A patient experiencing multisystem fluid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

Effects of rapidly infused intravenous fluids.

The body's natural compensatory mechanisms.

Pharmacological effects of a diuretic.

Cardiac failure.

Answer and Explanation

The Correct Answer is B

Choice B rationale:

The patient's tachycardia, pale, cool skin, and decreased urine output are signs of the body's natural compensatory mechanisms in response to fluid volume deficit. When the body

experiences a decrease in fluid volume, it tries to compensate by increasing heart rate (tachycardia) to maintain blood flow to vital organs and constricting blood vessels to preserve fluid and maintain blood pressure. Pale, cool skin is a result of vasoconstriction, and decreased urine output is a way the body conserves water during dehydration.

Choice A rationale:

Effects of rapidly infused intravenous fluids are not the cause of the patient's current findings. In fact, the nurse's notes indicate that the IV fluid therapy (0.9% sodium chloride) was initiated at 125 mL/hr, which is a relatively standard and cautious rate. Rapidly infused fluids could potentially cause fluid overload, but that is not the situation here.

Choice C rationale:

Pharmacological effects of a diuretic are not relevant to this patient's presentation. There is no mention of diuretic use in the nurse's notes, and the symptoms presented are more consistent with fluid volume deficit and dehydration rather than diuretic use.

Choice D rationale:

Cardiac failure is not the correct answer, as there is no indication of heart failure in the patient's presentation or nurse's notes. The symptoms and findings described are more indicative of fluid volume deficit, which is not synonymous with cardiac failure.

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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. Sweet Potatoes. B. Bananas. C. Grapes. D. Watermelon.

Correct Answer is ["A","B","D"]

Explanation

The correct answer is choices A, B, and D. Here are the rationales for each choice:

Choice A rationale:

Sweet potatoes are an excellent source of potassium. One medium sweet potato contains about 542 mg of potassium, making it a great option for a high-potassium diet.

Choice B rationale:

Bananas are well-known for their high potassium content. A medium banana provides approximately 451 mg of potassium, which is beneficial for maintaining proper muscle and nerve function.

Choice C rationale:

Grapes are not particularly high in potassium compared to other fruits. They contain some potassium, but not enough to be considered a significant source for a high-potassium diet.

Choice D rationale:

Watermelon is a good source of potassium. Two wedges of watermelon contain about 640 mg of potassium, making it a suitable choice for increasing potassium intake.

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A patient experiencing multisystem fluid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

Nursing Test Bank

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 planning to teach a client about a high-potassium diet. Which of the following foods should the nurse instruct the client to eat? (Select all that apply.).

Correct Answer is ["A","B","D"]

Explanation

A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volumes should the nurse notify the patient's healthcare provider?

A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider?

The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.

The nurse is caring for a patient diagnosed with hypocalcemia. What additional assessments should the nurse include when caring for this patient?

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?

A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

A patient with fluid overload is prescribed furosemide (Lasix) 20 mg by mouth each day. What should the nurse include when teaching the patient about this medication? Select all that apply.