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

Choice A rationale:

Hypophosphatemia is a condition characterized by low levels of phosphate in the blood, which can be caused by various factors, including malnutrition. In this case, the patient has a history of stomach ulcers, which might have contributed to poor nutrient absorption. The nurse should request a dietitian consult to ensure the patient receives an appropriate diet rich in phosphorus, which is essential for cellular function, bone health, and energy metabolism.

Choice B rationale:

Providing aluminum hydroxide antacids as prescribed is not the appropriate intervention for hypophosphatemia. Aluminum hydroxide antacids can bind to phosphate in the gastrointestinal tract, reducing its absorption and potentially worsening the patient's already low phosphate levels.

Choice C rationale:

Instructing the patient to avoid poultry, peanuts, and seeds is not suitable for this situation. These foods are good sources of phosphorus, and avoiding them would further deplete the patient's already low phosphate levels.

Choice D rationale:

Instructing the patient to avoid the intake of sodium phosphate is not necessary for hypophosphatemia. While sodium phosphate preparations are used as laxatives, there is no indication that the patient is taking them, and they are not relevant to the management of hypophosphatemia.

A. Sodium level. B. Tissue turgor. C. Daily weight. D. Intake and output.

Correct Answer is C

Explanation

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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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

A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. What intervention should the nurse include in this patient's plan of care?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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