Choice A reason:

Increased skin turgor is not a sign of fluid volume deficit, but rather a sign of normal hydration. Skin turgor is the elasticity of the skin that allows it to return to its original shape after being pinched. Fluid volume deficit causes decreased skin turgor, which means the skin stays tented or takes longer to flatten after being pinched.

Choice B reason:

Hypertension is not a sign of fluid volume deficit, but rather a sign of fluid volume excess. Fluid volume deficit causes hypotension, which means low blood pressure. Fluid volume excess causes hypertension, which means high blood pressure. This is because fluid volume affects the amount of blood in the vessels and the pressure it exerts on the vessel walls.

Choice C reason:

Tachycardia is a sign of fluid volume deficit. Tachycardia means fast heart rate, usually more than 100 beats per minute. Fluid volume deficit causes tachycardia because the heart has to pump faster and harder to compensate for the low blood volume and maintain adequate blood flow to the vital organs.

Choice D reason:

Crackles in the lungs are not a sign of fluid volume deficit, but rather a sign of fluid volume excess or pulmonary edema. Crackles are abnormal lung sounds that indicate fluid accumulation in the alveoli or air sacs of the lungs. Fluid volume deficit does not cause fluid accumulation in the lungs, but rather dehydration of the lung tissues. Some additional information: Fluid volume deficit, also known as dehydration, is a condition where the body loses more fluids than it takes in. This can result from excessive vomiting, diarrhea, sweating, burns, hemorrhage, or diuretic use. Fluid volume excess, also known as overhydration or hypervolemia, is a condition where the body retains more fluids than it needs. This can result from excessive fluid intake, kidney failure, heart failure, liver cirrhosis, or steroid use. Fluid balance is essential for maintaining homeostasis and normal functioning of the body systems. Fluid balance is regulated by various mechanisms such as thirst, urine output, hormones, and electrolytes.

Choice A reason:

Monitoring daily weight is an important action for the nurse to take because it reflects the fluid status of the client. A sudden increase in weight indicates fluid retention, while a sudden decrease indicates fluid loss. The nurse should weigh the client at the same time every day, using the same scale and clothing.

Choice B reason:

Restricting sodium intake is another action that the nurse should take because sodium attracts water and increases fluid volume. The nurse should limit or avoid foods that are high in sodium, such as processed meats, canned soups, cheese, pickles, and salty snacks. The nurse should also educate the client about reading food labels and choosing low-sodium alternatives.

Choice C reason:

Administering diuretics as prescribed is a third action that the nurse should take because diuretics increase urine output and reduce fluid volume. The nurse should monitor the client's electrolyte levels, blood pressure, and urine output before and after giving diuretics. The nurse should also inform the client about the possible side effects of diuretics, such as dehydration, hypotension, hypokalemia, and ototoxicity.

Choice D reason:

Encouraging oral fluids is not an action that the nurse should take because it would worsen the fluid volume excess. The nurse should limit or restrict oral fluids as ordered by the provider. The nurse should also measure and record all fluid intake and output accurately.

Choice E reason:

Elevating the head of the bed is a fourth action that the nurse should take because it improves respiratory function and reduces pulmonary congestion. The nurse should elevate the head of the bed to at least 30 degrees or more, depending on the client's comfort and tolerance. The nurse should also monitor the client's oxygen saturation, breath sounds, and dyspnea.

Choice A reason:

A client who has chronic kidney disease should limit the intake of bananas and oranges because they are high in potassium, which can accumulate in the blood and cause hyperkalemia. Hyperkalemia can lead to cardiac arrhythmias and muscle weakness.

Choice B reason:

A client who has chronic kidney disease should not drink at least 3 liters of water every day because this can cause fluid overload and hypertension. Fluid overload can worsen the kidney function and increase the risk of heart failure and pulmonary edema. Hypertension can damage the blood vessels and organs.

Choice C reason:

A client who has chronic kidney disease should not eat more cheese and yogurt because they are high in phosphorus, which can bind with calcium and cause hypocalcemia and hyperphosphatemia. Hypocalcemia can lead to muscle cramps, tetany, and osteoporosis. Hyperphosphatemia can cause soft tissue calcification and itching.

Choice D reason:

A client who has chronic kidney disease should not use salt substitutes instead of table salt because they often contain potassium chloride, which can also increase the potassium level in the blood and cause hyperkalemia. Salt substitutes are not recommended for clients who have kidney disease or who are on potassium-sparing diuretics.

Choice A reason:

Feeling less thirsty is a sign of improved hydration status and a positive outcome of IV fluid therapy. Thirst is a subjective symptom of dehydration that is triggered by increased osmolality of the blood or decreased blood volume. When IV fluids are administered, they restore the fluid balance and reduce the thirst sensation.

Choice B reason:

Urine that is dark and concentrated is a sign of inadequate hydration and a negative outcome of IV fluid therapy. Urine color and concentration are influenced by the amount of fluid intake and output. When a person is dehydrated, the kidneys conserve water and produce less urine that is more concentrated and darker in color. When IV fluids are administered, they increase the urine output and dilute the urine, making it lighter in color.

Choice C reason:

A heart rate of 110 beats per minute is a sign of tachycardia and a negative outcome of IV fluid therapy. Tachycardia is an abnormal increase in heart rate that can be caused by dehydration, among other factors. Dehydration reduces the blood volume and lowers the blood pressure, which triggers the heart to beat faster to maintain adequate perfusion to the vital organs. When IV fluids are administered, they increase the blood volume and pressure and normalize the heart rate.

Choice D reason:

Having a headache and dizziness is a sign of cerebral dehydration and a negative outcome of IV fluid therapy. Headache and dizziness are common symptoms of dehydration that result from reduced blood flow to the brain and increased osmolality of the blood. When IV fluids are administered, they improve the cerebral perfusion and osmotic balance and relieve the headache and dizziness.

• Choice A reason:

• Administering hypotonic IV fluids is an appropriate intervention for a client who has hypernatremia. Hypotonic fluids have a lower concentration of solutes than the blood, so they can help dilute the excess sodium and rehydrate the cells.

• Choice B reason:

• Monitoring blood glucose levels is not directly related to hypernatremia, although it may be indicated for other reasons, such as diabetes. Hypernatremia can be caused by uncontrolled diabetes, but it is not a consequence of high blood glucose levels.

• Choice C reason:

• Providing oral care every 4 hours is a supportive measure for a client who has hypernatremia, but it is not a specific intervention to correct the electrolyte imbalance. Oral care can help relieve thirst and dry mouth, which are common symptoms of hypernatremia, but it does not address the underlying cause of fluid loss or sodium gain.

• Choice D reason:

• Increasing dietary intake of potassium is not helpful for a client who has hypernatremia. Potassium is another electrolyte that plays a role in fluid balance and nerve function, but it is not affected by hypernatremia. In fact, increasing potassium intake may worsen the condition by causing further dehydration or hyperkalemia (high potassium levels)