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

Sodium 155 mEq/L. Choice A rationale:

A urine specific gravity of 1.035 indicates concentrated urine and is consistent with fluid volume deficit. However, it is not the most specific finding for this condition.

Choice B rationale:

A BUN (blood urea nitrogen) level of 19 mg/dL can be a normal value. It is within the reference range (usually around 7-20 mg/dL) and does not provide specific information about fluid volume deficit.

Choice C rationale:

A hematocrit of 44.9% can also be within the normal range for some individuals, and while it can be elevated in cases of fluid volume deficit, it is not as sensitive as other parameters for detecting this condition.

Choice D rationale:
This is the correct answer because a sodium level of 155 mEq/L is elevated and indicates hypernatremia, which is associated with fluid volume deficit. Hypernatremia occurs when there is a relative lack of water in relation to the sodium concentration in the blood, and it can lead to dehydration

A. Hypokalemia. B. Hypercalcemia. C. Hypovolemia. D. Hyperglycemia.

Correct Answer is D

Explanation

Choice A rationale:

Hypokalemia is not a direct adverse effect of dextrose 10% in water infusion. This solution does not contain potassium, and unless the patient already has low potassium levels or other contributing factors, it would not cause hypokalemia.

Choice B rationale:

Hypercalcemia is unrelated to dextrose 10% in water infusion. The solution does not contain calcium, and it would not lead to an increase in serum calcium levels.

Choice C rationale:

Hypovolemia, or low blood volume, is not typically associated with dextrose 10% in water infusion. However, if administered rapidly in large amounts, it could potentially cause fluid overload leading to hypervolemia.

Choice D rationale:

Hyperglycemia is a possible adverse effect of dextrose 10% in water infusion. The solution contains a high concentration of glucose, which can raise blood sugar levels if the body cannot adequately utilize or regulate the glucose. Regular monitoring of blood glucose levels is essential during such an infusion, especially in patients with diabetes or impaired glucose tolerance.

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

Correct Answer is A

Explanation

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?

Correct Answer is D

Explanation

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