Which client is at the greatest risk for developing an acid-base imbalance or electrolyte disorder?
18-month-old who has had watery stools for 3 days
A client who has a gastrostomy tube
70-year-old with constipation
27-year-old with a 24-hour history of nausea and vomiting
The Correct Answer is A
A. 18-month-old who has had watery stools for 3 days: Young children have a higher risk of dehydration and electrolyte imbalances due to their smaller body fluid reserves. Prolonged diarrhea can cause significant fluid and electrolyte loss, leading to potential acid-base imbalances.
B. A client who has a gastrostomy tube: While a gastrostomy tube can present risks for infection and nutritional imbalances, it is typically managed to ensure adequate nutrition and fluid intake, making electrolyte imbalances less likely unless complications arise.
C. 70-year-old with constipation: Constipation alone is less likely to cause significant fluid and electrolyte disturbances compared to prolonged diarrhea, although chronic constipation can lead to other complications such as fecal impaction.
D. 27-year-old with a 24-hour history of nausea and vomiting: A short-term episode of nausea and vomiting can lead to temporary fluid and electrolyte imbalances, but it is less severe compared to several days of diarrhea, particularly in a young child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Respiratory rate and pulse: Albuterol is a bronchodilator that works by relaxing the muscles in the airways, improving airflow and reducing wheezing and shortness of breath. After administration, it is important to monitor the respiratory rate to assess the patient’s breathing status and any changes in work of breathing. The pulse should also be monitored because albuterol can cause tachycardia as a side effect. An increase in heart rate is a common reaction to this medication and needs to be assessed to ensure it remains within safe limits.
B. Glucose: Monitoring glucose levels is not typically necessary after administering albuterol unless the patient has diabetes or there is a specific concern for hyperglycemia. Albuterol can cause an increase in blood glucose levels, but this is usually not a primary concern for an acute respiratory distress assessment unless the patient has an underlying condition that warrants it.
C. Pulse oximetry: Pulse oximetry measures the oxygen saturation in the blood, which is crucial for evaluating the effectiveness of albuterol in improving oxygenation. An increase in oxygen saturation levels after administration would indicate improved ventilation and gas exchange. Given that the patient initially has a pulse oximetry reading of 91%, it is important to reassess this to ensure that oxygen levels are improving with treatment.
D. Capillary refill: While capillary refill is an important general assessment for perfusion and circulatory status, it is not specifically required to evaluate the effectiveness of albuterol. It is more relevant in assessing overall circulation rather than the respiratory status directly impacted by albuterol.
E. Lung sounds: Reassessing lung sounds is critical after administering albuterol. The goal is to observe for changes such as reduced wheezing or improved airflow, which would indicate that the bronchodilator is effectively opening the airways. Listening for any changes in breath sounds helps to evaluate the patient’s response to the medication and detect any potential complications like paradoxical bronchospasm.
Correct Answer is D
Explanation
A. Respiration: Respiration refers to the overall process of gas exchange, including both external (between air and blood in the lungs) and internal (between blood and tissues) respiration. It does not specifically describe blood flow.
B. Inspiration: Inspiration is the process of inhaling air into the lungs. It involves the movement of air, not blood.
C. Expiration: Expiration is the process of exhaling air out of the lungs. Like inspiration, it involves the movement of air, not blood.
D. Perfusion: Perfusion refers to the flow of blood through the lungs' blood vessels, allowing for the exchange of gases with the alveoli. It is the correct term for blood flow through the lungs.
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