Page 271 - Saunders Comprehensive Review For NCLEX-RN

50. Answer: 1

Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to
meet the fluid needs of the body. Causes of a fluid volume deficit include vomiting,
diarrhea, conditions that cause increased respirations or increased urinary output,
insufficient intravenous fluid replacement, draining fistulas, and the presence of an
ileostomy or colostomy. A client with heart failure or on long-term corticosteroid
therapy or a client receiving frequent wound irrigations is most at risk for fluid
volume excess.
Test-Taking Strategy: Note the strategic words, most likely. Read the question
carefully, noting the subject, the client at risk for a deficit. Read each option and
think about the fluid imbalance that can occur in each. The clients with heart failure,
on long-term corticosteroid therapy, and receiving frequent wound irrigations retain
fluid. The only condition that can cause a deficit is the condition noted in the correct
option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Foundations of Care: Fluids & Electrolytes
Health Problem: Adult Health: Gastrointestinal: Dehydration
Priority Concepts: Clinical Judgment; Fluids and Electrolytes
Reference: Lewis et al. (2017), p. 276.

51. Answer: 1

Rationale: A fluid volume deficit occurs when the fluid intake is not sufficient to
meet the fluid needs of the body. Assessment findings in a client with a fluid volume
deficit include increased respirations and heart rate, decreased central venous
pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased
urine volume, increased specific gravity of the urine, increased hematocrit, and
altered level of consciousness. Lung congestion, increased urinary output, and
increased blood pressure are all associated with fluid volume excess.
Test-Taking Strategy: Focus on the subject, assessment findings in a fluid volume
deficit. Think about the pathophysiology for fluid volume deficit and fluid volume
excess to answer correctly. Note that options 2, 3, and 4 are comparable or alike and
are manifestations associated with fluid volume excess.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Foundations of Care: Fluids & Electrolytes
Health Problem: N/A
Priority Concepts: Clinical Judgment; Fluids and Electrolytes
Reference: Lewis et al. (2017), p. 276.

52. Answer: 4

Rationale: A fluid volume excess is also known as overhydration or fluid overload

271