CORRECT ANSWERS
A nurse is admitting a client who reports nausea, vomiting, and weakness. Upon assessment, the client
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has dry oral mucous membranes, temperature 38.5° C (101.3° F), pulse 92/min, respirations 24/min, skin
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cool with tenting present, and blood pressure 102/64 mm Hg. His urine is concentrated with a high specific
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gravity. Which of the following are clinical manifestations of fluid volume deficit? (Select all that apply.)
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A. Decreased skin turgor
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B. Concentrated urine
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C. Bradycardia
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D. Low-grade fever
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E. Tachypnea - correct answer A. CORRECT: Decreased skin turgor is a clinical manifestation present with fluid
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volume deficit. Skin e e
turgor is decreased to due to the lack of fluid within the body and results in dryness of the skin.
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B. CORRECT: Concentrated urine is a clinical manifestation present with fluid volume deficit. The
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urine is concentrated due to urinary output being decreased.
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D. CORRECT: Low-grade fever is a clinical manifestation present with fluid volume deficit. Low-grade fever
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is one of the body's ways to maintain homeostasis to compensate for lack of fluid within the body.
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E. CORRECT: Tachypnea is a clinical manifestation present with fluid volume deficit. Increased
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respirations are the body's way to obtain oxygen due to the lack of fluid volume within the body.
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A nurse is admitting an older adult client who is experiencing dyspnea, weakness, and weight gain
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, of 2 lb, with 1+ bilateral edema of the lower extremities. Upon assessment, the client has a temperature
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37.2° C (99° F), pulse 96/min, respirations 26/min, oxygen saturation 94% on 3 L oxygen via nasal
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cannula, and blood pressure 152/96 mm Hg. Which of the following clinical manifestations are indicative
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of fluid volume excess? (Select all that apply.)
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A. Dyspnea e
B. Edema e
C. Bradycardia
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D. Hypertension
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E. Weakness - correct answer A. CORRECT: Dyspnea is a clinical manifestation present with fluid volume
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excess. Dyspnea is due to e e e e
an excess of fluids within the body and lungs, and the client is struggling to breath to obtain oxygen.
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B. CORRECT: Edema is a clinical manifestation present with fluid volume excess. Edema is due to the
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excess of fluid within the body. Weight gain can be a result of edema.
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D. CORRECT: Hypertension is a clinical manifestation related to fluid volume excess. Blood pressure
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rises as the heart must work harder due to the excess fluid.
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E. CORRECT: Weakness is a clinical manifestation present with fluid volume excess. Weakness is due
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to the excess fluid that is retained, which depletes energy and increases the workload for the body.
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A nurse is caring for a client who is dehydrated. Which of the following clinical manifestations should
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the nurse assess for that is indicative of fluid volume deficit?
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A. Moist skine e
B. Distended neck veins
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C. Increased urinary output
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D. Tachycardia - correct answer D. CORRECT: Tachycardia is an attempt to maintain blood pressure, a clinical
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manifestation
indicative of fluid volume deficit. e e e e
A nurse is caring for an older adult client in a long-term care facility. The client has become weak and
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confused. He ate 40% of his breakfast and lunch. Upon assessment, the client's temperature is 38.3° C
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