Question 1
A 65-year-old male patient with a history of congestive heart failure and chronic kidney disease is admitted with symptoms of dehydration after a prolonged period of vomiting and diarrhea. The nurse assesses the patient and notes dry mucous membranes, decreased skin turgor, and an orthostatic blood pressure change. Which of the following interventions should the nurse prioritize to address the patient’s fluid volume deficit?
A) Encourage ambulation every 2 hours
B) Administer oral potassium supplements
C) Monitor intake and output meticulously
D) Provide a high-protein diet
E) Increase room humidity
Rationale: Monitoring intake and output is essential in managing fluid volume deficit, as it helps in evaluating the severity of dehydration and effectiveness of rehydration therapy. It allows for accurate assessment of fluid losses and needs, guiding interventions to restore fluid balance. Encouraging ambulation and providing a high-protein diet do not directly address fluid volume deficit. Potassium supplements may be necessary if electrolyte imbalance is present but do not constitute the initial step in treatment. Increasing room humidity can provide comfort but does not correct fluid volume deficit.
Question 2
A nurse is caring for a child who presents to the emergency department with signs of severe dehydration due to gastroenteritis. Which of the following clinical manifestations would most likely indicate a severe fluid volume deficit in this child?
A) Bradycardia
B) Polyuria
C) Delayed capillary refill
D) Hypertension
E) Edema
Rationale: Delayed capillary refill, longer than 2 seconds, is a critical sign of severe dehydration, indicating poor perfusion and significant fluid volume deficit. Bradycardia and hypertension are not typical signs of dehydration; instead, tachycardia and hypotension would be more expected. Polyuria and edema are signs of fluid overload, not deficit.
Question 3
A 75-year-old woman with a history of type 2 diabetes mellitus is admitted with mild dehydration after experiencing flu-like symptoms. The nurse plans to administer IV fluids as prescribed. Which of the following assessments is most important for the nurse to monitor for signs of effective treatment?
A) Urine color
B) Blood glucose levels
C) Temperature
D) Skin elasticity
E) Heart rate
Rationale: Urine color is a direct indicator of hydration status. Light or clear urine suggests adequate hydration, while dark urine indicates dehydration. Monitoring urine color helps assess the effectiveness of IV fluid therapy in treating dehydration. While blood glucose levels, temperature, skin elasticity, and heart rate are important assessments, they do not directly measure the improvement of fluid volume deficit as effectively as changes in urine color.
Question 4
A patient is diagnosed with fluid volume deficit due to severe burns. The nurse is aware that fluid shift in this condition can lead to hypovolemia. Which of the following symptoms should the nurse expect to find during assessment?
A) Jugular vein distension
B) Crackles in the lungs
C) Increased blood pressure
D) Weak, rapid pulse
E) Decreased hematocrit
Rationale: A weak, rapid pulse is indicative of hypovolemia caused by a fluid volume deficit, as the body attempts to maintain cardiac output in the face of reduced blood volume. Jugular vein distension, crackles in the lungs, and increased blood pressure are associated with fluid overload, not deficit. Decreased hematocrit may occur with hemodilution from fluid overload rather than deficit.
Question 5
A nurse is assessing a patient who has been experiencing severe diarrhea for the past three days. Which of the following findings would be most indicative of a fluid volume deficit?
A) Pitting edema
B) Bounding pulse
C) Systolic hypertension
D) Sunken eyes
E) Frothy sputum
Rationale: Sunken eyes are a classic sign of fluid volume deficit, particularly in severe cases, reflecting the loss of subcutaneous fat due to dehydration. Pitting edema, a bounding pulse, and systolic hypertension are typically associated with fluid overload. Frothy sputum is more indicative of pulmonary edema, not dehydration.
Question 6
An elderly patient is admitted to the hospital with a diagnosis of gastroenteritis and suspected fluid volume deficit. The nurse is reviewing the patient’s laboratory test results. Which of the following lab findings would support the diagnosis of fluid volume deficit?
A) Decreased serum sodium
B) Increased hemoglobin and hematocrit
C) Decreased serum potassium
D) Increased serum creatinine
E) Decreased blood urea nitrogen (BUN)
Rationale: Increased hemoglobin and hematocrit levels can indicate a fluid volume deficit because they suggest hemoconcentration, which occurs when the plasma volume decreases relative to the number of red blood cells. This condition is common in dehydration, where fluid loss leads to a relative increase in the concentration of blood cells and other blood components. Decreased serum sodium and potassium might be seen in various conditions but do not directly indicate fluid volume deficit without considering clinical context. Increased serum creatinine and BUN can indicate renal impairment, which may be a consequence of severe dehydration, but increased hemoglobin and hematocrit more directly reflect the hemoconcentration associated with fluid volume deficit.
Question 7
A pediatric nurse is caring for a 4-year-old child with vomiting and diarrhea. The child’s parent expresses concern about the child’s decreased urine output. Which of the following actions should the nurse take first to assess for fluid volume deficit?
A) Check the child’s weight
B) Measure the child’s temperature
C) Assess the child’s mucous membranes
D) Listen to the child’s lung sounds
E) Palpate the child’s abdomen
Rationale: Checking the child’s weight is the most accurate and immediate method to assess for fluid volume deficit, especially in pediatric patients, as weight changes can quickly indicate fluid loss or gain. Daily weights provide essential information about the fluid status, with rapid weight loss suggesting significant fluid volume deficit. While assessing mucous membranes, measuring temperature, listening to lung sounds, and palpating the abdomen are important in the overall assessment, they do not offer the direct quantitative measure of fluid loss that weight does.
Question 8
A home health nurse is visiting an elderly patient with a recent history of mild dehydration. To prevent recurrence, which of the following dietary recommendations is most appropriate for the nurse to provide to the patient?
A) Increase sodium-rich foods
B) Drink at least eight glasses of water daily
C) Restrict fluid intake in the evening
D) Consume more diuretic beverages, like coffee and tea
E) Increase intake of high-protein foods
Rationale: Drinking at least eight glasses of water daily is a foundational recommendation for preventing dehydration, particularly in elderly patients who may have a diminished sense of thirst. This practice helps maintain hydration and supports overall health. Increasing sodium-rich foods is not advised without specific medical indications, as it can contribute to hypertension and fluid retention. Restricting fluid intake in the evening might be recommended for patients with nocturia or heart failure but does not prevent dehydration. Diuretic beverages can actually contribute to dehydration by increasing urine output. High-protein foods are important for nutrition but do not specifically prevent dehydration.
Question 9
A nurse is planning care for a patient with a fluid volume deficit related to excessive sweating due to high environmental temperatures. Which of the following nursing interventions is most appropriate to include in the plan of care?
A) Apply a cooling blanket
B) Limit oral fluid intake
C) Encourage the consumption of sports drinks
D) Administer diuretics as prescribed
E) Increase dietary sodium intake without increasing fluids
Rationale: Encouraging the consumption of sports drinks is appropriate for a patient with fluid volume deficit related to excessive sweating, as these beverages can help replenish electrolytes lost through sweat in addition to providing fluids. Sports drinks contain electrolytes such as sodium and potassium, which are important for maintaining fluid balance and preventing hyponatremia. Applying a cooling blanket addresses the external temperature but does not replenish lost fluids or electrolytes. Limiting oral fluid intake and administering diuretics would exacerbate the fluid deficit. Increasing dietary sodium without increasing fluid intake could lead to hypernatremia and worsen dehydration.
Question 10
A nurse is assessing a group of patients for risk factors associated with fluid volume deficit. Which of the patient’s condition poses the highest risk for developing this condition?
A) A patient with a fractured leg immobilized in a cast
B) A patient with congestive heart failure on diuretic therapy
C) A patient recovering from a viral upper respiratory infection
D) A patient with hypothyroidism
E) A patient undergoing chemotherapy treatment
Rationale: Patients undergoing chemotherapy treatment are at a high risk for fluid volume deficit due to the side effects of the treatment, such as vomiting, diarrhea, and decreased appetite, which can lead to inadequate fluid intake and increased fluid loss. While congestive heart failure patients on diuretic therapy are also at risk, their fluid status is usually closely monitored to balance the effects of the diuretics.