A nurse is admitting a client who reports nausea, vomiting, and weakness. The client has dry
oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings
should the nurse identify as manifestations of fluid volume deficit? (Select all that apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea - ANSWER A; Decreased skin turgor is a manifestation present with fluid
volume deficit. Skin turgor is decreased due to the lack of fluid within the body and results in
dryness of the skin.
B; Concentrated urine is a manifestation present with fluid volume deficit. Urine is concen-
trated due to lack of fluid in the vascular system, causing a decreased profusion of the kid-
neys resulting in an increased urine specific gravity.
D; Low-grade fever is a manifestation present with fluid volume deficit. Low-grade fever is
one of the body's ways to maintain homeostasis to compensate for lack of fluid within the
body.
E; Tachypnea is a manifestation present with fluid volume deficit. Increased respirations are
the body's way to obtain oxygen due to the lack of fluid volume within the body.
A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr.
Which of the following manifestations of fluid volume excess should the nurse expect? (Se-
lect all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
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, D. Hypertension
E. Weakness - ANSWER A; Dyspnea is a manifestation present with fluid volume excess.
Dyspnea is due to an excess of fluids within the body and lungs, and the client is struggling
to breathe to obtain oxygen.
B; Weight gain can be a result of edema.
D; Blood pressure rises as the heart must work harder due to the excess fluid.
E; Weakness is due to the excess fluid that is retained, which depletes energy and increases
the workload for the body.
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 - ANSWER D; Tachycardia is an attempt to maintain blood pressure, a man-
ifestation of fluid volume deficit.
A nurse is caring for a client in a long-term facility who has become weak, confused, and ex-
perienced dizziness when standing. The client's temperature is 38.3 degrees C (100.9 de-
grees F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of
the following actions should the nurse take?
A. Initiate fluid restrictions to limit intake
B. Check for peripheral edema
C. Encourage the client to ambulate to promote oxygenation
D. Monitor for orthostatic hypotension - ANSWER D; Monitor for orthostatic hypotension
because they have manifestations of dehydration due to decreased circulatory volume.
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oral mucous membranes and blood pressure 102/64 mm Hg. Which of the following findings
should the nurse identify as manifestations of fluid volume deficit? (Select all that apply.)
A. Decreased skin turgor
B. Concentrated urine
C. Bradycardia
D. Low-grade fever
E. Tachypnea - ANSWER A; Decreased skin turgor is a manifestation present with fluid
volume deficit. Skin turgor is decreased due to the lack of fluid within the body and results in
dryness of the skin.
B; Concentrated urine is a manifestation present with fluid volume deficit. Urine is concen-
trated due to lack of fluid in the vascular system, causing a decreased profusion of the kid-
neys resulting in an increased urine specific gravity.
D; Low-grade fever is a manifestation present with fluid volume deficit. Low-grade fever is
one of the body's ways to maintain homeostasis to compensate for lack of fluid within the
body.
E; Tachypnea is a manifestation present with fluid volume deficit. Increased respirations are
the body's way to obtain oxygen due to the lack of fluid volume within the body.
A nurse is admitting an older adult client who reports a weight gain of 2.3 kg (5 lb) in 48 hr.
Which of the following manifestations of fluid volume excess should the nurse expect? (Se-
lect all that apply.)
A. Dyspnea
B. Edema
C. Bradycardia
1
, D. Hypertension
E. Weakness - ANSWER A; Dyspnea is a manifestation present with fluid volume excess.
Dyspnea is due to an excess of fluids within the body and lungs, and the client is struggling
to breathe to obtain oxygen.
B; Weight gain can be a result of edema.
D; Blood pressure rises as the heart must work harder due to the excess fluid.
E; Weakness is due to the excess fluid that is retained, which depletes energy and increases
the workload for the body.
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 - ANSWER D; Tachycardia is an attempt to maintain blood pressure, a man-
ifestation of fluid volume deficit.
A nurse is caring for a client in a long-term facility who has become weak, confused, and ex-
perienced dizziness when standing. The client's temperature is 38.3 degrees C (100.9 de-
grees F), pulse 92/min, respirations 20/min, and blood pressure 108/60 mm Hg. Which of
the following actions should the nurse take?
A. Initiate fluid restrictions to limit intake
B. Check for peripheral edema
C. Encourage the client to ambulate to promote oxygenation
D. Monitor for orthostatic hypotension - ANSWER D; Monitor for orthostatic hypotension
because they have manifestations of dehydration due to decreased circulatory volume.
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