A nurse asks the unlicensed assistive personnel (UAP) to assist in determining the fluid status of a client. Which of the following actions should the nurse delegate to the UAP? (Select All That Apply)

Record intake and output

Assess bowel sounds

Obtain routine vital signs

Document the presence of edema

Answer and Explanation

Correct Answer : A,C,D

A. Record intake and output: This task is within the UAP's scope of practice as it involves documenting fluid balance.

B. Assess bowel sounds: This task requires clinical judgment and assessment skills and should be performed by a licensed nurse.

C. Obtain routine vital signs: This is appropriate for the UAP to perform, as it involves routine measurements that do not require clinical assessment.

D. Document the presence of edema: The UAP can document observable findings such as edema, which is within their scope of practice.

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Correct Answer is C

Explanation

A. Serum potassium 5.0 mEq/L: This is within the normal range for serum potassium (3.5-5.0 mEq/L). While potassium levels are important, they are not the primary concern with symptoms of confusion and a bounding pulse due to excessive water intake.
B. Serum osmolality 294 mmol/kg: This value is within the normal range for serum osmolality (275-295 mmol/kg). Elevated or normal osmolality would not be expected in a case of water intoxication, which dilutes serum electrolytes.
C. Serum sodium of 127 mEq/L: A serum sodium level of 127 mEq/L indicates hyponatremia, a condition often caused by excessive water intake that dilutes the sodium in the bloodstream. Symptoms such as confusion, headache, and a full bounding pulse are consistent with hyponatremia, making this the expected abnormality.
D. Serum hemoglobin 15.7 grams/dL: This is within the normal range for hemoglobin (12-16 grams/dL for women and 13.8-17.2 grams/dL for men). Hemoglobin levels would not be expected to change significantly due to water intoxication.

A. Kidney conservation of bicarbonate and excretion of hydrogen ions B. Deep, rapid respirations to increase CO2 excretion C. Respiratory hypoventilation to retain CO2 and kidney excretion of bicarbonate D. Shifting of bicarbonate into cells in exchange for chloride

Correct Answer is C

Explanation

A. Kidney conservation of bicarbonate and excretion of hydrogen ions: This option is not correct for metabolic alkalosis. In metabolic alkalosis, the kidneys would typically excrete bicarbonate rather than conserve it.
B. Deep, rapid respirations to increase CO2 excretion: This is incorrect because deep, rapid respirations are more associated with compensating for metabolic acidosis by increasing CO2 excretion. In metabolic alkalosis, the body attempts to retain CO2.
C. Respiratory hypoventilation to retain CO2 and kidney excretion of bicarbonate: This is the correct choice. In metabolic alkalosis, the body compensates by reducing respiration rate (hypoventilation) to retain CO2, which helps to counteract the elevated pH. Additionally, the kidneys may excrete bicarbonate to balance the pH.
D. Shifting of bicarbonate into cells in exchange for chloride: This mechanism is more related to respiratory alkalosis rather than metabolic alkalosis. In metabolic alkalosis, the primary compensatory mechanisms involve changes in respiratory rate and renal bicarbonate excretion.

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A nurse asks the unlicensed assistive personnel (UAP) to assist in determining the fluid status of a client. Which of the following actions should the nurse delegate to the UAP? (Select All That Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A student nurse is working with their preceptor on a medical-surgical unit. While reviewing concepts related to acid-base balance, what should the preceptor state is a compensatory mechanism for metabolic alkalosis?

Correct Answer is C

Explanation

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