A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client’s spouse became alarmed when the client demonstrated confusion and elevated temperature and reported “dry mouth.” The nurse suspects the client is experiencing which condition?

Hypovolemia

Hypernatremia

Hypokalemia

Metabolic acidosis

Answer and Explanation

The Correct Answer is A

Choice A reason: Hypovolemia is likely, as vomiting and diarrhea cause significant fluid loss, leading to dehydration. Confusion (from cerebral hypoperfusion), elevated temperature (from concentrated blood), and dry mouth (from reduced saliva) reflect low intravascular volume, making this the most fitting diagnosis for the client’s condition.

Choice B reason: Hypernatremia results from excessive sodium relative to water, often from inadequate water intake. Vomiting and diarrhea deplete water and electrolytes, causing hypovolemia, not sodium excess. Confusion and fever align with dehydration, making hypernatremia an incorrect diagnosis in this scenario.

Choice C reason: Hypokalemia may occur with diarrhea due to potassium loss, but confusion, fever, and dry mouth primarily reflect hypovolemia from fluid loss. Potassium loss is secondary, as hypovolemia’s systemic effects are more immediate, making this a less comprehensive diagnosis for the client’s symptoms.

Choice D reason: Metabolic acidosis can occur with diarrhea due to bicarbonate loss, but confusion, fever, and dry mouth primarily reflect hypovolemia from fluid loss. Acidosis may contribute, but hypovolemia drives these systemic signs, making it the more accurate diagnosis in this context.

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Correct Answer is B

Explanation

Choice A reason: A 30-pack-year smoking history indicates COPD risk but not acute distress. Smoking is a chronic factor, not an immediate symptom requiring urgent assessment. Clients with active respiratory distress, like accessory muscle use, take priority due to immediate risks of hypoxia.

Choice B reason: A 52-year-old in a tripod position using accessory muscles indicates severe respiratory distress in COPD, reflecting hypoxia or hypercapnia. This posture and muscle use signal increased work of breathing, requiring immediate assessment to prevent respiratory failure, making this client the highest priority.

Choice C reason: Dependent edema and clubbed fingers in a 68-year-old suggest chronic COPD with possible cor pulmonale. These are chronic findings, not acute distress. Clients with immediate respiratory compromise, like accessory muscle use, take priority due to the risk of rapid decompensation.

Choice D reason: Chronic cough with thick secretions is common in COPD but less urgent than acute respiratory distress. Secretions contribute to airway obstruction, but tripod positioning and accessory muscle use indicate immediate hypoxia risk, requiring priority assessment over chronic symptoms.

A. Elevated sodium level B. Decreased potassium level C. Elevated magnesium level D. Decreased calcium level

Correct Answer is B

Explanation

Choice A reason: Elevated sodium level (hypernatremia) is unlikely with high NG drainage, as gastric fluid contains sodium, risking hyponatremia. The large volume (2,500 mL) suggests significant electrolyte loss, particularly potassium, not sodium accumulation, making this an incorrect imbalance to prioritize in this scenario.

Choice B reason: Decreased potassium level (hypokalemia) is a concern with high NG drainage, as gastric fluid contains potassium. Losing 2,500 mL in 6 hours depletes potassium, risking arrhythmias, muscle weakness, and prolonged ileus. Monitoring potassium prevents life-threatening complications, making it the priority in this postoperative client.

Choice C reason: Elevated magnesium level (hypermagnesemia) is not associated with NG drainage, as gastric fluid has minimal magnesium. Excessive drainage leads to losses of potassium and sodium, not magnesium accumulation, making this an incorrect imbalance to prioritize in this client with postoperative ileus.

Choice D reason: Decreased calcium level (hypocalcemia) is less likely, as gastric fluid has low calcium content. Potassium and sodium losses are more significant due to their higher concentrations in gastric secretions, making hypokalemia a greater concern than hypocalcemia in this high-drainage postoperative scenario.

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A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client’s spouse became alarmed when the client demonstrated confusion and elevated temperature and reported “dry mouth.” The nurse suspects the client is experiencing which condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client with chronic obstructive pulmonary disease (COPD) will the nurse assess first?

Correct Answer is B

Explanation

A nurse is caring for a client who has a postoperative ileus and a nasogastric (NG) tube that has drained 2,500 mL in the past 6 hours. Which electrolyte imbalance should the nurse monitor the client for?

Correct Answer is B

Explanation

Which of the following most accurately indicates that a postoperative client’s peristalsis has returned?

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A client has a sodium level of 121 mEq/L. What is the priority nursing intervention?

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The nurse is caring for a client with a diagnosis of hypervolemia. Which intervention is the priority for the nurse to implement?

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