A nurse is assessing clients on a medical-surgical unit. Which adult client should the nurse identify as being at greatest risk for insensible water loss?
Client taking furosemide (Lasix)
Anxious client who has tachypnea
Client who is on fluid restrictions
Client who is constipated with abdominal pain
The Correct Answer is B
A. Client taking furosemide (Lasix): Furosemide is a diuretic that primarily affects urine volume and does not directly increase insensible water loss. Insensible water loss refers to water lost through skin and respiratory routes, not through urination.
B. Anxious client who has tachypnea: Tachypnea, or rapid breathing, increases the rate of water loss through the respiratory system (insensible water loss). When breathing rapidly, the body loses more moisture in the form of vapor, making this client at greatest risk.
C. Client who is on fluid restrictions: Although fluid restrictions limit overall intake, this does not increase the risk for insensible water loss, which occurs primarily through skin and respiratory loss. Fluid restriction impacts overall fluid balance rather than insensible losses.
D. Client who is constipated with abdominal pain: Constipation and abdominal pain may contribute to some discomfort or difficulty with fluid intake, but they are not related to increased insensible water loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Osmosis: Osmosis is the process of moving water across a semi-permeable membrane from an area of lower particle concentration (lower solute concentration) to an area of higher particle concentration (higher solute concentration). This is a passive process and doesn’t require energy.
B. Filtration: Filtration is the process by which fluid and solutes are forced through a membrane by hydrostatic pressure, from an area of higher pressure to an area of lower pressure.
C. Diffusion: Diffusion is the movement of particles from an area of higher concentration to an area of lower concentration, not specifically involving water or particle concentration differences.
D. Active transport: Active transport requires energy to move particles against a concentration gradient (from lower to higher concentration). This process differs from osmosis, which is a passive process.
Correct Answer is C
Explanation
A. Increased urinary output: Increased urinary output is not a primary compensatory mechanism for metabolic acidosis. The kidneys help compensate by excreting hydrogen ions and reabsorbing bicarbonate, but this does not directly lead to increased urinary output.
B. Reduced abdominal distention: Abdominal distention is unrelated to the compensatory mechanism for metabolic acidosis. The primary compensatory mechanism is respiratory, not gastrointestinal.
C. Kussmaul respirations: Kussmaul respirations are deep, rapid breaths that occur as a compensatory mechanism for metabolic acidosis. The body increases the respiratory rate and depth to expel CO2, which is acidic and raise the blood pH, helping to correct the acid-base imbalance.
D. Decreased blood pressure: Decreased blood pressure can occur in various conditions, including metabolic acidosis, but it is not part of the compensatory mechanism. The body's response to metabolic acidosis is increasing ventilation to expel CO2 and correct the pH imbalance.
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