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 D

Explanation

Extracellular fluid deficit.

Choice A rationale:

Intracellular fluid deficit is a decrease in the fluid inside the cells, which may occur in conditions such as diabetic ketoacidosis. Severe burns are more likely to cause extracellular fluid shifts rather than intracellular fluid deficits.

Choice B rationale:

Interstitial fluid deficit involves a decrease in fluid in the interstitial spaces between cells. While burns can lead to fluid shifts, the primary concern is fluid loss from the vascular space (extracellular fluid).

Choice C rationale:

Intracellular fluid overload is not a typical health problem associated with severe burns. Burn injuries are more likely to cause fluid loss and shifts out of the intracellular space.

Choice D rationale:

Severe burns can result in significant loss of plasma and extracellular fluid, leading to hypovolemia and extracellular fluid deficit. This fluid loss can lead to hypovolemic shock and other complications if not adequately managed.

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.

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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 planning care for a patient with severe burns. What health problem should the nurse realize that this patient could develop?

Correct Answer is D

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

A patient with atrial fibrillation and a serum potassium level of 3.0 mEq/L takes digoxin (Lanoxin), ASA (aspirin), KCL (potassium chloride), and warfarin (Coumadin) daily. The patient reports visual disturbances. The nurse suspects problems with which medication?

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?

The nurse is admitting a patient who was diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most affected with this disorder?

A nurse is reviewing the laboratory results of a client who has fluid volume deficit. The nurse would expect which of the following findings?

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?

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 four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

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.).