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A nurse is admi ng a client who reports, nausea, vomi ng, and weakness. The client has dry
oral mucous membranes and blood pressure 102/64 mmHg. Which of the following findings
should the nurse iden fy as manifesta ons of fluid volume deficit? (Select all that apply.)
a. Decreased skin turgor
b. Concentrated urine
c. Bradycardia
d. Low-grade fever
e. Tachypnea
a, b, d, e
A nurse is admi ng an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr.
Which of the following manifesta ons of fluid volume excess should the nurse expect? (Select
all that apply.)
a. Dyspnea
b. Edema
c. Bradycardia
d. Hypertension
e. Weakness
a, b, d, e
AD
A nurse is assessing a client who is dehydrated. Which of the following findings should the nurse
expect?
a. Moist skin
b. Distended neck veins
c. Increased urinary output
d. Tachycardia
d
A nurse is caring for a client in a long-term care facility who has become weak, confused, and
experienced dizziness when standing. The client's temperature is 38.3º C (100.9º F), pulse
,92/min, respira ons 20/min, and blood pressure 108/60 mmHg. Which of the following ac ons
should the nurse take?
a. Ini ate fluid restric ons to limit intake
b. Check for peripheral edema
c. Encourage the client to ambulate to promote oxygena on
d. Monitor for orthosta c hypotension
d
A nurse is assessing a client who has dehydra on. Which of the following assessments is the
priority?
a. Skin turgor
b. Urine output
c. Weight
d. Mental status
d
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A nurse is caring for a client who has dehydra on and is receiving IV fluids. When assessing for
complica ons, the nurse should recognize which of the following manifesta ons of fluid
overload?
a. Increased urine specific gravity
b. Hypoac ve bowel sounds
c. Bounding peripheral pulses
d. Decreased respiratory rate
c
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,A nurse is providing teaching to a client who has venous insufficiency of the lower extremi es.
Which of the following statements by the client indicates an understanding of teaching?
a. "If my stockings feel ght, I'll roll them down for a while."
b. "I'll put on my elas c stockings at the first sign of swelling."
c. "When I sit down to watch television, I'll be sure to put my feet up."
d. "It's okay to cross my legs as long as it's for less than one hour."
c
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A nurse is assessing a client who has fluid volume overload from a client from a cardiovascular
disorder. Which of the following manifesta ons should the nurse expect? (Select all that apply.)
a. Jugular vein disten on
b. Moist crackles
c. Postural hypotension
d. Increased heart rate
e. Fever
a, b, d
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A nurse is caring for a client who has a major burn injury and is experiencing third spacing.
Which of the following fluid or electrolyte imbalances should the nurse expect?
a. Hypokalemia
b. Hypernatremia
c. Elevated Hct
d. Decreased Hgb
c
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A nurse is assessing a client who has isotonic dehydra on. Which of the following findings
should the nurse expect?
a. Increased hematocrit level
b. Bradycardia
c. Distended neck veins
d. Decreased urine specific gravity
a
A nurse is caring for a client with dehydra on who has developed hypovolemic shock. Which of
the following laboratory values should the nurse expect for this client?
a. BUN 18 mg/dL
b. Capillary refill 1.5 sec
c. Hct 55%
d. Urine specific gravity 1.001
c
A nurse is assessing a client who has late-stage heart failure and is experiencing fluid volume
overload. Which of the following findings should the nurse expect?
a. Weight gain of 1 kg (2.2 lb) in 1 day
b. Pi ng edema +1
c. Client report of a nocturnal cough
d. B-type natriure c pep de (BNP) level of 100 pg/mL
a
AD
A nurse is evalua ng a client who is receiving IV fluids. to treat isotonic dehydra on. Which of
the following laboratory findings indicates that the fluid therapy has been effec ve?
a. BUN 26 mg/dL
b. Serum sodium 138 mEq/L
c. Hct 56%
d. Urine specific gravity 1.035