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The nurse determines taht which client is at highes risk for developing a fluid volume deficit (FVD).
1. A 76 year old client who has a nasogastric tube to low suction following surgery for colon cancer.
2. A thin 55 year old client who smokess and takes glucocorticoids for chronic lung disease.
3. A one year old child being treated in the clinic for runny nose and ear infection.
4. A 30 year old client jogging in 50 degree weather.
A 78 year old client is admitted with dehydration and urinary tract infection. After IV infusion of 750 ml NS the client begins to cough and asks for the head of the bed to be raised to ease breathing. The nurse assesses jugular vein distention (JVD) and increased respiratory rate. How should the nurse interpret this data?
1. The Fluid volume deficit is worsening.
2. Hypervolemia is developing.
3. Hypotonic water intoxicationis begining
4. Ascites is causing respiratory compromise
The nurse is helping a client who was recently placed on a low sodium diet to reduce fluid retention to choose foods for lunch. The nurse recommends which lunch menu that would be beneficial for this client?
1. Grilled chicken sandwich on white bread, apple, salad, and ice tea.
2. Tuna salad sandwhich on wheat bread canned fruit cocktail salad and a soda.
3. Ham and bean soup fresh fruit salad, low sodium crackers and a diet soda.
Cheese burgers grapes fresh pineapple and tomato juice.
A 28 year old client is admitted with severe bleeding from a fractured femur. Which IV fluid does the nurse anticipate as the most appropriate for use to replace potential fluid losses?
1. 0.9% sodium chloride
2. 3% sodium chloride
3. 5% dextrose in water
4. 5% dextrose in .22% sodium chloride
A 17 year old client who sustained an injury in a motorcycle collision two days ago is responsive only to pain. Which IV fluid order would the nurse question because it could increase the risk of complications?
1. Ringers solution
2. 5% destrose in water
3. 0.9% sodium chloride
4. Lactated ringes solution
The nurse is caring for a client admitted with heart failure. when assessing the clients risk for fluid imbalances teh nurse should check which laboratory values? Select all that apply
3. Atrieal Natriuretic peptide
4. Blood glucose
5. liver enzymes
1, 2, 3
A client with a nursing diagnosis of Excess fluid volume has been treated with diuretics and fluid restriction. Which findings would best indicate to the nurse that fluid volume balance has not yet been totally acheieved?
1. S3 heart sounds and moist lung crackles resolving
2. Returning to cohernt conversation and appropriate behavior.
3. Oral mucous membranes are no longer sticky and cracked and skin is warm and dry.
4. Skin tentin decreasing and conjuctiva of eyes moist.
During intershift report the nurse is told that a client who has suffered a stroke has also developed diabetes insipidus. The nurse conclude this client is now at risk for which of the following?
1. Severe deficient fluid volume because of excess urine output.
2. Severe excess fluid volume because of inadequate urine output
3. Hyperglycemia because of poor insulin production
4. Hypoglycemia because of excess insulin production
Which serum electrolyte imbalance would the nurse asses for in a child admitted with a high fever and severe dehydration? Select all that apply
Which of the following client would the nurse identify as being most at risk to develop a sodium imbalance.
1. An adult client taking corticosteroid therapy
2. An older adult client who drinks eight glasses of water each day
3. A school age client with diabetes mellitus who is under glycemeic control
4. a teenager wiho is drinking gatorade during exercise workouts.
Which of the following interventions does the nurse complete when caring for a client admitted with a sodium level of 152 meq/L
1. Provide extra blackets for warmth
2. observe client for nausea and malaise
3. Observe and prepare for possible seizures
4. Restrict fluids up to 1200 ml per day
The nurse is caring for a client who is experiencing a steady decline in sodium level. The nurses place highes priority on which of the following intervention?
1. Close monitoring of neurological status
2. Preventing weakness and fatigue
3. Spacing activities to conserve energy
4. Providing oral hygiene and skin care
A Client with abnormal sodium loss is receiving a regular diet. To encourage foods high in sodium, the nurse would recommend which of the following foods for lunch.
1. A cheese and ham snadwhich
2. Chicken salad on lettuce
3. Tossed salad with vinegar dressing
4. White fish and plain baked potato
Which intervention should the nurse anticipate implementing in a client who is experiencing dilutional hyponatremia?
1. Adminstration of hyptonic iv solution
2. Restriction of additional oral fluids
3. Increasing sodium intake in the diet
4. Encouraging intake of tap water
a client receiving treatment for hypernatremia is being monitored for s/s of complications of therapy the nurse would asses this client for which of the following?
1. Cellular dehydration
2. cerebral edema
3. RBC destruction
4. Renal shutdown