Chapter 40 Flashcards
Which body fluid is the fluid within the cells, constituting about 70% of the total body water? A) Extracellular fluid (ECF) B) Intracellular fluid (ICF) C) Intravascular fluid D) Interstitial fluid
B) Intracellular fluid (ICF)
Intracellular fluid is the fluid within the cells, constituting about 70% of total body fluid. Extracellular fluid is all flu outside the cells and includes intravascular and interstitial fluids
Based on knowledge of total body fluids, a nurse is especially watchful for a fluid volume deficit in an infant. Why
would the nurse do this?
A) Infants have less total body fluid and ECF than adults.
B) Infants have more total body fluid and ECF than adults.
C) Infants drink less fluid than adults.
D) Infants lose more fluids through output than adults.
B) Infants have more total body fluid and ECF than adults.
An infant has considerably more total body fluid and ECF than an adult does. Because ECF is more easily lost from body than ICF, infants are more prone to fluid volume deficits.
What is the average adult fluid intake and loss in each 24 hours? A) 500 to 1,000 mL B) 1,000 to 1,500 mL C) 1,500 to 2,000 mL D) 1,500 to 3500 mL
D) 1,500 to 3500 mL
The desirable amount of fluid intake and loss in adults ranges from 1,500 to 3,500 mL each 24 hours, with most people
averaging 2,500 to 2,600 mL per day
A nurse monitoring the intake and output of fluids for a client with severe diarrhea knows that normally how much body
fluid is lost via the gastrointestinal tract?
A) 300 mL
B) 1,000 mL
C) 1,300 mL
D) 2,600 mL
A) 300 mL
Generally, fluid intake averages 2,600 mL per day, with approximately 1,300 mL coming from ingested water, 1,000
mL coming from ingested food, and 300 mL from metabolic oxidation
A nurse reads the laboratory report and notes that the client has hyponatremia. What physical assessment should be made? A) Observe skin color and texture. B) Auscultate bowel sounds. C) Percuss lung density. D) Monitor for GI symptoms
D) Monitor for GI symptoms
Hyponatremia is an ECF sodium deficit, resulting in osmotic pressure changes as ECF moves into the cells. When this occurs, anorexia, nausea, and vomiting may occur; the nurse should monitor for these symptoms. Skin color and texture, bowel sounds, and lung density are not affected with hypernatremia.
A home care client reports weakness and leg cramps. Per order, the nurse draws blood and requests a potassium level.
What is the rationale for this request?
A) The nurse is concerned that the client’s diet has caused sodium loss.
B) The nurse recognizes these symptoms of hypokalemia.
C) The client is actively seeking increased attention.
D) The client had bananas and orange juice for breakfast
B) The nurse recognizes these symptoms of hypokalemia.
Hypokalemia is a potassium deficit in the ECF. When the ECF potassium falls, potassium moves out of the cells,
creating an intracellular potassium deficiency. Typical symptoms include muscle weakness and leg cramps.
A client’s PaCO2 is abnormal on an ABG report. Which of is the most likely be the medical diagnosis? A) Rheumatoid arthritis B) Sexually transmitted infection C) Chronic obstructive pulmonary disease D) Infection of the bladder and ureters
C) Chronic obstructive pulmonary disease
Arterial blood gases are laboratory tests used to assess and treat acid–base disorders. PaCO2 is the abbreviation for the
partial pressure of carbon dioxide. The PaCO2 is influenced almost entirely by respiratory activity, with a disease such as
chronic obstructive pulmonary disease resulting in abnormal results.
Which question about fluid balance would be appropriate when conducting a health history for a client?
A) “Describe your usual urination habits.”
B) “Describe your problems with constipation.”
C) “How did you feel when your calcium was low?”
D) “Do you eat fruits and vegetables each day?
A) “Describe your usual urination habits.”
Questions and leading statements about fluid balance are part of a comprehensive health history. The usual urinary
output is one factor to consider in fluid balance.
A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan? A) Impaired Skin Integrity B) Risk for Deficient Fluid Volume C) Impaired Urinary Elimination D) Urinary Retention
B) Risk for Deficient Fluid Volume
An appropriate nursing diagnosis for a client taking a diuretic that increases urinary output would be Risk for Deficient
Fluid Volume. The nurse would educate the client on the symptoms of dehydration, how to increase fluid intake, and the need to maintain a record of daily weights.
A nurse measures a client’s 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?
A) Compare the client’s intake with the normal range of adult fluid intake.
B) Report the exact milliliter of intake to the physician’s office nurse.
C) Compare the total intake and output of fluids for the 24 hours.
D) Ensure that the information is included in the verbal end-of-shift report.
C) Compare the total intake and output of fluids for the 24 hours
The nurse must pay attention to certain parameters when assessing a client’s fluid status. This means comparing the total
intake and output of fluids for a given period of time.
A physician writes an order to “force fluids.” What will be the first action the nurse will take in implementing this order?
A) Explain to the client why this is needed.
B) Tell the client and family to increase oral intake.
C) Decide how much fluid to increase each eight hours.
D) Divide the intake so the largest amount is at night.
A) Explain to the client why this is needed.
Several techniques are recommended to help the client drink greater than average amounts of fluids. Begin by explaining
to the client in understandable terms the rationale for the increased fluids and the specific goal of taking the daily
amount of fluids prescribed.
A client has an order to restrict fluids. What is one comfort measure nurses can implement for this client to alleviate a common problem? A) Back rubs B) Chewing gum C) Hair care D) Oral hygiene
D) Oral hygiene
Clients with restrictions on fluid intake often complain of thirst or a dry mouth. Provide oral hygiene at regular intervals.
Offering hard candy or gum is no longer recommended.
A nurse is administering a potassium supplement to a client. What will the nurse do to disguise the taste and decrease gastric irritation? A) Dilute it B) Give it after meals C) Mix it with food D) Freeze it
A) Dilute it
Nurses must accurately administer supplements, following manufacturer’s guidelines. Potassium supplements should be
diluted to disguise the unpleasant taste and decrease gastric irritation
A student is learning how to administer intravenous fluids, including accessing a vein. Although all of the following may
occur, which is the most potentially harmful risk posed for the client when accessing the vein?
A) Discomfort
B) Pain
C) Minor bleeding
D) Infection
D) Infection
Accessing a vein increases the risk for infection. Sterile technique must be used when puncturing the vein
Which location might the nurse use to assess the condition of an insertion site for a central venous access device? A) Below the sternum B) Over the fourth intercostal space C) Over the jugular vein D) The back of the hand
C) Over the jugular vein
Central venous access devices are usually introduced into the subclavian or jugular vein and passed to the superior vena cava, just above the atrium. The nurse would assess the insertion site over the jugular vein in this question
