A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

Crackles in lung bases.

Periorbital edema.

Swelling at the IV site.

Bounding radial pulse.

Flat neck veins when supine.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:

Crackles in lung bases Crackles in the lung bases are often indicative of fluid accumulation in the lungs, which can occur in conditions like heart failure. These crackles are discontinuous and sound like "fine rales.”. They can be heard during inspiration and expiration.

Choice B rationale:

Periorbital edema Periorbital edema, or swelling around the eyes, can be a sign of fluid volume overload, especially in the context of an older adult receiving IV therapy. It suggests that excess fluid is accumulating in the body.

Choice D rationale:

Bounding radial pulse A bounding radial pulse is a sign of increased stroke volume and can occur when the heart is working harder to pump the increased blood volume associated with fluid overload.

Choice C rationale:

Swelling at the IV site Swelling at the IV site can be a local reaction and may not necessarily indicate fluid volume overload unless it is associated with other systemic signs.

Choice E rationale:

Flat neck veins when supine Flat neck veins when the client is supine are not typically associated with fluid volume overload. In fact, flat neck veins are more characteristic of hypovolemia. Now, let's address the final question.

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Correct Answer is A

Explanation

Choice A rationale:

Metabolic alkalosis Metabolic alkalosis is characterized by an elevated pH (above the normal range of 7.35-7.45) and an increased bicarbonate (HCO3) level (above the normal range of 22-28 mEq/L). In this case, the client's pH of 7.6 and HCO3 level of 32 mEq/L indicate a primary metabolic alkalosis. It can be caused by excessive bicarbonate intake, loss of acid (as in vomiting or excessive diuretic use), or other factors that result in an excess of bicarbonate in the body. The PaCO2 level is within the normal range (35-45 mm Hg), which is consistent with compensatory hypoventilation seen in metabolic alkalosis.

Choice B rationale:

Metabolic acidosis Metabolic acidosis is characterized by a decreased pH and bicarbonate level. The client's ABG results do not align with metabolic acidosis. In this case, the pH is elevated, and the bicarbonate level is above the normal range.

Choice C rationale:

Respiratory alkalosis Respiratory alkalosis is characterized by an elevated pH and decreased PaCO2. The client's ABG results show a normal PaCO2 of 40 mm Hg, which does not align with respiratory alkalosis. In respiratory alkalosis, you would typically see a lower PaCO2.

Choice D rationale:

Respiratory acidosis Respiratory acidosis is characterized by a decreased pH and elevated PaCO2. The client's ABG results do not align with respiratory acidosis. In this case, the PaCO2 is within the normal range, and the pH is elevated, which is not indicative of respiratory acidosis.

A. The medication will reduce inflammation. B. The medication will open the airways. C. The medication will prevent wheezing. D. The medication will increase the amount of mucus. E. The medication will decrease coughing episodes.

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

Explanation

Choice A rationale:

Albuterol primarily acts as a bronchodilator by opening up the airways. It does not have a significant anti-inflammatory effect. Inhaled corticosteroids are more commonly used to reduce airway inflammation in asthma.

Choice B rationale:

Albuterol, a beta-2 agonist, helps with breathing by relaxing the smooth muscles in the airways, which opens them up. This action allows for improved airflow and ease of breathing. Therefore, this choice is correct.

Choice C rationale:

Albuterol is used to relieve bronchospasm, which can prevent wheezing in individuals with asthma. It does not have a direct effect on reducing mucus production or coughing.

Choice D rationale:

Albuterol does not increase the amount of mucus production. In fact, it can help reduce coughing by relieving bronchospasm, but it does not directly suppress coughing episodes.

Choice E rationale:

Albuterol can help reduce coughing episodes by improving airflow and reducing the irritation that leads to coughing.

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A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the arterial blood gas (ABG) results of a client. The client's ABGs are:. A. pH: 7.6. B. PaCO2: 40 mm Hg. C. HCO3: 32 mEq/L. Which of the following acid-base conditions should the nurse identify the client is experiencing?

Correct Answer is A

Explanation

A nurse is caring for a client who has asthma. The client asks the nurse how albuterol helps his breathing. Which of the following information should the nurse include in the response? (Select all that apply.).

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

Explanation

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