A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

Distended neck veins.

Poor skin turgor.

Concentrated hemoglobin and hematocrit levels.

Decreased urine output.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Fluid volume overload is an excess of fluid in the intravascular and/or interstitial spaces. One of the hallmark signs of fluid volume overload is distended neck veins, which indicates increased venous pressure due to the accumulation of fluid. The neck veins become more visible and prominent, especially when the patient is in a semi-Fowler's position.

Choice B rationale:

Poor skin turgor is a sign of dehydration, not fluid volume overload. It is characterized by the skin's inability to return to its normal position after being gently pinched. In fluid volume overload, the skin may become edematous and puffy, but it does not exhibit poor turgor.

Choice C rationale:

Concentrated hemoglobin and hematocrit levels are seen in conditions of dehydration or hemoconcentration, not in fluid volume overload. In fluid volume overload, there is excess fluid, which may lead to dilutional effects, resulting in decreased concentration of blood components.

Choice D rationale:

Decreased urine output is associated with fluid volume deficit (dehydration) rather than fluid volume overload. In fluid volume overload, there is often an increase in urine output as the body tries to eliminate the excess fluid.

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

Explanation

The correct answer is choice A, C, and D.

Choice A rationale:

Lethargy is a common symptom of metabolic alkalosis due to the body’s attempt to compensate for the altered pH balance, leading to decreased energy levels and fatigue.

Choice B rationale:

Kussmaul’s respirations are typically associated with metabolic acidosis, not alkalosis. These deep, labored breaths are the body’s way of trying to expel excess carbon dioxide to correct acidosis.

Choice C rationale:

Circumoral paresthesia, or tingling around the mouth, is a symptom of metabolic alkalosis. This occurs due to changes in calcium ion concentration affecting nerve function.

Choice D rationale:

Bicarbonate excess is a direct cause of metabolic alkalosis. Elevated bicarbonate levels in the blood lead to an increased pH, resulting in alkalosis.

Choice E rationale:

Flushing is not a typical symptom of metabolic alkalosis. It is more commonly associated with conditions that cause vasodilation or increased blood flow to the skin.

A. Respiratory acidosis. B. Metabolic alkalosis. C. Respiratory alkalosis. D. Metabolic acidosis.

Correct Answer is B

Explanation

Metabolic alkalosis.

Choice A rationale:

The given blood gas results show a pH of 7.53, which is alkaline (above the normal range of

7.35 to 7.45), and a high bicarbonate level of 36 mEq/L (normal range is 22 to 26 mEq/L). This combination indicates metabolic alkalosis, a condition where there is an excessive accumulation of bicarbonate in the blood, leading to increased pH.

Choice B rationale:

Metabolic alkalosis is characterized by increased blood bicarbonate levels, which can occur due to conditions like vomiting, diuretic use, or excessive ingestion of bicarbonate-containing substances. It results in symptoms such as muscle twitching, tetany, and respiratory depression.

Choice C rationale:

Respiratory alkalosis is characterized by an elevated blood pH and low carbon dioxide levels (hypocapnia). However, the bicarbonate level is not directly related to respiratory alkalosis, making this choice incorrect based on the given information.

Choice D rationale:

Metabolic acidosis is characterized by a decreased blood pH and low bicarbonate levels. The presented blood gas results show an alkaline pH and high bicarbonate, making this choice incorrect.

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A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

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Naxlex Comprehensive Predictor Exams

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.).

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

Explanation

A patient's blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. The nurse realizes that the patient is demonstrating which acid-base disorder?

Correct Answer is B

Explanation

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