ATI Nursing: A Concept-Based Approach to Learning Vol. 1 & 2, 3e (Pearson) Fluids and Electrolytes Test Bank 2024

1) The nurse on a medical-surgical unit completes the shift assessment for a client diagnosed with a multisystem fluid volume deficit. In the assessment, the nurse documents that the client is experiencing tachycardia, decreased urine output, and pale, cool skin. Based on this information, which should the nurse anticipate as the cause of the client's current symptoms? A) Natural compensatory mechanisms B) Cardiac failure C) Pharmacological effects of a diuretic D) Rapidly infused intravenous fluids Answer: A Explanation: A) Vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally to protect the brain and heart. A diuretic would cause further fluid loss and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. Also, the manifestations reported are not indicative of cardiac failure in this client. B) Vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally to protect the brain and heart. A diuretic would cause further fluid loss and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. Also, the manifestations reported are not indicative of cardiac failure in this client. C) Vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally to protect the brain and heart. A diuretic would cause further fluid loss and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. Also, the manifestations reported are not indicative of cardiac failure in this client. D) Vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally to protect the brain and heart. A diuretic would cause further fluid loss and is contraindicated. Rapidly infused intravenous fluids would not cause a decrease in urine output. Also, the manifestations reported are not indicative of cardiac failure in this client. Page Ref: 378 Cognitive Level: Applying Client Need/Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes. | AACN Essential Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing Process: Evaluation Learning Outcome: 6.2 Differentiate alterations in fluids and electrolytes. MNL LO: Demonstrate understanding of the concept of fluid and electrolytes in the care of a patient with a fluid and electrolyte imbalance