The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit?

The client with an ileostomy

The client with cirrhosis

The client with heart failure

The client with decreased renal function

Answer and Explanation

The Correct Answer is A

Choice A reason: The client with an ileostomy is at risk for fluid volume deficit because an ileostomy is a surgical opening in the ileum, the last part of the small intestine, that allows the drainage of intestinal contents. This can result in a loss of fluids and electrolytes, especially sodium and potassium, which can lead to dehydration and hypovolemia.

Choice B reason: The client with cirrhosis is not at risk for fluid volume deficit, but rather fluid volume excess. Cirrhosis is a chronic liver disease that causes scarring and impaired liver function. This can lead to portal hypertension, which is an increase in the pressure in the portal vein that carries blood from the digestive organs to the liver. Portal hypertension can cause ascites, which is the accumulation of fluid in the abdominal cavity, and edema, which is the swelling of the tissues due to fluid retention.

Choice C reason: The client with heart failure is not at risk for fluid volume deficit, but rather fluid volume excess. Heart failure is a condition where the heart is unable to pump enough blood to meet the body's needs. This can lead to congestion of the blood vessels, which can cause pulmonary edema, which is the accumulation of fluid in the lungs, and peripheral edema, which is the swelling of the extremities due to fluid retention.

Choice D reason: The client with decreased renal function is not at risk for fluid volume deficit, but rather fluid volume excess. Decreased renal function is a condition where the kidneys are unable to filter the blood and remove excess fluids and wastes. This can lead to oliguria, which is a decrease in urine output, and anuria, which is the absence of urine output. This can cause fluid overload, which can affect the heart and the lungs.

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Correct Answer is D

Explanation

Choice A reason: Respiratory alkalosis is caused by hyperventilation, which lowers the carbon dioxide levels in the blood and raises the pH. This is not likely to occur in a client with a nasogastric tube on low suction.

Choice B reason: Metabolic acidosis is caused by an excess of acids or a loss of bases in the body, which lowers the pH. This can occur in conditions such as diabetic ketoacidosis, renal failure, or diarrhea. This is not likely to occur in a client with a nasogastric tube on low suction.

Choice C reason: Respiratory acidosis is caused by hypoventilation, which raises the carbon dioxide levels in the blood and lowers the pH. This can occur in conditions such as chronic obstructive pulmonary disease, asthma, or sedative overdose. This is not likely to occur in a client with a nasogastric tube on low suction.

Choice D reason: Metabolic alkalosis is caused by a loss of acids or an excess of bases in the body, which raises the pH. This can occur in conditions such as vomiting, gastric suction, or diuretic use. This is the most likely acid-base disorder to occur in a client with a nasogastric tube on low suction, as the tube removes gastric acid from the stomach.

A. pH 7.50, PCO2 30 mmHg B. pH 7.45, PCO2 52 mmHg C. pH 7.25, PCO2 50 mmHg D. pH 7.35, PCO2 40 mmHg

Correct Answer is C

Explanation

Choice A reason: This is incorrect because this represents respiratory alkalosis, not acidosis. Respiratory alkalosis is characterized by a high pH and a low PCO2.

Choice B reason: This is incorrect because this represents a mixed disorder, not a pure respiratory acidosis. A mixed disorder occurs when both the pH and the PCO2 are abnormal, but in opposite directions.

Choice C reason: This is correct because this represents respiratory acidosis. Respiratory acidosis is characterized by a low pH and a high PCO2.

Choice D reason: This is incorrect because this represents normal values, not respiratory acidosis. Normal values for pH and PCO2 are 7.35 to 7.45 and 35 to 45 mmHg, respectively.

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The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Correct Answer is D

Explanation

The registered nurse reviews the result of the arterial blood gas values with the licensed practical nurse and tells the LPN that the client has respiratory acidosis. The LPN would expect to note which of the following on the laboratory result report?

Correct Answer is C

Explanation

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