The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)
Diarrhea
Urinary output
Profuse sweating
Vomiting
Increased respiratory effort
Correct Answer : B,E
A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.
B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.
C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.
D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.
E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Baked chicken, canned peas & carrots, macaroni & cheese, and hot tea: This meal option contains canned vegetables, which are likely to be high in sodium due to added salt for preservation. Additionally, macaroni and cheese are typically high in sodium, and hot tea may contain added sodium if processed or prepared with salt. Therefore, this option is not suitable for a client on a low-sodium diet.
B. Pepperoni pizza, salad, and a diet soda: Pepperoni pizza is a high-sodium food due to the processed meats and cheese. Salad can be a healthy option, but it depends on the dressing and toppings; if these are high in sodium, it may not be appropriate. Diet soda typically does not contain sodium, but it is not an ideal beverage choice for a client with fluid volume excess. Overall, this option is not suitable for a low-sodium diet.
C. Baked turkey breast, corn on the cob, dinner roll, and skim milk: This is the correct answer. Baked turkey breast is a lean protein source that is naturally low in sodium. Corn on the cob and skim milk are also low in sodium. A dinner roll may contain some sodium, but if chosen wisely, it can be a suitable option for a low-sodium diet. Overall, this meal option provides a balanced and low-sodium meal for a client with fluid volume excess.
D. Bologna sandwich on whole wheat bread, potato chips, sliced cucumbers, and iced tea: Bologna, potato chips, and iced tea are all high-sodium food items and not suitable for a client on a low-sodium diet. While sliced cucumbers are low in sodium, they alone cannot offset the high sodium content of the other items in this meal option.
Correct Answer is ["B","E"]
Explanation
A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.
B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.
C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.
D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.
E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.
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