Fluid Volume Deficit (FVD)
What is a common cardiovascular sign of fluid volume deficit?
What is tachycardia?
Rationale: The body compensates for low fluid volume by increasing heart rate to maintain perfusion.
What lung sounds may indicate fluid volume excess?
What are crackles?
Rationale: Crackles are heard with pulmonary congestion due to excess fluid.
What age group is most at risk for both FVD and FVE?
What is adults over 65?
Rationale: Age-related changes in renal and cardiovascular function make older adults more vulnerable.
Which symptom of FVD involves the skin?
What is decreased skin turgor?
Rationale: Turgor decreases due to poor hydration and elasticity.
What is the first action for a client with FVD and low blood pressure?
What is initiate IV fluid bolus?
Rationale: IV fluids restore intravascular volume and improve perfusion.
A client has dry mucous membranes, decreased skin turgor, and urine output of 20 mL/hr. What imbalance is this?
What is fluid volume deficit (FVD)?
Rationale: These are hallmark signs of FVD due to dehydration or fluid loss.
Which condition increases the risk for fluid overload?
What is heart failure?
Rationale: The heart cannot pump effectively, leading to fluid retention and overload.
Which environmental factor can lead to FVD during exercise?
What is heat exposure or hot weather?
Rationale: Sweating during activity in heat leads to water and electrolyte loss.
A client with FVE complains of difficulty breathing. What should the nurse assess?
What are lung sounds?
Rationale: Fluid accumulation in the lungs can cause dyspnea and crackles.
What is the best non-invasive way to monitor fluid status daily?
What is measuring daily weights?
Rationale: Daily weight is the most accurate indicator of fluid changes.
What happens to hematocrit levels in fluid volume deficit?
What is increased hematocrit?
Rationale: Hemoconcentration occurs when plasma volume is low, making red blood cells appear more concentrated.
What peripheral sign is commonly seen in clients with FVE?
What is pitting edema?
Rationale: Fluid accumulates in dependent areas, causing visible indentations when pressed.
Which disease commonly causes fluid loss through vomiting and diarrhea?
What is gastroenteritis?
Rationale: This condition leads to significant fluid loss via the GI tract.
What weight change indicates fluid retention?
What is sudden weight gain?
Rationale: Weight gain of more than 2 lbs in 24 hours may indicate fluid overload.
What lab values should be monitored with fluid imbalance?
What are electrolytes?
Rationale: Sodium, potassium, and other electrolytes shift with fluid status and must be tracked.
Which vital sign change should the nurse expect with FVD when the client stands up?
What is orthostatic hypotension?
Rationale: Decreased circulating volume causes a drop in blood pressure upon standing.
What should the nurse restrict in a client with fluid overload?
What is fluid and sodium?
Rationale: Sodium causes water retention, and fluid restriction helps prevent further volume accumulation.
Which chronic disease contributes to fluid retention?
What is chronic kidney disease?
Rationale: Impaired kidneys cannot eliminate fluid properly, leading to FVE.
What type of pulse is seen in FVE?
What is a bounding pulse?
Rationale: Increased fluid volume strengthens the pulse amplitude.
How often should I&O be assessed in a hospitalized client with fluid imbalance?
What is at least every 8 hours?
Rationale: Timely monitoring helps detect trends early and guide interventions.
What is the expected urine specific gravity in FVD?
What is increased?
Rationale: The kidneys conserve water, concentrating the urine and increasing specific gravity.
What happens to blood pressure in fluid volume excess?
What is elevated?
Rationale: Increased fluid in the vascular system raises blood pressure.
What causes third-spacing of fluid, increasing FVD risk?
What are burns or trauma?
Rationale: These conditions shift fluid into the interstitial space, reducing circulatory volume.
What symptom of FVD may cause a safety risk during ambulation?
What is dizziness or lightheadedness?
Rationale: Orthostatic hypotension can lead to falls if not monitored.
A client with FVE is on a sodium-restricted diet. What should the nurse teach the client to avoid?
What is processed or canned foods?
Rationale: These foods are typically high in sodium and worsen fluid retention.