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S2 Terms in this set (20)Edema happens when there is which fluid volume imbalance? extracellular fluid volume deficit When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space. The nurse is working with a child with altered genitourinary status. Which intervention would be included in the plan of care for the client with excess fluid volume? Weigh the child daily on the same scale. A child with edema and fluid overload should be weighed daily, on the same scale, at the same time, with the same amount of clothing. This gives the most accurate picture of fluid gain or loss. The nurse also should assess the blood pressure and pulse rate regularly to determine if hypovolemia is occurring. This can occur from fluid shifts occurring if fluid is lost too quickly. Medications need to be administered, especially diuretics to help reduce the edema. The child should be on fluid restriction. This includes PO and IV. If IV fluids are necessary the volume should be calculated into the daily amount of fluid restriction. Nitrates in the urine do not affect edema. They indicate an infection. The nurse is completing an initial assessment of a client admitted with chronic kidney disease. Which finding indicates the client has fluid volume excess? weight gain When the kidneys are not functioning, fluid volume excess presents. Signs of fluid excess are indicated by weight gain, hypertension, jugular vein distention, adventitious breath sounds (including crackles), and a wet cough. Cool, dry skin and poor tissue turgor are signs of fluid volume deficit. A child is admitted to the pediatric medical unit with the diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Based on the typical signs and symptoms of this disorder, which nursing diagnosis will the nurse identify as relating to this client? Imbalanced nutrition: More than body requirements Syndrome of inappropriate antidiuretic hormone (SIADH) occurs when ADH (vasopressin) is secreted in the presence of low serum osmolality because the feedback mechanism that regulates ADH does not function properly. ADH continues to be released, and this leads to water retention, decreased serum sodium due to hemodilution, and extracellular fluid volume expansion; thus, Excess fluid volume from edema is the highest priority. The nurse is developing a plan of care for a client with Meniere's disease and identifies a nursing diagnosis of excess fluid volume related to fluid retention in the inner ear. Which intervention would be most appropriate to include in the plan of care? Limit foods that are high in sodium. Sodium and fluid retention disrupts the delicate balance between the endolymph and perilymph in the inner ear. Therefore, many clients can control their symptoms by adhering to a low-sodium diet. Caffeinated fluids are to be avoided because of their diuretic effect. Diuretics, not antihistamines, would be prescribed to lower the pressure in the endolymphatic system. Foods high in potassium would be encouraged if the client is prescribed a diuretic that causes potassium loss. A client with chronic renal failure is admitted with a heart rate of 122 beats/minute, a respiratory rate of 32 breaths/minute, a blood pressure of 190/110 mm Hg, jugular vein distention, and bibasilar crackles. Which nursing diagnosis takes highest priority for this client? toileting self-care deficit A client with renal failure can't eliminate sufficient fluid. This issue increases the risk of fluid overload and consequent respiratory and electrolyte problems. This client shows signs of excess fluid volume and is acutely ill. Urine retention may cause renal failure but is a less urgent concern than fluid imbalance. Electrolyte disturbance and Toileting self-care deficit may also be appropriate nursing diagnoses but they take lower priority because they aren't life-threatening. Select the nursing diagnosis that would warrant immediate health care provider notification. Acute pain related to upper airway irritation secondary to an infection Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention. Which of the following statements is an appropriate nursing diagnosis for a client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? Fluid Volume Excess related to loss of sodium and potassium Extracellular volume excess is the state in which a person experiences an excess of vascular and interstitial fluid. Which clinical manifestation would lead the nurse to suspect a client has developed fluid volume excess? Decreased urine output Isotonic fluid volume excess is manifested by an increase in interstitial and vascular fluids and is characterized by weight gain over a short period of time. As vascular volume increases, central venous pressure increases, leading to distended neck veins, slow-emptying peripheral veins, a full and bounding pulse, and an increase in central venous pressure. Decreased blood pressure as well as a weak, rapid pulse reflect volume deficit. BUN and hematocrit may decrease as a result of dilution due to expansion of the plasma volume. A client is brought to the emergency department with reports of shortness of breath. Assessment reveals a full, bounding pulse, severe edema, and audible crackles in lower lung fields bilaterally. The nurse notifies the physician to obtain orders for which of these problems? Hyperkalemia Peripheral and pulmonary edema as well as a bounding pulse and dyspnea are indicators of fluid volume overload. A client is returning from the operating room after inguinal hernia repair. The nurse notes that the client has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? jugular vein distention Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition. The nurse is performing an assessment for a client who is experiencing shortness of breath. The nurse notes a full and bounding pulse, crackles in the lung fields, and jugular vein distention. The nurse recognizes symptoms of which problem? Hyponatremia Isotonic fluid volume excess is manifested by an increase in interstitial and vascular fluids. It is characterized by weight gain over a short period of time. An increase in vascular volume may be evidenced by distended neck veins, slow-emptying peripheral veins, a full and bounding pulse, and an increase in central venous pressure. When excess fluid accumulates in the lungs, there are complaints of shortness of breath and difficult breathing, respiratory crackles, and a productive cough. A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom? nausea and vomiting Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status?
Checking the client's lungs for crackles during every shift Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs. A client is at postoperative day 1 after
abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate? The client's 24-hour intake is 1800 mL (75 x 24). The client's 24-hour output is 3180 mL [(200 × 3) + (50 × 3) + 2430]. Because the output is significantly higher than the intake, the client is at risk for fluid volume deficit. The nurse should not discontinue the nasogastric suctioning without a physician's order. The findings should be documented and reassessed, but the nurse needs to take more action to prevent complication. Edema is usually associated with fluid volume excess. Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Decreased blood pressure Clinical manifestations of FVE include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client's fluid status? weighing the client daily at the same time each day Increased fluid volume leads to rapid weight gain — 2.2 lb (1 kg) for each liter of fluid retained. Weighing the client daily at the same time and in similar clothing provides more objective data than measuring fluid intake and output, which may be inaccurate because of omitted measurements such as insensible losses. Changes in vital signs are less reliable than daily weight because these changes usually are subtle during early stages of fluid retention. Weight gain is an earlier sign of excess fluid volume than crackles, which represent pulmonary edema. The nurse should plan to detect fluid accumulation before pulmonary edema occurs. The nurse is caring for a client with a disease causing excess antidiuretic hormone (ADH). When performing the assessment, the nurse should focus on which manifestation of excess ADH? Dehydration The nurse is caring for a client with a disease causing excess antidiuretic hormone (ADH). When performing the assessment, the nurse should focus on which manifestation of excess ADH? During a period of extreme excess fluid volume, a renal dialysis client may be administered which type of IV solution to shrink the swollen cells by pulling water out of the cell? 0.9% sodium chloride. When cells are placed in a hypotonic solution, which has a lower effective osmolality than the ICF, they swell as water moves into the cell. When they are placed in a hypertonic solution, which has a greater effective osmolality than the ICF, they shrink as water is pulled out of the cell. Edema happens when there is which fluid volume imbalance? When excess fluid cannot be eliminated, hydrostatic pressure forces some of it into the interstitial space. Sets found in the same folderPatho. Unit 1 Test 196 terms kaitlin_billiot patho exam 377 terms DisneyFan27 Test 3310 terms johnstay30 patho43 terms kayleeweikel Other sets by this creatorEKG and Dysrhythmias NCLEX18 terms Kristen_Fitzgerald7 Dysrhythmias with Pictures20 terms Kristen_Fitzgerald7 What did you learn? Anemia18 terms Kristen_Fitzgerald7 Chapter 67: Acute Respiratory Failure and Acute Re…27 terms Kristen_Fitzgerald7 Verified questions
physics A jet airplane in level flight has a mass of $8.66 \times 10^4$ kg, and the two wings have an estimated total area of 90.0 m$^2$. Explain why all aircraft have a “ceiling,” a maximum operational altitude. Verified answer
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physics A small laser used as a pointer produces a beam of red light 5 mm in diameter and has a power output of 5 mW. What is the magnitude of the electric field in the laser beam? Verified answer Other Quizlet setspsych 331 ch. 4.210 terms taylor_thompson176 black history month challenge questions 26-5328 terms tyykenzo Accounting10 terms quizlette79439 Chapter 8: Service Innovation and Design38 terms grevemaddy What is one of the signs and symptoms of extracellular fluid volume excess?The signs of hypervolemia include: swelling, also called edema, most often in the feet, ankles, wrists, and face. discomfort in the body, causing cramping, headache, and stomach bloating. high blood pressure caused by excess fluid in the bloodstream.
What are signs and symptoms of fluid volume excess quizlet?Assessment findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and decreased hematocrit.
Which can cause an excess of extracellular fluid volume?Volume overload generally refers to expansion of the extracellular fluid (ECF) volume. ECF volume expansion typically occurs in heart failure, kidney failure, nephrotic syndrome, and cirrhosis. Renal sodium retention leads to increased total body sodium content.
Which of the following assessment findings would indicate fluid volume excess?Evaluation. |
Which of the following is an indication of extracellular fluid volume excess quizlet?
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