NURN 160: FLUID & ELECTROLYTE BALANCE: TEST
QUESTIONS WITH COMPLETE SOLUTIONS
1) What are some things related to fluid balance disruptions a nurse can assess? --
Answer ✔✔ Tightness of clothing, rings, and shoes
- Decrease in tightness may indicate dehydration
- increase may indicate a fluid shift to the interstitial space
Orthostatic Hypotension
Sensation of palpitations or lightheadedness
Abnormal or excessive fluid losses
2) factors affecting fluid balance -- Answer ✔✔ acute illness
chronic illness
environment
nutrition
medications
3) signs and symptoms of fluid deficit -- Answer ✔✔ Increased pulse rate
Thready pulse quality
Decreased BP
Postural hypotension
Flat neck and hand veins independent positions
Diminished peripheral pulses, weaker& easier to block
Delayed CRT
Mouth dry with fissures & paste-like coating
Poor skin turgor
Decreased weight over several days
,4) signs and symptoms of fluid excess -- Answer ✔✔ Increased pulse rate
Bounding pulse quality
Peripheral pulses full
Increased BP
Decreased pulse pressure
Increased central venous pressure
Distended neck & hand veins
Engorged venous varicosities
S3 gallop
Edema
Increased weight over several days
5) S/S of fluid excess related to gas exchange -- Answer ✔✔ - Increased rate of
respirations
- Shallow respirations
- Dyspnea increases with exertion or in the supine position
- Moist crackles present on auscultation
6) S/S of fluid deficit related to gas exchange -- Answer ✔✔ Increased rate of
respirations
- Increased depth of respirations
- especially with acidosis
7) S/S of fluid deficit related to nutrition/ elimination -- Answer ✔✔ - decreased
motility
- Diminished bowel sounds
- Constipation
- Thirst
- Weight loss
- Anorexia
- Nausea & vomiting
- decreased urine output
, 8) S/S of fluid excess related to nutrition/ elimination -- Answer ✔✔ - increased
motility
- Weight gain
- Anorexia
- Nausea & vomiting
- increased urine output
- Nocturia
9) S/S of fluid deficit related to cognition/ neural regulation -- Answer ✔✔ -
decreased CNS activity
- Flat affect at first
- Progressive apprehension, restlessness, lethargy, confusion
- If circulation to cerebral tissues is impaired, it causes delirium & coma
10) S/S of fluid excess related to cognition/ neural regulation -- Answer ✔✔ -
Altered level of consciousness
- Headache
- Visual disturbances
- Skeletal muscle weakness
- Paresthesia
11) Age related changes that create increased risk for fluid volume deficit -- Answer
✔✔ Decreased thirst sensation
Higher percentage of fat (which contains less water)
Changes in the kidneys affect the ability to concentrate urine
Elderly have a lower percentage of water due to increasing obesity/fat and lower
muscle content
12) filtration -- Answer ✔✔ process by which water and solutes pass through a
permeable membrane from high hydrostatic pressure to low hydrostatic pressure
13) diffusion -- Answer ✔✔ Movement of molecules from an area of higher
concentration to an area of lower concentration.
QUESTIONS WITH COMPLETE SOLUTIONS
1) What are some things related to fluid balance disruptions a nurse can assess? --
Answer ✔✔ Tightness of clothing, rings, and shoes
- Decrease in tightness may indicate dehydration
- increase may indicate a fluid shift to the interstitial space
Orthostatic Hypotension
Sensation of palpitations or lightheadedness
Abnormal or excessive fluid losses
2) factors affecting fluid balance -- Answer ✔✔ acute illness
chronic illness
environment
nutrition
medications
3) signs and symptoms of fluid deficit -- Answer ✔✔ Increased pulse rate
Thready pulse quality
Decreased BP
Postural hypotension
Flat neck and hand veins independent positions
Diminished peripheral pulses, weaker& easier to block
Delayed CRT
Mouth dry with fissures & paste-like coating
Poor skin turgor
Decreased weight over several days
,4) signs and symptoms of fluid excess -- Answer ✔✔ Increased pulse rate
Bounding pulse quality
Peripheral pulses full
Increased BP
Decreased pulse pressure
Increased central venous pressure
Distended neck & hand veins
Engorged venous varicosities
S3 gallop
Edema
Increased weight over several days
5) S/S of fluid excess related to gas exchange -- Answer ✔✔ - Increased rate of
respirations
- Shallow respirations
- Dyspnea increases with exertion or in the supine position
- Moist crackles present on auscultation
6) S/S of fluid deficit related to gas exchange -- Answer ✔✔ Increased rate of
respirations
- Increased depth of respirations
- especially with acidosis
7) S/S of fluid deficit related to nutrition/ elimination -- Answer ✔✔ - decreased
motility
- Diminished bowel sounds
- Constipation
- Thirst
- Weight loss
- Anorexia
- Nausea & vomiting
- decreased urine output
, 8) S/S of fluid excess related to nutrition/ elimination -- Answer ✔✔ - increased
motility
- Weight gain
- Anorexia
- Nausea & vomiting
- increased urine output
- Nocturia
9) S/S of fluid deficit related to cognition/ neural regulation -- Answer ✔✔ -
decreased CNS activity
- Flat affect at first
- Progressive apprehension, restlessness, lethargy, confusion
- If circulation to cerebral tissues is impaired, it causes delirium & coma
10) S/S of fluid excess related to cognition/ neural regulation -- Answer ✔✔ -
Altered level of consciousness
- Headache
- Visual disturbances
- Skeletal muscle weakness
- Paresthesia
11) Age related changes that create increased risk for fluid volume deficit -- Answer
✔✔ Decreased thirst sensation
Higher percentage of fat (which contains less water)
Changes in the kidneys affect the ability to concentrate urine
Elderly have a lower percentage of water due to increasing obesity/fat and lower
muscle content
12) filtration -- Answer ✔✔ process by which water and solutes pass through a
permeable membrane from high hydrostatic pressure to low hydrostatic pressure
13) diffusion -- Answer ✔✔ Movement of molecules from an area of higher
concentration to an area of lower concentration.
