AH1 HESI Review Questions - Fluids and Electrolytes with 100% Correct Answers

AH1 HESI Review Questions - Fluids and Electrolytes with 100% Correct Answers The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic and crackles are audible on auscultation. What additional signs would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss 2. Flat neck and hand veins 3. An increase in blood pressure 4. Decreased central venous pressure (CVP) *Ans* 3. An increase in blood pressure Rationale: A fluid volume excess is also known as overhydration or fluid overload and occurs when fluid intake or fluid retention exceeds the fluid needs of the body. Assessment findings associated with fluid volume excess, bounding pulse, elevated CVP, weight gain, edema, neck and hand vain distention, altered level of consciousness, and decreased hematocrit. The remaining options identify signs noted in fluid volume deficit. Test Taking Strategy: Focus on the subject, fluid volume excess. Note that weight loss, flat veins, and a decreased CVP are comparable or alike in that each of these signs reflects a decrease. The correct option reflects an increase. Review: Assessment findings in Fluid volume excess The nurse if preparing to care of a client with a potassium deficit. The nurse reviews the client's record and determines that the client was at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Is taking a potassium retaining diuretic *Ans* 2. Requires nasogastric suction Rationale: The normal serum potassium level is 3.5 mEq/L to 5.0 mEq/L. A potassium deficit is known as hypokalemia. Potassium rich gastrointestinal fluids are lost through gastrointestinal suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client taking a potassium retaining diuretic are at risk for hyperkalemia. Test taking strategy: Note that the subject of the questions is potassium deficit. The correct option is the only one that identifies a loss of body fluid.