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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
The correct answers are Choices B, C, and D.
Choice A rationale: Normal saline is not typically used to treat low phosphate levels. It is often used to treat dehydration and electrolyte imbalances that do not include hypophosphatemia.
Choice B rationale: Potassium phosphate is used to treat low phosphate levels. It directly supplements phosphate levels in the body, making it an appropriate treatment for hypophosphatemia.
Choice C rationale: Additional milk intake can help increase phosphate levels, as milk is a good source of phosphate. This is a suitable recommendation for a patient with low phosphate levels.
Choice D rationale: Increased Vitamin D intake can enhance phosphate absorption from the gastrointestinal tract, making it a beneficial treatment for a patient with low phosphate levels.
Correct Answer is D
Explanation
Digoxin. Choice A rationale:
Potassium chloride (KCL) is a supplement used to treat or prevent low potassium levels. While it can have side effects, visual disturbances are not typically associated with KCL. Therefore, it is not the medication the nurse suspects to be causing the problem.
Choice B rationale:
Warfarin (Coumadin) is an anticoagulant used to prevent blood clot formation. Visual disturbances are not a known side effect of warfarin. Therefore, it is unlikely to be the cause of the patient's symptoms.
Choice C rationale:
Aspirin (ASA) is a pain reliever and antiplatelet medication, and while it can cause visual disturbances in some cases, it is not a common or significant side effect. Aspirin is also not specifically linked to atrial fibrillation.
Choice D rationale:
Digoxin (Lanoxin) is used to treat atrial fibrillation and heart failure. Visual disturbances are a known side effect of digoxin toxicity. Given the patient's diagnosis of atrial fibrillation and the reported symptoms, the nurse suspects the problem lies with digoxin and should further investigate and report to the provider.
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