Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 13: Clients with Fluid Imbalances
MULTIPLE CHOICE
1. Because the nurse is aware that extracellular dehydration can occur in his elderly
client with gastroenteritis, he assesses for
a. temperature of 96° F.
b. tenting of skin.
c. decrease in urine output.
d. increase in diastolic blood pressure.
ANS: c
The decrease in urinary output is the only reliable quick assessment for dehydration in the elderly as
their temperature is lower than normal and tenting of skin is found due to the loss of elasticity
related to age. The blood pressure would decrease in dehydration.
DIF: Cognitive Level: Application
REF: Text Reference: 205
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
2. The nurse is assessing the client load for risk of fluid deficit would be most concerned
about a client with
a. Addison's disease who is sweating profusely.
b. pneumonia on IV fluids continuously.
c. congestive heart failure taking a diuretic.
d. heat stroke on IV fluids continuously.
ANS: a
The client with Addison's who is sweating is the greatest risk; the congestive failure is overhydrated
and the pneumonia and heat stroke are on fluid replacement therapy.
DIF: Cognitive Level: Application
REF: Text Reference: 207
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
3.
a.
b.
c.
d.
The nurse is concerned when she assesses a client with cellular dehydration and finds
polyuria.
dyspnea.
bradycardia.
restlessness.
ANS: d
Cellular dehydration can cause neurological manifestations such as restlessness and apprehension.
DIF: Cognitive Level: Application
REF: Text Reference: 208
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
4. When the nurse assesses dyspnea in a client with congestive heart failure, she assesses
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Chapter 13: Clients with Fluid Imbalances
a.
b.
c.
d.
for other manifestations of fluid volume excess including
decreased blood pressure.
peripheral edema.
increased hematocrit level.
decreased urine output.
ANS: b
Fluid volume excess leads to respiratory and cardiovascular manifestations such as weight gain,
increased blood pressure, peripheral edema and decreased hematocrit.
DIF: Cognitive Level: Application
REF: Text Reference: 214
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
5. Because of the fluid loss during a severe bout of diarrhea, the nurse is not surprised at
his assessment of a reduced urine output volume related to an ADH secretion which is
a. stimulated.
b. inhibited.
c. static.
d. wildly fluctuating.
ANS: a
The ADH ( antidiuretic hormone) is stimulated in many conditions like ECF volume depletion. The
body retains much of its fluid rather than excreting them.
DIF: Cognitive Level: Application
REF: Text Reference: 206, Figure 13-1;
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
6. The nurse is vigilant in her assessments of a client with renal disease as she is aware
that the client is at risk for
a. extracellular fluid volume excess.
b. intracellular fluid volume excess.
c. hyperosmolar fluid volume deficit.
d. iso-osmolar fluid volume deficit.
ANS: a
Causes for ECFVE include renal and heart failure, cirrhosis of the liver, and increased ingestion of
high sodium foods.
DIF: Cognitive Level: Application
REF: Text Reference: 214
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
7. The nurse has an 85-year-old client who has had a temperature elevation for the last
several days. Fearing the development of an extracellular fluid volume deficit the
nurse includes in her plan of care
a. encouraging a food selection low in sodium.
b. auscultating breath sounds every 4 hours.
c. monitoring the weight at the same time each day.
d. assessing the BP for increase diastolic pressure.
ANS: c
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Chapter 13: Clients with Fluid Imbalances
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Careful assessment of weight can indicate fluid volume loss. A loss of a kilogram of weight is equal
to 1 liter of fluid.
DIF: Cognitive Level: Application
REF: Text Reference: 211
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
8. When assessing a client with a gunshot wound, the emergency department nurse will
most likely see as an indication of fluid shifts related to blood loss
a. crackles in lower lobes.
b. decreased blood pressure.
c. severe abdominal pain.
d. excessive urine output.
ANS: b
With a tissue injury, increased capillary permeability leads to shifting of plasma proteins and fluid to
the interstitial space resulting in depleted intravascular volume, thus a lowered blood pressure.
DIF: Cognitive Level: Application
REF: Text Reference: 208
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
9. The nurse has a client who received large amounts of D5W during and following
surgery, yet her urinary output is low and the urine is concentrated. Prior to notifying
the physician, the nurse will assess
a. neurologic check.
b. consistency of last bowel movement.
c. skin turgor.
d. temperature.
ANS: a
ICFVE can occur in clients who receive large amounts of D5W. Cerebral cells absorb hyposmolar
fluid more readily than do other cells, leading to neurologic manifestations of irritability,
restlessness, and disorientation.
DIF: Cognitive Level: Application
REF: Text Reference: 215
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
10. The nurse who is caring for a client on diuretics and fluid restriction to control edema
can most easily evaluate the effectiveness of the medical protocol by
a. careful weight assessment.
b. measuring the ankle circumference.
c. checking the lab report on serum sodium.
d. calculating plasma osmolality.
ANS: a
A careful recording of the daily weight at the same time of day on the same scales is the easiest
method to evaluate the effectiveness of diuretic therapy.
DIF: Cognitive Level: Application
REF: Text Reference: 207
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
Elsevier items and derived items  2005 by Elsevier Inc.
Chapter 13: Clients with Fluid Imbalances
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11. The nurse working on a medical unit would most closely assess relative to the risk of
dehydration the client who is
a. 32-years-old with a fractured arm.
b. 47-years-old with hyperthyroidism.
c. 53-years-old with pulmonary embolism.
d. 78-years-old with dementia.
ANS: d
Elderly clients are at risk for several age-related reasons. In addition, persons with dementia may not
recognize the urge to drink.
DIF: Cognitive Level: Application
REF: Text Reference: 207
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
12. The nurse makes the evaluation that the intake of one of the adult clients in her care
is adequate when she measures the total daily intake as
a. 750 ml.
b. 900 ml.
c. 1000 ml.
d. 2000 ml.
ANS: d
The adequate daily fluid intake of an adult is between 1500 and 2000 ml.
DIF: Cognitive Level: Application
TOP: Nursing Process Step: Evaluation
13.
a.
b.
c.
d.
REF: Text Reference: 205
MSC: NCLEX: Physiological Integrity
The nurse anticipates that an order for an isotonic intravenous (IV) solution will read
5% dextrose in lactated Ringer’s.
0.9% sodium chloride.
5% dextrose in water.
5% dextrose 0.45% sodium chloride.
ANS: b
The solution of 0.9% sodium chloride, or normal saline, is isotonic. Options 1 and 4 are hypertonic,
option 3 is hypotonic.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: N/A
REF: Text Reference: 210, Table 13-1;
MSC: NCLEX: Physiological Integrity
14. The nurse assesses a client’s urine output and recognizes as indicative of a
complication the finding of
a. 30 ml over 2 hours.
b. 50 ml over 90 minutes.
c. 300 ml over 8 hours.
d. 1400 ml over 24 hours.
ANS: a
An output of 30 ml or less over 2 hours is indicative of a complication.
Elsevier items and derived items  2005 by Elsevier Inc.
Chapter 13: Clients with Fluid Imbalances
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DIF: Cognitive Level: Application
REF: Text Reference: 207
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
15. When assessing the laboratory values for an assigned client with fluid excess, the
nurse finds the value that is consistent with this diagnosis to be
a. plasma osmolality of 285 mOsm/kg.
b. BUN 12 mg/dl.
c. hematocrit of 46%.
d. plasma sodium of 129 mEq/L.
ANS: d
With fluid overload, the concentration of solutes is decreased by the excess fluid. Typical findings
include plasma osmolality of less the 275 mOsm/kg, plasma sodium less than 135 mEq/l, hematocrit
less than 45%, BUN less than 8mg/dl.
DIF: Cognitive Level: Application
REF: Text Reference: 218
TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity
16. A client with a severe burn has “third spacing.” The nurse explains to the client that
often this is self-limiting and will begin to mobilize back into the intravascular space
within
a. 4 hours.
b. 10 hours.
c. 24 hours.
d. 48 hours.
ANS: d
Once the inflammation stage passes the fluid will mobilize within 48 hours.
DIF: Cognitive Level: Application
REF: Text Reference: 219
TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity
17. The nurse should assess the client on an IV diuretic for indication of which
troublesome side effect of the medication?
a. increase in urine
b. decrease in potassium
c. decrase in edema
d. decrease in weight
ANS: b
Increased urine and decrease of edema and weight are expected outcomes of diuretic therapy. Loss
of potassium can cause arrhythmia and seizures.
DIF: Cognitive Level: Analysis
TOP: Nursing Process Step: Assessment
REF: Text Reference: 216
MSC: NCLEX: Physiological Integrity
Elsevier items and derived items  2005 by Elsevier Inc.