The nurse caring for a frail 92-year-old dehydrated patient should add to the plan of care:
Potential for over-hydration related to excessive thirst
Potential for diarrhea related to dehydration
Potential for pulmonary congestion related to excessive fluid intake
Potential for fall related to confusion
The Correct Answer is D
Choice A reason: This is incorrect because over-hydration is unlikely in a dehydrated patient. Over-hydration is a condition where the body has too much water, which can cause hyponatremia, edema, and cerebral swelling.
Choice B reason: This is incorrect because diarrhea is a cause, not a consequence, of dehydration. Diarrhea is the frequent and watery passage of stool, which can lead to fluid and electrolyte loss.
Choice C reason: This is incorrect because pulmonary congestion is also unlikely in a dehydrated patient. Pulmonary congestion is a condition where the lungs are filled with fluid, which can cause dyspnea, cough, and crackles.
Choice D reason: This is correct because fall is a potential complication of dehydration. Dehydration can cause confusion, dizziness, weakness, and hypotension, which can increase the risk of falling and injuring oneself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct because metabolic alkalosis is characterized by a high pH and a high HCO3-. The client's pH and HCO3- are both high, indicating a metabolic disorder. The condition is uncompensated because the PaCO2 is normal, meaning the respiratory system is not compensating for the metabolic alkalosis.
Choice B reason: This is incorrect because metabolic acidosis is characterized by a low pH and a low HCO3-. The client's pH and HCO3- are both high, indicating alkalosis, not acidosis.
Choice C reason: This is incorrect because respiratory alkalosis is characterized by a high pH and a low PaCO2. The client's pH is high, but PaCO2 is normal, indicating a metabolic problem, not a respiratory one.
Choice D reason: This is incorrect because respiratory acidosis is characterized by a low pH and a high PaCO2. The client's pH is high, and PaCO2 is normal, indicating a metabolic problem, not a respiratory one.
Correct Answer is D
Explanation
Choice A reason: Kidney function is not indicated by the PaCO2 level, but rather by the creatinine and blood urea nitrogen (BUN) levels. The kidneys are responsible for regulating the HCO3- level, which is the other component of the carbonic acid-bicarbonate buffer system.
Choice B reason: Bicarbonate buffers are not indicated by the PaCO2 level, but rather by the HCO3- level. Bicarbonate buffers are substances that can accept or donate hydrogen ions to maintain the pH of the blood. They are part of the carbonic acid-bicarbonate buffer system, which is the main buffer system in the body.
Choice C reason: Phosphate buffers are not indicated by the PaCO2 level, but rather by the PO4^3^- level. Phosphate buffers are substances that can accept or donate hydrogen ions to maintain the pH of the intracellular fluid and the urine. They are part of the phosphoric acid-phosphate buffer system, which is the second most important buffer system in the body.
Choice D reason: Lung ventilation is indicated by the PaCO2 level, which is the partial pressure of carbon dioxide in the blood. Lung ventilation is the process of moving air in and out of the lungs, which affects the amount of carbon dioxide exhaled. The lungs are responsible for regulating the PaCO2 level, which is the other component of the carbonic acid-bicarbonate buffer system.
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