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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.

Choice B rationale:

Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.

Choice C rationale:

Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.

Choice D rationale:

Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.

Choice E rationale:

Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.

A. Request a dietitian consult for selecting foods high in phosphorous. B. Provide aluminum hydroxide antacids as prescribed. C. Instruct the patient to avoid poultry, peanuts, and seeds. D. Instruct the patient to avoid the intake of sodium phosphate.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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

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

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.

The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What findings did the nurse use to come to this conclusion? Select all that apply.

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 patient is admitted with hypernatremia caused by being stranded on a boat in the Atlantic Ocean for five days without a fresh water source. What is this patient at risk for developing?

A nurse is teaching a client who is on a low-sodium diet. Which of the following instructions should the nurse include? (Select All that Apply.).

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.).