A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

Sodium level.

Tissue turgor.

Daily weight.

Intake and output.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Sodium level is a laboratory parameter that can be helpful in assessing fluid balance, but it does not directly measure fluid retention. Abnormal sodium levels may indicate fluid imbalances, but it is not the most reliable measure of fluid retention.

Choice B rationale:

Tissue turgor refers to the skin's elasticity, and it can be used to assess dehydration rather than fluid retention. Poor turgor may indicate dehydration, but it does not specifically measure fluid volume increase.

Choice C rationale:

Daily weight is a reliable measure of fluid retention. An increase in weight over a short period may indicate fluid accumulation in the body, while a decrease in weight could signify fluid loss. It is essential to monitor weight consistently under standardized conditions (e.g., same time, same clothing) for accurate assessment.

Choice D rationale:

Intake and output records provide information about fluid intake and output but may not always reflect fluid retention accurately. It is helpful for assessing fluid balance, but daily weight is a more direct and reliable measure of fluid retention.

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Correct Answer is A

Explanation

The correct answer is choice A: Encourage the patient to breathe in and out slowly into a paper bag.

Choice A rationale:The patient’s arterial blood gas (ABG) results indicate respiratory alkalosis, as evidenced by the elevated pH (7.48) and decreased PaCO2 (25 mm Hg). Respiratory alkalosis often results from hyperventilation, which can occur due to anxiety. Breathing into a paper bag helps to increase CO2 levels in the blood, thereby correcting the alkalosis.

Choice B rationale:Administering oxygen is not appropriate in this scenario because the patient’s PaO2 is already elevated (110 mm Hg), indicating that oxygenation is not the issue. Providing additional oxygen would not address the underlying problem of hyperventilation and respiratory alkalosis.

Choice C rationale:Intravenous sodium bicarbonate is used to treat metabolic acidosis, not respiratory alkalosis. In this case, the patient’s HCO3 is within the normal range (24 mEq/L), indicating that there is no metabolic acidosis present.

Choice D rationale:Starting an intravenous fluid bolus with isotonic fluids is not indicated for correcting respiratory alkalosis. This intervention is more appropriate for patients experiencing hypovolemia or dehydration, which is not suggested by the patient’s ABG results.

A. A client who has a phosphate of 5.7 mg/dL. B. A client who has a calcium of 9.8 mg/dL. C. A client who has a vitamin D of 25 ng/mL. D. A client who has a magnesium of 1.8 mEq/L.

Correct Answer is A

Explanation

Choice A rationale:

The client with a phosphate level of 5.7 mg/dL likely has a manifestation of hypoparathyroidism. Hypoparathyroidism leads to decreased parathyroid hormone (PTH) secretion, which causes increased renal phosphate reabsorption, leading to elevated phosphate levels in the blood.

Choice B rationale:

A calcium level of 9.8 mg/dL is within the normal range (8.5-10.2 mg/dL) and does not indicate hypoparathyroidism.

Choice C rationale:

A vitamin D level of 25 ng/mL is within the normal range (30-100 ng/mL) and does not suggest hypoparathyroidism.

Choice D rationale:

A magnesium level of 1.8 mEq/L is within the normal range (1.7-2.2 mEq/L) and does not directly indicate hypoparathyroidism.

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A nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. Which intervention should the nurse expect to be prescribed to correct this problem?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory results for four clients. The nurse should recognize which of the following clients has a manifestation of hypoparathyroidism?

Correct Answer is A

Explanation

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