A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?
Increased BUN
Increased urine ketones
Decreased urine specific gravity
Decreased Hgb
The Correct Answer is A
Choice A Reason: This is correct because BUN stands for blood urea nitrogen, which is a waste product of protein metabolism that is excreted by the kidneys. Increased BUN indicates fluid volume deficit, as the blood becomes more concentrated and the kidneys have less fluid to filter. A normal BUN level is 7 to 20 mg/dL. The nurse should monitor the client's fluid intake and output, weight, and serum electrolytes, and administer fluids as ordered.
Choice B Reason: This is incorrect because urine ketones are not related to fluid volume deficit, but to diabetic ketoacidosis, which is a complication of diabetes mellitus that occurs when the body breaks down fat for energy and produces ketones as a by-product. Increased urine ketones indicate diabetic ketoacidosis, which can cause
dehydration, acidosis, and coma. A normal urine ketone level is negative or trace. The nurse should monitor the client's blood glucose, pH, and bicarbonate levels, and administer insulin and fluids as ordered.
Choice C Reason: This is incorrect because urine specific gravity is a measure of the concentration of solutes in the urine. Decreased urine specific gravity indicates fluid volume excess, as the urine becomes more diluted and the kidneys excrete more fluid. A normal urine specific gravity range is 1.005 to 1.030. The nurse should monitor the client's fluid balance, vital signs, and edema, and administer diuretics as ordered.
Choice D Reason: This is incorrect because Hgb stands for hemoglobin, which is a protein in red blood cells that carries oxygen. Decreased Hgb indicates anemia, which is a condition that occurs when the blood has a low number of red blood cells or hemoglobin. Anemia can cause fatigue, weakness, and pallor. A normal Hgb level for adult males is 14 to 18 g/dL and for adult females is 12 to 16 g/dL. The nurse should monitor the client's oxygen saturation, iron level, and blood transfusion needs, and administer iron supplements or erythropoietin as ordered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Intracellular fluid overload is incorrect because it is a condition where the fluid inside the cells exceeds the normal range. This can cause cellular swelling and dysfunction. Intracellular fluid overload can be caused by conditions such as hyponatremia, water intoxication, or syndrome of inappropriate antidiuretic hormone secretion (SIADH).
Choice B: Intracellular fluid deficit is incorrect because it is a condition where the fluid inside the cells is below the normal range. This can cause cellular shrinkage and dysfunction. Intracellular fluid deficit can be caused by conditions such as hypernatremia, dehydration, or diabetes insipidus.
Choice C: Extracellular fluid deficit is correct because it is a condition where the fluid outside the cells is below the normal range. This can cause hypovolemia, hypotension, and impaired tissue perfusion. Extracellular fluid deficit can be caused by conditions such as burns, hemorrhage, vomiting, diarrhea, or excessive diuresis.
Choice D: Interstitial fluid deficit is incorrect because it is a condition where the fluid in the spaces between the cells is below the normal range. This can cause edema, impaired wound healing, and increased risk of infection. Interstitial fluid deficit can be caused by conditions such as inflammation, infection, or lymphatic obstruction.
Correct Answer is B
Explanation
Choice A: Hyperkalemia is not an imbalance that this patient is demonstrating, because this condition occurs when the blood potassium level is too high. This can happen in patients who have renal failure, acidosis, or excessive potassium intake. Hyperkalemia can cause muscle weakness, cardiac arrhythmias, and paralysis.
Choice B: Hyponatremia is an imbalance that this patient is demonstrating, because this condition occurs when the blood sodium level is too low. This can happen in patients who have watery diarrhea, which causes the loss of sodium and water from the body. Hyponatremia can cause abdominal and muscle cramping, nausea, confusion, and seizures.
Choice C: Fluid volume excess is not an imbalance that this patient is demonstrating, because this condition occurs when the body retains more fluid than it excretes. This can happen in patients who have heart failure, kidney failure, or excessive fluid intake. Fluid volume excess can cause edema, distended neck veins, and crackles in the lungs.
Choice D: Hypernatremia is not an imbalance that this patient is demonstrating, because this condition occurs when the blood sodium level is too high. This can happen in patients who have dehydration, diabetes insipidus, or excessive sodium intake. Hypernatremia can cause thirst, dry mucous membranes, agitation, and coma.
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