A nurse is admitting a client who reports persistent nausea, vomiting, and weakness for three days. The client has dry oral mucous membranes, weak peripheral pulses, and decreased skin turgor. What additional assessment findings should the nurse identify as manifestations related to the fluid imbalance? (Select All That Apply)

Muscle cramps

Bradycardia

Concentrated urine

Tachycardia

Increased thirst

Answer and Explanation

Correct Answer : A,C,D,E

A. Muscle cramps: Muscle cramps can occur due to electrolyte imbalances, such as low potassium, which are common in states of dehydration and fluid imbalance.
B. Bradycardia: Bradycardia is not typically associated with dehydration or fluid imbalance. Dehydration usually causes an increase in heart rate (tachycardia) as the body tries to maintain adequate circulation.
C. Concentrated urine: Concentrated urine is a common sign of dehydration as the kidneys conserve water, leading to reduced urine output and higher urine concentration.
D. Tachycardia: Tachycardia is a compensatory mechanism in response to decreased fluid volume, as the heart pumps faster to maintain adequate blood flow and blood pressure.
E. Increased thirst: Increased thirst is a natural response to dehydration as the body signals the need for more fluid intake to correct the fluid imbalance.

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Correct Answer is D

Explanation

A. A 47-year-old client who reports two loose stools with a serum sodium of 139 mmol/L: Although diarrhea can lead to electrolyte imbalances, a serum sodium level of 139 mmol/L is within normal range, so this client is not the highest priority.
B. A 71-year-old client with a calcium level of 8.9 mg/dL and a negative Trousseau sign: A calcium level of 8.9 mg/dL is slightly low but not critically low, especially with a negative Trousseau sign. This client is stable compared to others.
C. A 52-year-old client with fluid volume excess and BUN of 18 mg/dL: A BUN of 18 mg/dL indicates mild elevation, and fluid volume excess can be managed with adjustments in treatment; this client does not require immediate priority.
D. A 60-year-old client with a serum potassium of 3.2 mEq/L and heart palpitations: A potassium level of 3.2 mEq/L indicates hypokalemia, which can cause serious cardiac issues and symptoms like palpitations. This client requires urgent attention to address the potential risk of cardiac complications.

A. Decrease the TPN rate to 60 ml/hr B. Replace TPN infusion with an intravenous dextrose solution C. Begin infusion of 0.9% normal saline at 30 ml/hr D. Discontinue TPN infusion E. Discontinue TPN infusion

Correct Answer is B

Explanation

A. Decrease the TPN rate to 60 ml/hr: Gradually decreasing the TPN rate is a common practice, but it is typically done in conjunction with transitioning to another form of nutrition, not as a standalone order.
B. Replace TPN infusion with an intravenous dextrose solution: This is the correct choice. When weaning off TPN, it is important to prevent hypoglycemia by replacing the TPN with a dextrose solution to maintain blood glucose levels while transitioning to oral or enteral feeding.
C. Begin infusion of 0.9% normal saline at 30 ml/hr: While saline may be used for hydration, it does not address the need to manage blood glucose levels during the transition from TPN.
D. Discontinue TPN infusion: Discontinuing TPN abruptly can lead to complications such as hypoglycemia. It is important to gradually taper off TPN while replacing it with a dextrose solution.

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Naxlex Comprehensive Predictor Exams

The nurse working on a medical surgical unit is assigned four clients at the start of their shift. What client should be given the highest priority?

Correct Answer is D

Explanation

Orders were written for a client to be weaned off of total parenteral nutrition (TPN) and started on a low-residue diet. The TPN solution has been infusing at a continuous rate of 90 ml/hr for three weeks. Which of the following orders should the nurse anticipate next?

Correct Answer is B

Explanation

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