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 A

Explanation

Choice A Reason: This is the correct answer because potassium 2.9 mEq/L indicates hypokalemia, which is a common and potentially lifethreatening adverse eﬀect of furosemide. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis. The nurse should report this finding to the provider and monitor the client's vital signs and electrocardiogram.
Choice B Reason: This is incorrect because calcium 8.2 mg/dL is within the normal range of 8.5 to 10.5 mg/dL. Furosemide does not aﬀect calcium levels significantly, and this result does not indicate an urgent problem for the client.
Choice C Reason: This is incorrect because phosphorus 4.5 mEq/L is within the normal range of 2.5 to 4.5 mEq/L. Furosemide does not aﬀect phosphorus levels significantly, and this result does not indicate an urgent problem for the client.
Choice D Reason: This is incorrect because sodium 145 mEq/L is within the normal range of 135 to 145 mEq/L. Furosemide can cause hyponatremia, which is a low sodium level, but this result does not indicate that condition. The nurse should monitor the client's ﬂuid balance and intake and output, but this result does not require immediate action.

A. Use an infusion controller for the IV. B. Add the ordered dose to the IV bag hanging. C. Monitor the injection site for redness. D. Monitor ﬂuid intake and output. E. Administer the dose IV push over 3 minutes.

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

Explanation

Choice A Reason: This is correct because using an infusion controller for the IV ensures that the KCL is delivered at a safe and accurate rate. KCL can cause cardiac arrest if infused too rapidly or in excess.

Choice B Reason: This is correct because adding the ordered dose to the IV bag hanging dilutes the KCL and reduces the risk of phlebitis and extravasation. KCL is irritating to the veins and can cause tissue damage if it leaks out of the vein.

Choice C Reason: This is correct because monitoring the injection site for redness can help detect signs of phlebitis and extravasation. The nurse should stop the infusion and notify the provider if these complications occur.

Choice D Reason: This is incorrect because monitoring ﬂuid intake and output is not directly related to administering KCL. However, the nurse should monitor the patient's serum potassium level and renal function before and during KCL therapy, as kidney impairment can cause hyperkalemia.

Choice E Reason: This is incorrect because administering the dose IV push over 3 minutes is dangerous and contraindicated. KCL should never be given by IV push, bolus, or undiluted, as it can cause fatal cardiac arrhythmias.

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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 takes furosemide. Which of the following results should the nurse identify as the priority finding?

Correct Answer is A

Explanation

The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.

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

Explanation

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