A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
Edema presence
Skin turgor
Urine output
Daily weight
The Correct Answer is D
Choice A reason: This statement is false. Edema is a sign of fluid overload, not fluid deficit. Edema occurs when fluid accumulates in the interstitial space due to increased capillary hydrostatic pressure or decreased plasma oncotic pressure. Edema is more common in patients with heart failure, liver disease, or kidney disease¹.
Choice B reason: This statement is false. Skin turgor is a measure of skin elasticity and hydration. It can be affected by factors such as age, skin condition, and ambient temperature. Skin turgor is not a reliable indicator of fluid balance, as it can be normal in patients with mild to moderate hypovolemia².
Choice C reason: This statement is false. Urine output is a measure of kidney function and fluid excretion. It can be influenced by factors such as fluid intake, diuretics, hormones, and renal diseases. Urine output is not a sensitive indicator of fluid balance, as it can be normal or even increased in patients with hypovolemia due to compensatory mechanisms.
Choice D reason: This statement is true. Daily weight is a measure of body mass and fluid status. It can reflect changes in fluid balance more accurately than other methods, as long as the weight is measured at the same time, on the same scale, and with the same clothing each day. A decrease in weight can indicate fluid loss due to hypovolemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is true. Fluid volume deficit, or hypovolemia, is a condition where the body loses more fluid than it gains. It can be caused by fluid loss from vomiting, diarrhea, bleeding, or excessive sweating. Fluid volume deficit can lead to dehydration, hypotension, tachycardia, and shock.
Choice B reason: This statement is false. Sodium imbalance, or dysnatremia, is a condition where the blood sodium level is either too high or too low. It can be caused by fluid imbalance, kidney disease, hormonal disorders, or medications. Sodium imbalance can affect the brain function, causing confusion, seizures, or coma.
Choice C reason: This statement is false. Potassium imbalance, or dyskalemia, is a condition where the blood potassium level is either too high or too low. It can be caused by kidney disease, acid-base disorders, medications, or dietary intake. Potassium imbalance can affect the heart function, causing arrhythmias, cardiac arrest, or death.
Choice D reason: This statement is false. Fluid volume excess, or hypervolemia, is a condition where the body gains more fluid than it loses. It can be caused by fluid overload, heart failure, kidney failure, or liver disease. Fluid volume excess can lead to edema, hypertension, dyspnea, and pulmonary congestion.
Correct Answer is C
Explanation
Choice A reason: This statement is false. 3% Sodium Chloride is a hypertonic solution that can cause fluid overload, hypernatremia, and cellular dehydration. It is not indicated for a patient with nausea, vomiting, and Salmonella infection, who is likely to have fluid and electrolyte losses.
Choice B reason: This statement is false. Dextrose 10% in water is a hypotonic solution that can cause fluid shifts, hyponatremia, and cellular edema. It is not indicated for a patient with nausea, vomiting, and Salmonella infection, who is likely to have fluid and electrolyte losses.
Choice C reason: This statement is true. 0.9% Sodium Chloride with 40 mEq Potassium (KCl) is an isotonic solution that can maintain fluid and electrolyte balance. It is indicated for a patient with nausea, vomiting, and Salmonella infection, who is likely to have fluid and electrolyte losses, especially sodium and potassium.
Choice D reason: This statement is false. Lactated Ringers is an isotonic solution that can maintain fluid and electrolyte balance, but it also contains lactate, which can be converted to bicarbonate in the liver. It is not indicated for a patient with nausea, vomiting, and Salmonella infection, who may have metabolic acidosis due to diarrhea and lactate accumulation.
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