid-base balance of the body.
Choice D reason:
Increased chloride is a feature of normal anion gap metabolic acidosis, also known as hyperchloremic acidosis. This is because chloride replaces bicarbonate as the major anion in the blood when bicarbonate is lost or consumed by acids. However, increased chloride is not a feature of high anion gap metabolic acidosis, which is caused by accumulation of organic acids such as ketones or lactate.
A nurse is educating a client who has heart failure about the effects of diuretics on fluid and electrolyte balance. The nurse should instruct the client to report which of the following symptoms to the provider?
Explanation
Choice A reason:
Muscle weakness is a symptom of hypokalemia, which is a low level of potassium in the blood. Potassium is an important electrolyte that helps regulate the function of the heart and muscles. Diuretics can cause potassium loss through increased urine output, which can lead to hypokalemia. Hypokalemia can affect the heart rhythm and cause muscle cramps, weakness, fatigue, and constipation. Therefore, the client should report muscle weakness to the provider as it may indicate a need for potassium supplementation or a change in diuretic therapy.
Choice B reason:
Nausea and vomiting are not specific symptoms of diuretic use or fluid and electrolyte imbalance. They can be caused by many other factors, such as infection, food poisoning, medication side effects, or psychological stress. Nausea and vomiting can also lead to dehydration and electrolyte imbalance if not treated promptly. Therefore, the client should drink plenty of fluids and seek medical attention if nausea and vomiting persist or are severe, but they are not directly related to diuretic use or heart failure.
Choice C reason:
Headache and blurred vision are not common symptoms of diuretic use or fluid and electrolyte imbalance. They can be caused by many other factors, such as high blood pressure, migraine, eye strain, or neurological disorders. Headache and blurred vision can also be signs of a serious condition, such as stroke or brain tumor, that requires immediate medical attention. Therefore, the client should report headache and blurred vision to the provider as soon as possible, but they are not directly related to diuretic use or heart failure.
Choice D reason:
Constipation and abdominal pain are not common symptoms of diuretic use or fluid and electrolyte imbalance. They can be caused by many other factors, such as dietary changes, lack of fiber, medication side effects, or bowel obstruction. Constipation and abdominal pain can also be signs of a serious condition, such as appendicitis or diverticulitis, that requires immediate medical attention. Therefore, the client should report constipation and abdominal pain to the provider as soon as possible, but they are not directly related to diuretic use or heart failure.
A nurse is caring for a client who has fluid overload due to renal failure. Which of the following interventions should the nurse include in the plan of care?
Explanation
Choice A reason:
Administering IV fluids as prescribed is not an appropriate intervention for a client who has fluid overload due to renal failure. IV fluids will increase the fluid volume and worsen the condition. The nurse should monitor the client's fluid intake and output, and report any signs of fluid overload to the provider.
Choice B reason:
Restricting sodium intake is an appropriate intervention for a client who has fluid overload due to renal failure. Sodium causes water retention and increases the fluid volume in the body. The nurse should limit the client's sodium intake to less than 2 g per day, and avoid foods that are high in sodium, such as canned soups, processed meats, cheese, and salted snacks.
Choice C reason:
Elevating the head of the bed is an appropriate intervention for a client who has fluid overload due to renal failure. Elevating the head of the bed helps to reduce the pressure on the lungs and improve the client's breathing. The nurse should also monitor the client's respiratory status, and administer oxygen therapy as prescribed.
Choice D reason:
Encouraging ambulation is not an appropriate intervention for a client who has fluid overload due to renal failure. Ambulation may increase the workload on the heart and lungs, and exacerbate the symptoms of fluid overload. The nurse should assist the client with activities of daily living, and provide rest periods between activities.
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