A patient experiencing multisystem ﬂuid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

Eﬀects of rapidly infused intravenous ﬂuids.

The body's natural compensatory mechanisms.

Cardiac failure.

Pharmacological eﬀects of a diuretic.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because eﬀects of rapidly infused intravenous ﬂuids are not the cause of the patient's findings, but a possible treatment. Rapidly infused intravenous ﬂuids are used to restore ﬂuid volume and prevent shock in patients with ﬂuid volume deficit. Rapidly infused intravenous ﬂuids can cause increased blood pressure, increased urine output, and decreased heart rate.

Choice B Reason: This is correct because the body's natural compensatory mechanisms are the cause of the patient's findings. The body tries to maintain homeostasis and perfusion in response to ﬂuid volume deficit by activating the sympathetic nervous system, the renin-angiotensin-aldosterone system, and the antidiuretic hormone system. These mechanisms cause tachycardia, vasoconstriction, pale and cool skin, sodium and water retention, and decreased urine output.

Choice C Reason: This is incorrect because cardiac failure is not the cause of the patient's findings, but a possible complication. Cardiac failure occurs when the heart is unable to pump enough blood to meet the body's needs. Cardiac failure can result from prolonged ﬂuid volume deficit, as the heart becomes overstressed and weakened by the increased workload and decreased perfusion. Cardiac failure can cause dyspnea, edema, fatigue, and cyanosis.

Choice D Reason: This is incorrect because pharmacological eﬀects of a diuretic are not the cause of the patient's findings, but a possible cause of ﬂuid volume deficit. A diuretic is a medication that increases urine output and excretion of sodium and water. A diuretic can cause ﬂuid volume deficit if it is overdosed, misused, or taken with other medications that aﬀect ﬂuid balance. A diuretic can cause hypotension, dehydration, and electrolyte imbalances.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because phosphorus is not the most aﬀected electrolyte by acute renal failure. Phosphorus is a mineral that is involved in bone formation, energy metabolism, and acid-base balance. Acute renal failure can cause hyperphosphatemia, which is a high level of phosphorus in the blood, due to impaired excretion by the kidneys. However, hyperphosphatemia is usually asymptomatic and can be treated with phosphate binders and dietary restriction.

Choice B Reason: This is incorrect because magnesium is not the most aﬀected electrolyte by acute renal failure. Magnesium is a mineral that is essential for nerve and muscle function, blood pressure regulation, and bone health. Acute renal failure can cause hypermagnesemia, which is a high level of magnesium in the blood, due to impaired excretion by the kidneys. However, hypermagnesemia is rare and usually occurs in patients who receive excessive magnesium supplementation or antacids.

Choice C Reason: This is correct because potassium is the most aﬀected electrolyte by acute renal failure. Potassium is a mineral that is vital for nerve and muscle function, especially for the heart. Acute renal failure can cause hyperkalemia, which is a high level of potassium in the blood, due to impaired excretion by the kidneys. Hyperkalemia can cause muscle weakness, cardiac arrhythmias, and cardiac arrest. The nurse should monitor the patient's vital signs, electrocardiogram, and serum potassium level, and administer medications or dialysis as ordered.

Choice D Reason: This is incorrect because calcium is not the most aﬀected electrolyte by acute renal failure. Calcium is a mineral that is essential for muscle contraction, nerve transmission, and blood clotting. Acute renal failure can cause hypocalcemia, which is a low level of calcium in the blood, due to decreased production of active vitamin D by the kidneys. Hypocalcemia can cause tetany, seizures, and cardiac arrhythmias. The nurse should monitor the patient's vital signs, electrocardiogram, and Chvostek's and Trousseau's signs, and administer calcium and vitamin D supplements as ordered.

Choice E Reason: This is incorrect because sodium is not the most aﬀected electrolyte by acute renal failure. Sodium is a mineral that regulates ﬂuid balance, blood pressure, and nerve impulses. Acute renal failure can cause hyponatremia or hypernatremia, which are low or high levels of sodium in the blood, due to impaired regulation of water intake and output by the kidneys. Hyponatremia can cause confusion, seizures, and coma. Hypernatremia can cause thirst, agitation, and restlessness. The nurse should monitor the patient's ﬂuid balance, vital signs, and serum sodium level, and administer ﬂuids or diuretics as ordered.

A. Widened QRS complexes B. Hyperactive deep tendon reﬂexes C. Bounding peripheral pulses D. Warm, ﬂushed skin

Correct Answer is A

Explanation

Choice A: Widened QRS complexes is correct because it is a sign of cardiac dysrhythmias, which can occur in respiratory acidosis due to hyperkalemia, or high potassium level. Respiratory acidosis is a condition where the blood pH is low and the PaCO2 is high, indicating impaired gas exchange or hypoventilation. This can cause potassium to shift from the intracellular ﬂuid to the extracellular ﬂuid, thus raising the serum potassium level and aﬀecting the cardiac conduction.

Choice B: Hyperactive deep tendon reﬂexes is incorrect because it is a sign of hypocalcemia, or low calcium level, which can occur in metabolic alkalosis, not respiratory acidosis. Metabolic alkalosis is a condition where the blood pH is high and the HCO3 is high, indicating a loss of metabolic acids or an excess of bicarbonate in the body. This can cause calcium to bind to albumin and lower its availability in the blood, thus increasing the neuromuscular excitability.

Choice C: Bounding peripheral pulses is incorrect because it is a sign of ﬂuid overload, which can occur in heart failure, not respiratory acidosis. Fluid overload is a condition where the ﬂuid volume in the body exceeds the normal range, causing edema, hypertension, and dyspnea. This can be caused by conditions such as kidney disease, liver disease, or excessive sodium intake.

Choice D: Warm, ﬂushed skin is incorrect because it is a sign of vasodilation, which can occur in respiratory alkalosis, not respiratory acidosis. Respiratory alkalosis is a condition where the blood pH is high and the PaCO2 is low, indicating excessive loss of carbon dioxide through hyperventilation. This can cause the blood vessels to dilate and increase the blood ﬂow to the skin, thus causing warmth and redness.

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A patient experiencing multisystem ﬂuid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

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Naxlex Comprehensive Predictor Exams

The nurse is admitting a patient who was diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most aﬀected by this disorder?

Correct Answer is C

Explanation

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A patient with atrial fibrillation and a serum potassium level of 3.0 mEq/L takes digoxin (Lanoxin), ASA (aspirin), KCL (potassium chloride) and warfarin (Coumadin) daily. The patient reports visual disturbances. The nurse suspects problems with which medication?

The patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this patient?

The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What findings did the nurse use to come to this conclusion? (Select all that apply)

A nurse is planning to teach a client about a high-potassium diet. Which of the following foods should the nurse instruct the client to eat? (Select all that apply)

A patient with atrial fibrillation and a serum potassium level of 3.0 mEq/L takes digoxin (Lanoxin), ASA (aspirin), KCL (potassium chloride) and warfarin (Coumadin) daily. The patient reports visual disturbances. The nurse suspects problems with which medication?

A patient with ﬂuid overload is prescribed furosemide (Lasix) 20 mg by mouth each day. What should the nurse include when teaching the patient about this medication? (Select all that apply.)

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?

The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What findings did the nurse use to come to this conclusion? Select all that apply.