Unit 3: Fluid & Electrolyte balance
Which client is most likely to exhibit dehydration? -
an 8-month-old infant with persistent diarrhea for 24 hours
Infants and elderly persons have the greatest risk of fluid-related health problems. An infant's
body weight is 70% to 80% water content. An infant who is ill and has had persistent diarrhea
for 24 hours will quickly lose a significant amount of fluid and electrolytes if the diarrhea is
not stopped and replacement fluids given.Healthy young adults have a higher tolerance for
fluid loss and can quickly regain their fluid balance when fluids are lost through normal
activity.The 75-year-old woman who was placed on NPO status before surgery is not likely
to develop a fluid volume deficit within 8 hours, unless there are other fluid conditions
present that would precipitate fluid loss.The 60-year-old client with pneumonia and a fever
should be monitored for a fluid deficit, but he is not as likely to develop one as a client who is
actively losing fluids through diarrhea.
During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to
explain the physiology of the parathyroid glands. The nurse states that these glands produce
parathyroid hormone (PTH). PTH maintains the balance between calcium and -
phosphorus.
PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't
affect sodium, potassium, or magnesium regulation.
A client has vomited several times over the past 12 hours. The nurse should recognize the
risk of what complication? -
metabolic alkalosis
Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading
to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.
A child is brought to the emergency department with a full-thickness burn involving the
epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time.
Which statements by the nurse are correct about this type of burn? Select all that apply. -
This is a severe burn and nerve endings have been destroyed.
The child must be monitored for signs of fluid shift.
Rehabilitation and skin grafting will be necessary.
This is an example of a third-degree burn, which is very serious. This child must be carefully
monitored for complications. The fact that there is no pain is due to the destruction of the
nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also
require a long rehabilitation with skin grafting. Oral pain medication would not be
administered as the child would be NPO and oral medication would not be effective. This
burn is not superficial.
A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding
would support this diagnosis? -
orthostatic blood pressure changes
1|Page
,Fluid volume deficit is characterized by hypotension, tachycardia, increased body
temperature, and weakness. Leathery, pliable skin may not demonstrate fluid deficit; it may
reflect diabetes. Pitting edema and pedal pulses of 4+ demonstrate localized edema and
potential fluid excess.
During a clinic visit, the mother of an infant with hydrocele states that the infant's scrotum is
smaller now than when he was born. After teaching the mother about the infant's condition,
which statement by the mother indicates that the teaching has been effective? -
"It seems like the fluid is being reabsorbed."
A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the
spermatic cord that results from a patent processus vaginalis. As fluid is being absorbed,
scrotal size decreases. Elevation of the infant's bottom, massage, or keeping the infant quiet
or in an infant seat would have no effect in promoting fluid reabsorption in hydrocele.
The nurse determines that interventions for decreasing fluid retention have been effective
when the nurse makes which assessment in child with nephrotic syndrome? -
decreased abdominal girth
Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure
changes. Increased abdominal fluid is evidenced by an increase in abdominal girth.
Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues.
When fluid accumulates in the abdomen and interstitial spaces, the child does not feel hungry
and does not eat well. Although increased caloric intake may indicate decreased intestinal
edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory
rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the
diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume.
A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL,
serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What is the priority
nursing assessment? -
cardiac rhythm
Manifestations of CKD result from loss of the renal regulatory functions of filtering
metabolic waste products and maintaining fluid and electrolyte balance. These laboratory
results indicate CKD, but the most significant result is the potassium level. The normal range
of potassium is between 3.5 and 5.0 mEq/L. A potassium level greater than 7 mEq/L may
produce fatal cardiac dysrhythmias. Normal BUN level ranges from 8 to 23 mg/dL; normal
serum creatinine level ranges from 0.7 to 1.5 mg/dL.
A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution
intravenously over 5 minutes. The client weighs 132 lb (60 kg). How many grams would the
nurse administer? Record your answer as a whole number. -
12
First, convert the client's weight from pounds to kilograms:132 lb ÷ 2.2 lb/kg = 60 kg.Then,
to calculate the number of grams to administer, multiply the ordered number of grams by the
client's weight in kilograms:0.2g/kg X 60 kg = 12 g.
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, The nurse is caring for assigned clients on the oncology unit. Which client is at greatest risk
for dehydration? -
a 48-year-old having intracavitary radiation for cancer of the cervix
Dehydration can occur from fluid loss secondary to tissue destruction at the site of irradiation
at any age. After radical vulvectomy, wound drains are generally removed by postoperative
day four or five, and don't create a significant risk of dehydration. Tamoxifen therapy is
unrelated to dehydration. Although urine may escape through the vagina as a result of a
vesicovaginal fistula, it does not cause the loss of an unusual amount of urine or other fluid.
Which type of solution raises serum osmolarity and pulls fluid from the intracellular and
intrastitial compartments into the intravascular compartment? -
hypertonic
The osmolarity of a hypertonic solution is higher than that of serum. A hypertonic solution
draws fluid into the intravascular compartment from the intracellular and interstitial
compartments. An isotonic solution's osmolarity is about equal to that of serum. It expands
the intravascular and interstitial compartments. A hypotonic solution's osmolarity is lower
than serum's. A hypotonic solution hydrates the intracellular and interstitial compartments by
shifting fluid out of the intravascular compartment. Electrotonic solution is incorrect.
The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The
nurse's most appropriate response to is to tell the client that the priority reason for giving her
magnesium sulfate is to -
prevent seizures.
The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium
will act like calcium in the body. As a result, magnesium will block seizure activity in a
hyperstimulated neurologic system caused by preeclampsia by interfering with signal
transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and
increasing diuresis are secondary effects of magnesium.
The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period
of burn management. Which finding indicates that adequate fluid replacement has been
achieved? -
The urine output is greater than 35 mL/h.
A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns.
An increase in body weight may indicate fluid retention. A urine output greater than fluid
intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60
mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate
adequate fluid replacement.
During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the
nurse should monitor hourly which information that will be used to determine the IV infusion
rate? -
urine output
During the first 48 to 72 hours of fluid resuscitation therapy, hourly urine output is the most
accessible and generally reliable indicator of adequate fluid replacement. Fluid volume is also
3|Page
Which client is most likely to exhibit dehydration? -
an 8-month-old infant with persistent diarrhea for 24 hours
Infants and elderly persons have the greatest risk of fluid-related health problems. An infant's
body weight is 70% to 80% water content. An infant who is ill and has had persistent diarrhea
for 24 hours will quickly lose a significant amount of fluid and electrolytes if the diarrhea is
not stopped and replacement fluids given.Healthy young adults have a higher tolerance for
fluid loss and can quickly regain their fluid balance when fluids are lost through normal
activity.The 75-year-old woman who was placed on NPO status before surgery is not likely
to develop a fluid volume deficit within 8 hours, unless there are other fluid conditions
present that would precipitate fluid loss.The 60-year-old client with pneumonia and a fever
should be monitored for a fluid deficit, but he is not as likely to develop one as a client who is
actively losing fluids through diarrhea.
During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to
explain the physiology of the parathyroid glands. The nurse states that these glands produce
parathyroid hormone (PTH). PTH maintains the balance between calcium and -
phosphorus.
PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't
affect sodium, potassium, or magnesium regulation.
A client has vomited several times over the past 12 hours. The nurse should recognize the
risk of what complication? -
metabolic alkalosis
Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading
to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.
A child is brought to the emergency department with a full-thickness burn involving the
epidermis, dermis, and underlying subcutaneous tissue, but does not report pain at this time.
Which statements by the nurse are correct about this type of burn? Select all that apply. -
This is a severe burn and nerve endings have been destroyed.
The child must be monitored for signs of fluid shift.
Rehabilitation and skin grafting will be necessary.
This is an example of a third-degree burn, which is very serious. This child must be carefully
monitored for complications. The fact that there is no pain is due to the destruction of the
nerve endings. Fluid shift can occur and result in shock. A burn of this degree will also
require a long rehabilitation with skin grafting. Oral pain medication would not be
administered as the child would be NPO and oral medication would not be effective. This
burn is not superficial.
A client has a nursing diagnosis of fluid volume deficit. Which nursing assessment finding
would support this diagnosis? -
orthostatic blood pressure changes
1|Page
,Fluid volume deficit is characterized by hypotension, tachycardia, increased body
temperature, and weakness. Leathery, pliable skin may not demonstrate fluid deficit; it may
reflect diabetes. Pitting edema and pedal pulses of 4+ demonstrate localized edema and
potential fluid excess.
During a clinic visit, the mother of an infant with hydrocele states that the infant's scrotum is
smaller now than when he was born. After teaching the mother about the infant's condition,
which statement by the mother indicates that the teaching has been effective? -
"It seems like the fluid is being reabsorbed."
A hydrocele is a collection of fluid in the tunica vaginalis of the testicle or along the
spermatic cord that results from a patent processus vaginalis. As fluid is being absorbed,
scrotal size decreases. Elevation of the infant's bottom, massage, or keeping the infant quiet
or in an infant seat would have no effect in promoting fluid reabsorption in hydrocele.
The nurse determines that interventions for decreasing fluid retention have been effective
when the nurse makes which assessment in child with nephrotic syndrome? -
decreased abdominal girth
Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure
changes. Increased abdominal fluid is evidenced by an increase in abdominal girth.
Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues.
When fluid accumulates in the abdomen and interstitial spaces, the child does not feel hungry
and does not eat well. Although increased caloric intake may indicate decreased intestinal
edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory
rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the
diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume.
A client with chronic kidney disease (CKD) has a blood urea nitrogen (BUN) of 100 mg/dL,
serum creatinine of 6.5 mg/dL, potassium of 6.1 mEq/L, and lethargy. What is the priority
nursing assessment? -
cardiac rhythm
Manifestations of CKD result from loss of the renal regulatory functions of filtering
metabolic waste products and maintaining fluid and electrolyte balance. These laboratory
results indicate CKD, but the most significant result is the potassium level. The normal range
of potassium is between 3.5 and 5.0 mEq/L. A potassium level greater than 7 mEq/L may
produce fatal cardiac dysrhythmias. Normal BUN level ranges from 8 to 23 mg/dL; normal
serum creatinine level ranges from 0.7 to 1.5 mg/dL.
A client with marked oliguria is ordered a test dose of 0.2 g/kg of 15% mannitol solution
intravenously over 5 minutes. The client weighs 132 lb (60 kg). How many grams would the
nurse administer? Record your answer as a whole number. -
12
First, convert the client's weight from pounds to kilograms:132 lb ÷ 2.2 lb/kg = 60 kg.Then,
to calculate the number of grams to administer, multiply the ordered number of grams by the
client's weight in kilograms:0.2g/kg X 60 kg = 12 g.
2|Page
, The nurse is caring for assigned clients on the oncology unit. Which client is at greatest risk
for dehydration? -
a 48-year-old having intracavitary radiation for cancer of the cervix
Dehydration can occur from fluid loss secondary to tissue destruction at the site of irradiation
at any age. After radical vulvectomy, wound drains are generally removed by postoperative
day four or five, and don't create a significant risk of dehydration. Tamoxifen therapy is
unrelated to dehydration. Although urine may escape through the vagina as a result of a
vesicovaginal fistula, it does not cause the loss of an unusual amount of urine or other fluid.
Which type of solution raises serum osmolarity and pulls fluid from the intracellular and
intrastitial compartments into the intravascular compartment? -
hypertonic
The osmolarity of a hypertonic solution is higher than that of serum. A hypertonic solution
draws fluid into the intravascular compartment from the intracellular and interstitial
compartments. An isotonic solution's osmolarity is about equal to that of serum. It expands
the intravascular and interstitial compartments. A hypotonic solution's osmolarity is lower
than serum's. A hypotonic solution hydrates the intracellular and interstitial compartments by
shifting fluid out of the intravascular compartment. Electrotonic solution is incorrect.
The client with preeclampsia asks the nurse why she is receiving magnesium sulfate. The
nurse's most appropriate response to is to tell the client that the priority reason for giving her
magnesium sulfate is to -
prevent seizures.
The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium
will act like calcium in the body. As a result, magnesium will block seizure activity in a
hyperstimulated neurologic system caused by preeclampsia by interfering with signal
transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and
increasing diuresis are secondary effects of magnesium.
The nurse is evaluating the effectiveness of fluid resuscitation during the emergency period
of burn management. Which finding indicates that adequate fluid replacement has been
achieved? -
The urine output is greater than 35 mL/h.
A urine output of 30 to 50 mL/h indicates adequate fluid replacement in the client with burns.
An increase in body weight may indicate fluid retention. A urine output greater than fluid
intake does not represent a fluid balance. Depending on the client, blood pressure of 90/60
mm Hg could indicate the presence of a hypovolemic state; by itself, it does not indicate
adequate fluid replacement.
During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the
nurse should monitor hourly which information that will be used to determine the IV infusion
rate? -
urine output
During the first 48 to 72 hours of fluid resuscitation therapy, hourly urine output is the most
accessible and generally reliable indicator of adequate fluid replacement. Fluid volume is also
3|Page
