A nurse is caring for a client who has fluid overload due to heart failure. Which of the following clinical manifestations should the nurse expect to find in the client?

Dry mucous membranes

Decreased urine output

Crackles in the lungs

Hypotension

Answer and Explanation

The Correct Answer is C

The correct answer is: c. Crackles in the lungs

Choice A: Dry mucous membranes

Reason: Dry mucous membranes are typically associated with dehydration, not fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms such as edema and pulmonary congestion, rather than dryness of mucous membranes.

Choice B: Decreased urine output

Reason: Decreased urine output can occur in conditions like dehydration or renal failure. In fluid overload due to heart failure, the kidneys may initially try to excrete excess fluid, leading to increased urine output. However, as heart failure progresses, renal perfusion may decrease, potentially leading to reduced urine output. This is not a primary or consistent symptom of fluid overload.

Choice C: Crackles in the lungs

Reason: Crackles in the lungs are a hallmark sign of fluid overload, particularly in the context of heart failure. This occurs due to pulmonary edema, where excess fluid accumulates in the alveoli, causing the characteristic crackling sound during auscultation. This is a direct result of the heart’s inability to effectively pump blood, leading to fluid backing up into the lungs.

Choice D: Hypotension

Reason: Hypotension, or low blood pressure, is not typically associated with fluid overload. In fact, fluid overload can often lead to hypertension (high blood pressure) due to the increased volume of fluid in the circulatory system. Hypotension might occur in severe heart failure if the heart’s pumping ability is significantly compromised, but it is not a primary manifestation of fluid overload.

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Correct Answer is ["A","B","E"]

Explanation

Choice A reason:

Hyperkalemia is a common electrolyte imbalance in metabolic acidosis. The excess hydrogen ions in the blood cause a shift of potassium from the intracellular to the extracellular space, resulting in increased serum potassium levels.

Choice B reason:

Hyponatremia is a possible electrolyte imbalance in metabolic acidosis. The excess hydrogen ions in the blood can cause a dilutional effect on sodium, resulting in decreased serum sodium levels.

Choice C reason:

Hypercalcemia is not an electrolyte imbalance in metabolic acidosis. In fact, metabolic acidosis can cause hypocalcemia due to increased binding of calcium to albumin and decreased ionized calcium levels.

Choice D reason:

Hypophosphatemia is not an electrolyte imbalance in metabolic acidosis. In fact, metabolic acidosis can cause hyperphosphatemia due to increased renal excretion of hydrogen ions and decreased renal excretion of phosphate.

Choice E reason:

Hypochloremia is a common electrolyte imbalance in metabolic acidosis. The excess hydrogen ions in the blood cause a loss of chloride from the kidneys, resulting in decreased serum chloride levels.

A. "It is a compensatory mechanism to increase oxygen intake." B. "It is a sign of respiratory failure and impending coma." C. "It is an attempt to lower your blood pressure by exhaling more air." D. "It is a response to lower your blood acidity by exhaling more carbon dioxide."

Correct Answer is D

Explanation

Choice A reason:

Kussmaul respirations are not a compensatory mechanism to increase oxygen intake, but rather to decrease carbon dioxide levels in the blood. Oxygen intake is not affected by Kussmaul respirations, which are characterized by deep and rapid breaths.

Choice B reason:

Kussmaul respirations are not a sign of respiratory failure and impending coma, but rather a sign of metabolic acidosis and an attempt to correct it. Respiratory failure and coma can occur in DKA if the condition is not treated promptly and effectively, but they are not indicated by Kussmaul respirations alone.

Choice C reason:

Kussmaul respirations are not an attempt to lower blood pressure by exhaling more air, but rather an attempt to lower blood acidity by exhaling more carbon dioxide. Blood pressure is not affected by Kussmaul respirations, which are caused by increased acidity in the blood due to the accumulation of ketone bodies from fat breakdown.

Choice D reason:

Kussmaul respirations are a response to lower blood acidity by exhaling more carbon dioxide. Carbon dioxide is an acidic gas that can lower the pH of the blood when it accumulates. By exhaling more carbon dioxide, the body tries to raise the pH of the blood and compensate for the metabolic acidosis caused by DKA.

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A nurse is caring for a client who has fluid overload due to heart failure. Which of the following clinical manifestations should the nurse expect to find in the client?

Choice A: Dry mucous membranes

Choice B: Decreased urine output

Choice C: Crackles in the lungs

Choice D: Hypotension

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Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory results of a client who has metabolic acidosis. Which of the following electrolyte imbalances should the nurse anticipate? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is assessing a client who has diabetic ketoacidosis (DKA) and notes that the client has Kussmaul respirations. Which of the following explanations should the nurse give to the client about this type of breathing pattern?

Correct Answer is D

Explanation

A nurse is caring for a client who has fluid overload due to heart failure. Which of the following clinical manifestations should the nurse expect to find in the client?

A nurse is planning care for a client who has hypocalcemia. Which of the following interventions should the nurse include in the plan?

A nurse is teaching a client who has respiratory alkalosis about the causes and prevention of this condition. Which of the following statements by the client indicates an understanding of the teaching?