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 A

Explanation

Choice A Reason: This is correct because the client who has gastroenteritis and is febrile is likely to lose ﬂuid through vomiting, diarrhea, and sweating. These losses can lead to dehydration, hypotension, and electrolyte imbalances. The nurse should monitor the client's vital signs, ﬂuid intake and output, and weight, and administer ﬂuids and electrolytes as ordered.
Choice B Reason: This is incorrect because the client who has leftsided heart failure and has a BNP level of 600 pg/ml is likely to have ﬂuid volume excess, not deficit. BNP is a hormone that is released by the heart when it is stretched by increased blood volume. A high BNP level indicates that the heart is failing to pump eﬀectively and that ﬂuid is accumulating in the lungs and other tissues. The nurse should monitor the client's respiratory status, oxygen saturation, edema, and weight, and administer diuretics and other medications as ordered.
Choice C Reason: This is incorrect because the client who has endstage renal failure and is scheduled for dialysis today is likely to have ﬂuid volume excess, not deficit. Renal failure impairs the kidney's ability to excrete ﬂuid and waste products, leading to ﬂuid retention and azotemia. Dialysis is a procedure that removes excess ﬂuid and toxins from the blood using an artificial membrane. The nurse should monitor the client's blood pressure, ﬂuid intake and output, weight, and laboratory values, and prepare the client for dialysis as ordered.
Choice D Reason: This is incorrect because the client who has been NPO since midnight for endoscopy is unlikely to have a significant ﬂuid volume deficit, unless they have other risk factors or comorbidities. NPO means nothing by mouth, which is a common instruction before certain procedures or surgeries to prevent aspiration. Endoscopy is a procedure that uses a ﬂexible tube with a camera to examine the digestive tract. The nurse should verify the client's NPO status, check their consent form, and administer preoperative medications as ordered.

A. Hypertension B. Drug toxicity C. Other electrolyte disturbances D. Visual disturbances

Correct Answer is C

Explanation

Choice A: Hypertension is incorrect because it is not a common complication of hypocalcemia, which is a low level of calcium in the blood. Hypertension, or high blood pressure, can be caused by conditions such as kidney disease, diabetes, or preeclampsia.

Choice B: Drug toxicity is incorrect because it is not directly related to hypocalcemia, although some drugs can aﬀect the calcium level in the blood. For example, loop diuretics can increase the urinary excretion of calcium, while bisphosphonates can inhibit the bone resorption of calcium.

Choice C: Other electrolyte disturbances is correct because hypocalcemia can be associated with other imbalances of electrolytes, such as magnesium, phosphorus, and potassium. For example, hypomagnesemia, or low magnesium level, can impair the secretion and action of parathyroid hormone, which regulates calcium balance.

Hyperphosphatemia, or high phosphorus level, can bind to calcium and lower its availability in the blood. Hypokalemia, or low potassium level, can increase the renal excretion of calcium.

Choice D: Visual disturbances is incorrect because it is not a typical manifestation of hypocalcemia, although severe hypocalcemia can aﬀect the nervous system and cause confusion, hallucinations, or seizures. Visual disturbances can be caused by conditions such as glaucoma, macular degeneration, or diabetic retinopathy.

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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

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for ﬂuid volume deficit?

Correct Answer is A

Explanation

The nurse is caring for a patient diagnosed with hypocalcemia. What additional assessments should the nurse include when caring for this patient?

Correct Answer is C

Explanation

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