What is the nurse's primary concern regarding fluid & electrolytes when caring for an elderly
pt who is intermittently confused?
1. risk of dehydration
2. risk of kidney damage
3. risk of stroke
4. risk of bleeding - ANSWER Answer: 1
Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an al-
tered level of consciousness, there is an increased risk of dehydration & high serum osmolal-
ity.
Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & elec-
trolyte issues.
Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues.
Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte is-
sues.
The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk
for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit - ANSWER Answer: 1
Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished,
leading to an intracellular fluid deficit.
1
,Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus.
Because this pt was severely burned, the fluid within the cells is diminished, leading to an
intracellular fluid deficit.
Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the inter-
stitial fluid between the cells. Because this pt was severely burned, the fluid within the cells
is diminished, leading to an intracellular fluid deficit.
Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the inter-
stitial fluid between the cells. Because this pt was severely burned, the fluid within the cells
is diminished, leading to an intracellular fluid deficit.
A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale,
cool skin, & decreased urine output. The nurse realizes these findings are most likely a direct
result of which of the following?
1. the body's natural compensatory mechanisms
2. pharmacological effects of a diuretic
3. effects of rapidly infused intravenous fluids
4. cardiac failure - ANSWER Answer: 1
Rationale 1: The internal vasoconstrictive compensatory reactions within the body are re-
sponsible for the symptoms exhibited. The body naturally attempts to conserve fluid inter-
nally specifically for the brain & heart.
Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output.
Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.
A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagno-
sis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as
most appropriate?
1. Risk for Imbalanced Fluid Volume
2. Excess Fluid Volume
3. Imbalanced Nutrition
2
,4. Ineffective Tissue Perfusion - ANSWER Answer: 1
Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabe-
tes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that
can increase the serum levels of sodium.
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially
during the early stages of treatment.
Rationale 3: Imbalanced Nutrition does not apply.
Rationale 4: Ineffective Tissue Perfusion does not apply
A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the
pt's primary healthcare provider with which of the following 24-hour urine output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL - ANSWER Answer: 1
Rationale 1: A urine output of less than 30 mL per hour must be reported to the primary
healthcare provider. This indicates inadequate renal perfusion, placing the pt at increased
risk for acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over a 24-
hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).
A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assess-
ments should focus on which postoperative complication?
1. fluid volume excess
2. fluid volume deficit
3. seizure activity
4. liver failure - ANSWER Answer: 1
Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following
the stress response before, during, & immediately after surgery. This increase leads to so-
dium & water retention. Adding more fluids intravenously can cause a fluid volume excess &
stress upon the heart & circulatory system.
3
, Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid vol-
ume deficit, & stress upon the heart & circulatory system.
Rationale 3: Seizure activity would more commonly be associated with electrolyte imbal-
ances.
Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid admin-
istration.
A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need
which of the following precautions implemented?
1. seizure
2. infection
3. neutropenic
4. high-risk fall - ANSWER Answer: 1
Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet
environment, raised side rails, & having an oral airway at the bedside would be included.
Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia.
Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia.
Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.
A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of
the following might have contributed to the pt's health problem?
1. corticosteroid
2. thiazide diuretic
3. narcotic
4. muscle relaxer - ANSWER Answer: 1
Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as cor-
ticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.
Rationale 2: Excessive sodium is lost with the use of thiazide diuretics.
Rationale 3: Narcotics do not typically affect electrolyte balance.
Rationale 4: Muscle relaxants do not typically affect electrolyte balance.
4
pt who is intermittently confused?
1. risk of dehydration
2. risk of kidney damage
3. risk of stroke
4. risk of bleeding - ANSWER Answer: 1
Rationale 1: As an adult ages, the thirst mechanism declines. Adding this in a pt with an al-
tered level of consciousness, there is an increased risk of dehydration & high serum osmolal-
ity.
Rationale 2: The risks for kidney damage are not specifically related to aging or fluid & elec-
trolyte issues.
Rationale 3: The risk of stroke is not specifically related to aging or fluid & electrolyte issues.
Rationale 4: The risk of bleeding is not specifically related to aging or fluid & electrolyte is-
sues.
The nurse is planning care for a pt with severe burns. Which of the following is this pt at risk
for developing?
1. intracellular fluid deficit
2. intracellular fluid overload
3. extracellular fluid deficit
4. interstitial fluid deficit - ANSWER Answer: 1
Rationale 1: Because this pt was severely burned, the fluid within the cells is diminished,
leading to an intracellular fluid deficit.
1
,Rationale 2: The intracellular fluid is all fluids that exist within the cell cytoplasm & nucleus.
Because this pt was severely burned, the fluid within the cells is diminished, leading to an
intracellular fluid deficit.
Rationale 3: The extracellular fluid is all fluids that exist outside the cell, including the inter-
stitial fluid between the cells. Because this pt was severely burned, the fluid within the cells
is diminished, leading to an intracellular fluid deficit.
Rationale 4: The extracellular fluid is all fluids that exist outside the cell, including the inter-
stitial fluid between the cells. Because this pt was severely burned, the fluid within the cells
is diminished, leading to an intracellular fluid deficit.
A pt, experiencing multisystem fluid volume deficit, has the symptoms of tachycardia, pale,
cool skin, & decreased urine output. The nurse realizes these findings are most likely a direct
result of which of the following?
1. the body's natural compensatory mechanisms
2. pharmacological effects of a diuretic
3. effects of rapidly infused intravenous fluids
4. cardiac failure - ANSWER Answer: 1
Rationale 1: The internal vasoconstrictive compensatory reactions within the body are re-
sponsible for the symptoms exhibited. The body naturally attempts to conserve fluid inter-
nally specifically for the brain & heart.
Rationale 2: A diuretic would cause further fluid loss, & is contraindicated.
Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output.
Rationale 4: The manifestations reported are not indicative of cardiac failure in this pt.
A pregnant pt is admitted with excessive thirst, increased urination, & has a medical diagno-
sis of diabetes insipidus. The nurse chooses which of the following nursing diagnoses as
most appropriate?
1. Risk for Imbalanced Fluid Volume
2. Excess Fluid Volume
3. Imbalanced Nutrition
2
,4. Ineffective Tissue Perfusion - ANSWER Answer: 1
Rationale 1: The pt with excessive thirst, increased urination & a medical diagnosis of diabe-
tes insipidus is at risk for Imbalanced Fluid Volume due to the pt &'s excess volume loss that
can increase the serum levels of sodium.
Rationale 2: Excess Fluid Volume is not an issue for pts with diabetes insipidus, especially
during the early stages of treatment.
Rationale 3: Imbalanced Nutrition does not apply.
Rationale 4: Ineffective Tissue Perfusion does not apply
A pt recovering from surgery has an indwelling urinary catheter. The nurse would contact the
pt's primary healthcare provider with which of the following 24-hour urine output volumes?
1. 600 mL
2. 750 mL
3. 1000 mL
4. 1200 mL - ANSWER Answer: 1
Rationale 1: A urine output of less than 30 mL per hour must be reported to the primary
healthcare provider. This indicates inadequate renal perfusion, placing the pt at increased
risk for acute renal failure & inadequate tissue perfusion. A minimum of 720 mL over a 24-
hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours).
A pt is receiving intravenous fluids postoperatively following cardiac surgery. Nursing assess-
ments should focus on which postoperative complication?
1. fluid volume excess
2. fluid volume deficit
3. seizure activity
4. liver failure - ANSWER Answer: 1
Rationale 1: Antidiuretic hormone & aldosterone levels are commonly increased following
the stress response before, during, & immediately after surgery. This increase leads to so-
dium & water retention. Adding more fluids intravenously can cause a fluid volume excess &
stress upon the heart & circulatory system.
3
, Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid vol-
ume deficit, & stress upon the heart & circulatory system.
Rationale 3: Seizure activity would more commonly be associated with electrolyte imbal-
ances.
Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid admin-
istration.
A pt is diagnosed with severe hyponatremia. The nurse realizes this pt will mostly likely need
which of the following precautions implemented?
1. seizure
2. infection
3. neutropenic
4. high-risk fall - ANSWER Answer: 1
Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet
environment, raised side rails, & having an oral airway at the bedside would be included.
Rationale 2: Infection precautions not specifically indicated for a pt with hyponatremia.
Rationale 3: Neutropenic precautions not specifically indicated for a pt with hyponatremia.
Rationale 4: High-risk fall precautions not specifically indicated for a pt with hyponatremia.
A pt is diagnosed with hypokalemia. After reviewing the pt's current medications, which of
the following might have contributed to the pt's health problem?
1. corticosteroid
2. thiazide diuretic
3. narcotic
4. muscle relaxer - ANSWER Answer: 1
Rationale 1: Excess potassium loss through the kidneys is often caused by such meds as cor-
ticosteroids, potassium-wasting diuretics, amphotericin B, & large doses of some antibiotics.
Rationale 2: Excessive sodium is lost with the use of thiazide diuretics.
Rationale 3: Narcotics do not typically affect electrolyte balance.
Rationale 4: Muscle relaxants do not typically affect electrolyte balance.
4
