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.

Cardiac failure.

Pharmacological eﬀects of a diuretic.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because eﬀects of rapidly infused intravenous ﬂuids are not the cause of the patient's findings, but a possible treatment. Rapidly infused intravenous ﬂuids are used to restore ﬂuid volume and prevent shock in patients with ﬂuid volume deficit. Rapidly infused intravenous ﬂuids can cause increased blood pressure, increased urine output, and decreased heart rate.

Choice B Reason: This is correct because the body's natural compensatory mechanisms are the cause of the patient's findings. The body tries to maintain homeostasis and perfusion in response to ﬂuid volume deficit by activating the sympathetic nervous system, the renin-angiotensin-aldosterone system, and the antidiuretic hormone system. These mechanisms cause tachycardia, vasoconstriction, pale and cool skin, sodium and water retention, and decreased urine output.

Choice C Reason: This is incorrect because cardiac failure is not the cause of the patient's findings, but a possible complication. Cardiac failure occurs when the heart is unable to pump enough blood to meet the body's needs. Cardiac failure can result from prolonged ﬂuid volume deficit, as the heart becomes overstressed and weakened by the increased workload and decreased perfusion. Cardiac failure can cause dyspnea, edema, fatigue, and cyanosis.

Choice D Reason: This is incorrect because pharmacological eﬀects of a diuretic are not the cause of the patient's findings, but a possible cause of ﬂuid volume deficit. A diuretic is a medication that increases urine output and excretion of sodium and water. A diuretic can cause ﬂuid volume deficit if it is overdosed, misused, or taken with other medications that aﬀect ﬂuid balance. A diuretic can cause hypotension, dehydration, and electrolyte imbalances.

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Correct Answer is D

Explanation

Choice A: 18 mg/dL is incorrect because it is within the normal range of BUN, which is 7 to 20 mg/dL. BUN stands for blood urea nitrogen, which is a measure of the amount of nitrogen in the blood that comes from urea, a waste product of protein metabolism. BUN can reﬂect the kidney function and hydration status of the client.

Choice B: 10 mg/dL is incorrect because it is also within the normal range of BUN. A low BUN level can indicate liver problems, malnutrition, or overhydration.

Choice C: 13 mg/dL is incorrect because it is also within the normal range of BUN. A normal BUN level does not necessarily rule out dehydration, as other factors such as diet, medications, and blood loss can aﬀect the BUN level.

Choice D: 25 mg/dL is correct because it is above the normal range of BUN and indicates a high BUN level. A high BUN level can indicate dehydration, kidney failure, urinary tract obstruction, heart failure, or excessive protein intake. The nurse should report this value to the provider as it may require further evaluation and treatment.

A. Intracellular ﬂuid overload B. Intracellular ﬂuid deficit C. Extracellular ﬂuid deficit D. Interstitial ﬂuid deficit

Correct Answer is C

Explanation

Choice A: Intracellular ﬂuid overload is incorrect because it is a condition where the ﬂuid inside the cells exceeds the normal range. This can cause cellular swelling and dysfunction. Intracellular ﬂuid overload can be caused by conditions such as hyponatremia, water intoxication, or syndrome of inappropriate antidiuretic hormone secretion (SIADH).

Choice B: Intracellular ﬂuid deficit is incorrect because it is a condition where the ﬂuid inside the cells is below the normal range. This can cause cellular shrinkage and dysfunction. Intracellular ﬂuid deficit can be caused by conditions such as hypernatremia, dehydration, or diabetes insipidus.

Choice C: Extracellular ﬂuid deficit is correct because it is a condition where the ﬂuid outside the cells is below the normal range. This can cause hypovolemia, hypotension, and impaired tissue perfusion. Extracellular ﬂuid deficit can be caused by conditions such as burns, hemorrhage, vomiting, diarrhea, or excessive diuresis.

Choice D: Interstitial ﬂuid deficit is incorrect because it is a condition where the ﬂuid in the spaces between the cells is below the normal range. This can cause edema, impaired wound healing, and increased risk of infection. Interstitial ﬂuid deficit can be caused by conditions such as inﬂammation, infection, or lymphatic obstruction.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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