Nutrition and Fluid Balance Flashcards

The nurse assesses a patient for dehydration. Which finding is most consistent with dehydration?

Answer: Dark amber urine, dry mucous membranes, and increased thirst

Dark urine, dry mucous membranes, and thirst are classic signs of dehydration as the body conserves water and concentrates urine.

A patient with fluid overload would most likely exhibit which assessment finding?

Answer: Dependent pitting edema

Fluid overload causes excess fluid to accumulate in dependent areas due to gravity, resulting in pitting edema of the ankles and legs.

A urine specific gravity of 1.030 is most consistent with which condition?

Answer: Dehydration

A urine specific gravity of 1.030 indicates highly concentrated urine, which occurs when the kidneys are retaining water due to dehydration.

The nurse is monitoring a patient's daily weight. A weight gain of 2.2 lbs (1 kg) overnight most likely represents:

Answer: 1 liter of retained fluid

1 kg of body weight change overnight corresponds to approximately 1 liter of fluid gain or loss, not a change in fat or muscle mass.

Which term describes fluid loss that cannot be directly measured, such as from breathing and perspiration?

Answer: Insensible fluid loss

Insensible fluid loss refers to unmeasurable water loss through respiration and skin, averaging 600–900 mL/day in adults.

When assessing skin turgor in an older adult patient suspected of dehydration, the nurse should test skin on which body area for the most accurate result?

Answer: Sternum or clavicle area

In older adults, skin over the sternum or clavicle is most reliable for turgor assessment because age-related loss of skin elasticity makes hand/forearm results unreliable.

A patient has 3+ pitting edema. When the nurse presses on the ankle, the indentation:

Answer: Is 6 mm deep and takes up to 1 minute to rebound

3+ pitting edema produces a 6 mm indentation that takes 30–60 seconds to rebound, indicating significant fluid accumulation.