FUNDAMENTALS OF NURSING III (CHAP 39 FLUID,
ELECTROLYTE, AND ACID-BASE BALANCE PREP U)
ANSWERED PERFECTLY!!
A client admitted with heart failure requires careful monitoring of his fluid status.
What assessment parameter will provide the nurse with the best indication of the
client's fluid status?
Answers Daily weights
A dialysis unit nurse caring for a client with renal failure will expect the client to
exhibit which fluid and electrolyte imbalances?
Answers fluid volume excess & acidosis (fluid volume excess can be caused by
malfunction of the kidneys (renal failure), the kidneys are also responsible for acid-
base balance, and in the presence of renal failure, the kidneys cannot regulate
hydrogen ions and bicarbonate ions, so the client develops metabolic acidosis)
A client loses consciousness after strenuous exercise and needs to be admitted to a
health care facility. The client is diagnosed with dehydration. The nurse knows the
client needs restoration of?
Answers electrolytes
The nurse is assessing a newly admitted client and finds that he has edema in his
right ankle that is 2 mm and is just perceptible. The nurse documents this at which
grade?
Answers the edema in the client should be graded as +, which means the edema is
just perceptible and of 2 mm dimension. A measurement of 2+ or 3+ indicates
moderate edema of 4-6 mm. A measurement of 4+ indicates severe edema of 8 mm
or more
Which client is at risk for fluid volume deficit related to the loss of total body fluid
and extracellular fluid?
, Answers an infant age 4 mos, an infant has considerably more body fluid and
extracellular fluid (ECF) than an adult has, because ECF is more easily lost from
the body than intracellular fluid, infants are more prone to fluid volume deficits
A client with a diagnosis of colon cancer has opted for a treatment plan that will
include several rounds of chemotherapy. What vascular access device is most
likely to meet this client's needs?
Answers an implanted central venous access device (CVAD). Implanted CVAD's
are ideal for long-term uses such as chemotherapy
A home care nurse is visiting a client with renal failure who is on fluid restriction.
The client tells the nurse "I get thirsty often, what might help?" What would the
nurse include as a suggestion for this client?
Answers avoid salty or excessively sweet fluids (to minimize thirst in a client on
fluid restriction)
Upon assessment of a client's peripheral IV site, the nurse notices the area is red &
warm. The client complains of pain when the nurse gently palpates the area. These
signs and symptoms are indicative of what?
Answers phlebitis (phlebitis is an infection at the local site of an IV catheter
The nurse's morning assessment of a client who has a history of heart failure
reveals the presence of 2+ pitting edema in the clients feet and ankles bilaterally.
This assessment finding is suggestive of what?
Answers fluid volume excess (edema is a characteristic sign of fluid volume
excess, hypervolemia)
Endurance athlete's who exercise for long periods of time and consume only water
may experience a sodium deficit in their extracellular fluid. What is this electrolyte
balance known as?
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